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Fever in under 5s: Assessment and initial management

NICE guideline [NG143]Published: 07 November 2019 Last updated: 26 November 2021

This guideline covers the assessment and early management of fever with no obvious cause in children aged under 5. It aims to improve clinical assessment and help healthcare professionals diagnose serious illness among young children who present with fever in primary and secondary care.

First, healthcare professionals should identify any immediately life‑threatening features, including compromise of the airway, breathing or circulation, and decreased level of consciousness. 

 

Think “Could this be sepsis?” and refer to the NICE guideline on sepsis: recognition, diagnosis and early management if a child presents with fever and symptoms or signs that indicate possible sepsis.

Assess children with feverish illness for the presence or absence of symptoms and signs that can be used to predict the risk of serious illness using the traffic light system.

 

When assessing children with learning disabilities, take the individual child’s learning disability into account when interpreting the traffic light table.

 

Recognise that children with any of the following symptoms or signs are in a high-risk group for serious illness:

  • pale/mottled/ashen/blue skin, lips or tongue

  • no response to social cues

  • appearing ill to a healthcare professional

  • does not wake or if roused does not stay awake

  • weak, high-pitched or continuous cry

  • grunting

  • respiratory rate greater than 60 breaths per minute

  • moderate or severe chest indrawing

  • reduced skin turgor

  • bulging fontanelle.

Recognise that children with any of the following symptoms or signs are in at least an intermediate-risk group for serious illness:

  • pallor of skin, lips or tongue reported by parent or carer

  • not responding normally to social cues

  • no smile

  • wakes only with prolonged stimulation

  • decreased activity

  • nasal flaring

  • dry mucous membranes

  • poor feeding in infants

  • reduced urine output

  • rigors.

Recognise that children who have all of the following features, and none of the high- or intermediate-risk features, are in a low-risk group for serious illness:

  • normal colour of skin, lips and tongue

  • responds normally to social cues

  • content or smiles

  • stays awake or awakens quickly

  • strong normal cry or not crying

  • normal skin and eyes

  • moist mucous membranes.

Recognise that a capillary refill time of 3 seconds or longer is an intermediate-risk group marker for serious illness (‘amber’ sign)

 

Measure the blood pressure of children with fever if the heart rate or capillary refill time is abnormal and the facilities to measure blood pressure are available.

 

In children older than 6 months do not use height of body temperature alone to identify those with serious illness. 

 

Recognise that children younger than 3 months with a temperature of 38°C or higher are in a high-risk group for serious illness. (Note that some vaccinations have been found to induce fever in children aged under 3 months.) 

 

Recognise that children aged 3 to 6 months with a temperature of 39°C or higher are in at least an intermediate-risk group for serious illness. 

 

Do not use duration of fever to predict the likelihood of serious illness. However, children with a fever lasting 5 days or longer should be assessed for Kawasaki disease (see the recommendation on additional features of Kawasaki disease in the section on symptoms and signs of specific illnesses). 

 

Recognise that children with tachycardia are in at least an intermediate‑risk group for serious illness. Use the Advanced Paediatric Life Support criteria in table 1 to define tachycardia. 

 

Age

Heart rate (beats per minute)

Less than 12 months

More than 160

12 to 24 months

More than 150

2 to 5 years

More than 140

Look for a source of fever and check for the presence of symptoms and signs that are associated with specific diseases.

 

Summary table for symptoms and signs suggestive of specific diseases 

 

Meningococcal disease

Non-blanching rash, particularly with 1 or more of the following:

  • an ill-looking child

  • lesions larger than 2 mm in diameter (purpura)

  • capillary refill time of more than or equal to 3 seconds

  • neck stiffness

 

Bacterial meningitis
  • Neck stiffness
  • Bulging fontanelle
  • Decreased level of consciousness
  • Convulsive status epilepticus
  • Herpes simplex encephalitis
  • Focal neurological signs
  • Focal seizures
  • Decreased level of consciousness

 

Pneumonia
  • Tachypnoea (respiratory rate more than 60 breaths per minute, age 0 to 5 months; more than 50 breaths per minute, age 6 to 12 months; more than 40 breaths per minute, age more than 12 months)
  • Crackles in the chest
  • Nasal flaring
  • Chest indrawing
  • Cyanosis
  • Oxygen saturation less than or equal to 95%
Urinary tract infection (UTI)

