🔑 Key Learning

  • Fever = temperature > 38°C
  • Most commonly due to infection, but other causes include malignancy and Kawasaki disease  if persistent fever > 5 days.
  • 30% of children experience fever annually.
  • Use the NICE traffic light system to assess risk and guide management.

👀 Clinical Assessment

  • Perform full A–E assessment.
  • Include:
    • Temperature, heart rate, respiratory rate
    • Capillary refill time (CRT)
    • Hydration status and fluid input/output
  • Blood pressure must be checked if CRT or HR are abnormal.

🚦 Traffic Light System – NICE Guidelines for Fever in Children

Use this system to stratify the risk of serious illness in children with fever.

🟢 Green – Low Risk

  • Colour: Normal
  • Respiratory: Normal respiratory rate, no signs of distress
  • Other: No amber or red features
  • Activity: Alert, smiling, or content; interacts normally; wakes easily
  • Circulation: Normal heart rate for age
  • Hydration: Moist mucous membranes; normal urine output; feeding well

🟠 Amber – Intermediate Risk

  • Colour: Parent/carer reports pallor
  • Respiratory:
    • Nasal flaring
    • Crackles
    • SaO₂ ≤ 95%
    • Tachypnoea:
      • Age 6–12 months: RR > 50
      • Age > 12 months: RR > 40
  • Other:
    • Fever ≥ 39°C if age 3–6 months
    • Fever > 5 days
    • Rigors
    • Swelling of a limb or joint
    • Non-weight bearing / not using an extremity
    • Possible septic arthritis
  • Activity:
    • Reduced activity
    • Only wakes with prolonged stimulation
    • Not responding normally to social cues
  • Circulation:
    • Tachycardia:
      • < 12 months: HR > 160
      • 12–24 months: HR > 150
      • 2–5 years: HR > 140
    • Capillary refill ≥ 2 seconds
  • Hydration:
    • Dry mucous membranes
    • Poor feeding (<50% of usual intake)
    • Fewer than 3 wet nappies in 24 hours

🔴 Red – High Risk

  • Colour: Pale, mottled, ashen, or cyanosed/blue skin
  • Respiratory:
    • Grunting
    • Severe chest indrawing
    • Tachypnoea: RR ≥ 60
    • Apnoea
  • Other:
    • Age < 3 months with temp ≥ 38°C
    • Status epilepticus
    • Bulging fontanelle
    • Neck stiffness
    • Focal neurological signs
    • Non-blanching rash
  • Activity:
    • Appears ill
    • No response to social cues
    • Weak or high-pitched continuous cry
    • Does not wake or stay awake
  • Circulation:
    • Pale or mottled skin
    • Cool peripheries
    • Prolonged capillary refill
    • Hypotension (late sign)
  • Hydration:
    • Reduced skin turgor
    • No wet nappies in >12 hours

💊 Management at Home (Green features only)

  • Antipyretics:
    • Start with paracetamol or ibuprofen monotherapy
    • Do not use simultaneously
    • May alternate if one is ineffective
  • Investigate source if unclear — e.g. urine dipstick and MCS for unexplained fever
  • Hydration: Encourage fluids; use oral rehydration solution (ORS) if needed

🫀 Kawasaki Disease

Kawasaki Disease is an important differential in children with fever > 5 days, particularly under the age of 5.

👀 Clinical Features

  • Persistent high fever (≥ 5 days)
  • Bilateral conjunctival injection (non-purulent)
  • Red, cracked lips and strawberry tongue
  • Polymorphous rash (morbilliform or maculopapular)
  • Cervical lymphadenopathy
  • Redness/desquamation of palms and soles

💥 Complications

  • Coronary artery aneurysms – potentially life-threatening

🧪 Investigations

  • Echocardiogram to assess for coronary artery abnormalities

💊 Management

  • IV Immunoglobulin (IVIG) – first-line treatment
  • High-dose aspirin – reduces inflammation and thrombosis risk (monitor for Reye’s syndrome)

📝 Exam Clues & Clinchers

  • UTI in infant < 3 months with no clear focus → urgent referral
  • Fever > 5 days + conjunctivitis + rash → think Kawasaki
  • Avoid simultaneous use of paracetamol and ibuprofen

🔗 Useful Links and References