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CLINICAL: CHILDREN’S HEALTH Edward Purssell


RGN RSCN BSc MSc PhD Senior Lecturer


Florence Nightingale School of Nursing and Midwifery King’s College London


Fever in young children


Fever is one of the most common symptoms in young children, resulting in worry and concern from parents and professionals alike


A


lthough a very common and sometimes distressing symptom, fever is a normal physiological response to a number of conditions, most notably infection. It is important that primary care nurses and others involved in the care of children are able to distinguish those who need urgent


medical attention from those who do not, and to provide advice about antipyretic and other treatments, and offer reassurance where appropriate.


RECOGNISING FEVER Body temperature is under the control of the hypothalamus, which sets the normal temperature which the body then maintains though a variety of mechanisms. For example, if body temperature exceeds the set-point, vasodilation and sweating might be used to reduce it; if the temperature is lower than the set-point, vasoconstriction and shivering might ensue to increase it. In either case the result is the same - a body temperature that matches the hypothalamic set-point. In the case of fever, substances which act as pyrogens increase the set-point, resulting in a rise in temperature. Many of these pyrogenic substances are cytokines, chemical messengers produced during infections. Therefore a high temperature is normal during an infection, and is an important part of the overall immune response. This leads some to conclude that fever should never be treated.1


However, many parents do like to treat fever, so it is


important that practitioners have a good understanding of the rationale for how this should be done. One problem with identifying fever in young children is that there


is no single ‘normal’ temperature. One study of children aged between one and six years showed a mean tympanic temperature of 36.65°C, but with a range of 35.6 to 37.8°C.2


Not only is there


variation between children, but temperature also varies according to the site at which it is taken and the technique used3


and consequently there is variation between different guidelines as to


what constitutes a fever, although a general consensus appears to be in the region of 38°C.4 The National Institute of Health and Clinical Excellence (NICE)


defined fever in children as being an elevation of body temperature above the normal daily variation, noting the general acceptance of this figure of 38°C. Significantly however, NICE also recognised that not all parents have ready access to thermometers, and that many parents are able to identify fever by other methods, for example touch, and that this should be taken seriously by healthcare practitioners.5


This also acknowledges parents’ and carers’ unique knowledge of their own child and what is normal for them.


IDENTIFYING THE CAUSE Having identified that a child has a fever, the important issue is to differentiate those who have a serious infection from those who do not. The prevalence of serious infection in the community is very low, so most febrile children will have only a minor illness that does not require treatment.6


In order to identify those children who do need


treatment, NICE produced a ‘traffic light’ system, separating signs and symptoms into three categories, green, amber and red. If there are only ‘green’ signs and symptoms, these children can be managed at home with support. If there are any from the ‘amber’ category, they should be assessed face-to-face by someone experienced in the assessment of young children. If any ‘red’ symptoms are reported, an urgent assessment is required, normally in the accident and emergency department (see Table 1). Crucially, the guidelines require that those giving any advice to parents, in whatever context, provide them with ‘safety net’ advice, which should include information on signs that the child needs a further assessment, and how this should be accessed at different times.5 A number of the most serious infections of infancy and early


childhood are the focus of the infant immunisation programme, and since the expansion and acceleration of these vaccinations, there has been a fall in the incidence of these infections. It is important therefore that children are vaccinated with all doses and at the


56 Nursing in Practice March/April 2012


www.nursinginpractice.com


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