These symptoms and signs increase the likelihood that a UTI is present and should be used to inform a decision about whether urine collection and testing is necessary. They are taken from the section on symptoms and signs in the NICE guideline on urinary tract infection in under 16s

 

  • Painful urination (dysuria)
  • More frequent urination
  • New bedwetting
  • Foul smelling (malodorous) urine
  • Darker urine
  • Cloudy urine
  • Frank haematuria (visible blood in urine)
  • Reduced fluid intake
  • Shivering
  • Abdominal pain
  • Loin tenderness or suprapubic tenderness
  • Capillary refill longer than 3 seconds
  • Previous history of confirmed urinary tract infection

 

Septic arthritis
  • Swelling of a limb or joint
  • Not using an extremity
  • Non-weight bearing

 

Kawasaki disease 

Fever for 5 days or longer and may have some of the following:

  • bilateral conjunctival injection without exudate

  • erythema and cracking of lips; strawberry tongue; or erythema of oral and pharyngeal mucosa

  • oedema and erythema in the hands and feet

  • polymorphous rash

  • cervical lymphadenopathy

Children with any ‘red’ features but who are not considered to have an immediately life-threatening illness should be referred urgently to the care of a paediatric specialist.

 

If any ‘amber’ features are present and no diagnosis has been reached, provide parents or carers with a ‘safety net’ or refer to specialist paediatric care for further assessment.

 

Children with ‘green’ features and none of the ‘amber’ or ‘red’ features can be cared for at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services

 

Children with symptoms and signs suggesting pneumonia who are not admitted to hospital should not routinely have a chest X-ray.

 

See the section on symptoms and signs in the NICE guideline on urinary tract infection in under 16s for when to test the urine of babies and children with fever for a UTI.

 

When a child has been given antipyretics, do not rely on a decrease or lack of decrease in temperature to differentiate between serious and non‑serious illness.

Do not prescribe oral antibiotics to children with fever without apparent source.

 

Give parenteral antibiotics to children with suspected meningococcal disease at the earliest opportunity (either benzylpenicillin or a third‑generation cephalosporin). See the NICE guideline on meningitis (bacterial) and meningococcal septicaemia in under 16s.

Management by the paediatric specialist should start with a clinical assessment as described in the section on clinical assessment of children with fever. 

Infants younger than 3 months with fever should be observed and have the following vital signs measured and recorded:

  • temperature

  • heart rate

  • respiratory rate.

Perform the following investigations in infants younger than 3 months with fever:

Perform lumbar puncture in the following children with fever (unless contraindicated):

  • infants younger than 1 month

  • all infants aged 1 to 3 months who appear unwell

  • infants aged 1 to 3 months with a white blood cell count (WBC) less than 5 times 109 per litre or greater than 15 times 109 per litre.

 

When indicated, perform a lumbar puncture without delay and, whenever possible, before the administration of antibiotics.

 

Give parenteral antibiotics to:

  • infants younger than 1 month with fever

  • all infants aged 1 to 3 months with fever who appear unwell

  • infants aged 1 to 3 months with WBC less than 5 times 109 per litre or greater than 15 times 109 per litre.

 

When parenteral antibiotics are indicated for infants younger than 3 months of age, a third-generation cephalosporin (for example cefotaxime or ceftriaxone) should be given plus an antibiotic active against listeria (for example, ampicillin or amoxicillin).

Perform the following investigations in children with fever without apparent source who present to paediatric specialists with 1 or more ‘red’ features:

 

The following investigations should also be considered in children with ‘red’ features, as guided by the clinical assessment:

  • lumbar puncture in children of all ages (if not contraindicated)

  • chest X-ray irrespective of body temperature and WBC

  • serum electrolytes and blood gas.

 

Children with fever without apparent source presenting to paediatric specialists who have 1 or more ‘amber’ features, should have the following investigations performed unless deemed unnecessary by an experienced paediatrician:

 

Children who have been referred to a paediatric specialist with fever without apparent source and who have no features of serious illness (that is, the ‘green’ group), should have urine tested for urinary tract infection and be assessed for symptoms and signs of pneumonia (see table 3 and the sections on urine collection, preservation and testing in the NICE guideline on urinary tract infection in under 16s).

 

Do not routinely perform blood tests and chest X-rays in children with fever who have no features of serious illness (that is, the ‘green’ group)

Febrile children with proven respiratory syncytial virus or influenza infection should be assessed for features of serious illness. Consideration should be given to urine testing for urinary tract infection (see the section on symptoms and signs in the NICE guideline on urinary tract infection in under 16s).

In children aged 3 months or older with fever without apparent source, a period of observation in hospital (with or without investigations) should be considered as part of the assessment to help differentiate non-serious from serious illness.

 

When a child has been given antipyretics, do not rely on a decrease or lack of decrease in temperature at 1 to 2 hours to differentiate between serious and non-serious illness. Nevertheless, in order to detect possible clinical deterioration, all children in hospital with ‘amber’ or ‘red’ features should still be reassessed after 1 to 2 hours.

Children with fever and shock presenting to specialist paediatric care or an emergency department should be:

  • given an immediate intravenous fluid bolus of 20 ml/kg; the initial fluid should normally be 0.9% sodium chloride

  • actively monitored and given further fluid boluses as necessary.

 

Give immediate parenteral antibiotics to children with fever presenting to specialist paediatric care or an emergency department if they are:

  • shocked

  • unrousable

  • showing signs of meningococcal disease.

 

Immediate parenteral antibiotics should be considered for children with fever and reduced levels of consciousness. In these cases symptoms and signs of meningitis and herpes simplex encephalitis should be sought.

 

When parenteral antibiotics are indicated, a third-generation cephalosporin (for example, cefotaxime or ceftriaxone) should be given, until culture results are available. For children younger than 3 months, an antibiotic active against listeria (for example, ampicillin or amoxicillin) should also be given.

 

Give intravenous aciclovir to children with fever and symptoms and signs suggestive of herpes simplex encephalitis.

 

Oxygen should be given to children with fever who have signs of shock or oxygen saturation (SpO2) of less than 92% when breathing air. Treatment with oxygen should also be considered for children with an SpO2 of greater than 92%, as clinically indicated.

In a child presenting to hospital with a fever and suspected serious bacterial infection, requiring immediate treatment, antibiotics should be directed against Neisseria meningitidis, Streptococcus pneumoniae, Escherichia coli, Staphylococcus aureus and Haemophilus influenzae type b. A third-generation cephalosporin (for example, cefotaxime or ceftriaxone) is appropriate, until culture results are available. For infants younger than 3 months, an antibiotic active against listeria (for example, ampicillin or amoxicillin) should be added.

 

Refer to local treatment guidelines when rates of bacterial antibiotic resistance are significant

In addition to the child’s clinical condition, consider the following factors when deciding whether to admit a child with fever to hospital:

  • social and family circumstances

  • other illnesses that affect the child or other family members

  • parental anxiety and instinct (based on their knowledge of their child)

  • contacts with other people who have serious infectious diseases

  • recent travel abroad to tropical or subtropical areas, or areas with a high risk of endemic infectious disease

  • when the parent or carer’s concern for their child’s current illness has caused them to seek healthcare advice repeatedly

  • where the family has experienced a previous serious illness or death due to feverish illness which has increased their anxiety levels

  • when a feverish illness has no obvious cause, but the child remains ill longer than expected for a self-limiting illness.

Children with fever who are shocked, unrousable or showing signs of meningococcal disease should be urgently reviewed by an experienced paediatrician and consideration given to referral to paediatric intensive care. 

 

Give parenteral antibiotics to children with suspected meningococcal disease at the earliest opportunity (either benzylpenicillin or a third‑generation cephalosporin). 

 

Children admitted to hospital with meningococcal disease should be under paediatric care, supervised by a consultant and have their need for inotropes assessed. 

Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose. 

Tepid sponging is not recommended for the treatment of fever.

 

Children with fever should not be underdressed or over-wrapped.

Consider using either paracetamol or ibuprofen in children with fever who appear distressed. 

 

Do not use antipyretic agents with the sole aim of reducing body temperature in children with fever. 

 

When using paracetamol or ibuprofen in children with fever:

  • continue only as long as the child appears distressed

  • consider changing to the other agent if the child’s distress is not alleviated

  • do not give both agents simultaneously

  • only consider alternating these agents if the distress persists or recurs before the next dose is due. 

When to seek further help

Following contact with a healthcare professional, parents and carers who are looking after their feverish child at home should seek further advice if:

  • the child has a fit

  • the child develops a non-blanching rash

  • the parent or carer feels that the child is less well than when they previously sought advice

  • the parent or carer is more worried than when they previously sought advice

  • the fever lasts 5 days or longer

  • the parent or carer is distressed, or concerned that they are unable to look after their child.

Overview | Fever in under 5s: assessment and initial management | Guidance | NICE