(1)
Royal Free NHS Foundation Trust, London, UK
Assessment of child with fever
Measurement of temperature:
Age <4 weeks: electronic thermometer in axilla
4 weeks to 5 years: electronic thermometer or chemical dot thermometer in axilla, or infrared tympanic thermometer
Life-threatening features
Compromise of airway, breathing or circulation
Decreased level of consciousness
Low risk for serious illness (nice guidelines)
Normal colour of skin, lips and tongue
Normal response to social cues
Content/smiles
Stays awake or awakens quickly
Strong normal cry or absence of crying
Moist mucous membranes
Signs of toxicity
A: reduced alertness, arousal or activity (no response to social cues)
B: breathing difficulties: tachypnoea, increased work of breathing
C: colour (pale, blue, ashen or mottled), circulation (cool peripheries), cry (weak, high pitched or continuous)
D: decreased fluid intake or decreased urine output (fewer than four nappies a day)
Other concerning features
Persistent fever despite anti-pyretic treatment
Fever more than 5 days
Presence of vomiting, including bile-stained vomit
Localising signs in sepsis
Respiratory: localized crepitations, signs of consolidation
Gastrointestinal: focal/ rebound tenderness and guarding
CNS: signs of meningeal irritation, encephalopathy
Bone and soft tissue: focal redness, tenderness and oedema
Head and neck: cervical lymphadenopathy, paranasal sinus tenderness, stridor, tonsillo-pharyngeal exudate
Skin: pustular lesions
Cardiovascular: changing murmurs
Causes of fever without focus
Viral infection
Urinary tract infection
Malaria
Connective tissue disease
Occult abscess
Occult bacteraemia
Drug fever
Diagnostic criteria for Kawasaki Disease
Fever of at least 38.5 degrees Centigrade, lasting at least 5 days and typically unresponsive to antipyretics and antibiotics
At least four out of the following five
Bilateral non-purulent conjunctivitis; primarily bulbar
Mucosal changes of the oropharynx: dry red lips with fissures, strawberry tongue, oropharyngeal erythema; no discrete oral lesions or exudates
Changes in extremities: oedema and/or erythema of the palms of the hands and the soles of the feet; desquamation, beginning peri-ungually around the nail bed
Rash: usually truncal, polymorphous, erythematous or maculo-papular; no petechial, vesicular or bullous lesions
Cervical lymphadenopathy, often unilateral and large (>1.5 cm in diameter)
Exclusion of other diagnoses, including measles, rubella, adenovirus infection, streptococcal scarlet fever, toxic shock syndrome, Stevens-Johnson syndrome, leptospirosis, parvovirus infection
Recognition of the sick child
Airway: partial obstruction (bubbly noises, snoring, stridor)
Breathing: apnoeic episodes, bradypnoea, tachypnoea, chest recession (supraclavicular, intercostal, subcostal or substernal), tracheal tug, use of accessory muscles of respiration, head bobbing (neck extension during inspiration and neck flexion during expiration) in infants, nasal flaring(exaggerated opening of nostrils during breathing), end-expiratory grunting, cyanosis, gasping, wheezing, silent chest
Circulation: tachycardia, pallor, reduced level of consciousness, confusion, agitation, reduced urine output, prolonged capillary refill time, mottled skin, cold extremities
Disability: reduced alertness, high pitched or other abnormal quality of cry, seizure, floppiness, posturing
Normal values for children
Blood pressure in mmHg
Age | Systolic | Diastolic | Mean |
|---|---|---|---|
Neonate (<1 kg) | 40–60 | 15–35 | 25–45 |
(3 kg) | 50–70 | 25–45 | 35–55 |
Infant (6 months) | 85–105 | 55–65 | 65–80 |
Child (2 years) | 95–105 | 55–65 | 65–80 |
(7 years) | 100–110 | 55–70 | 70–85 |
Adolescent | 110–130 | 65–80 | 80–95 |
Normal systolic blood pressure = 70 mmHg + age in years × 2
Normal diastolic blood pressure = 2/3rds systolic blood pressure
Age (years) | Respiratory rate | Heart rate | Blood volume (ml/kg) |
|---|---|---|---|
<1 | 30–40 | 110–160 | 85–90 |
1–2 | 23–35 | 100–150 | 80–85 |
2–5 | 25–30 | 95–140 | 75–80 |
5–12 | 20–25 | 80–120 | 65–70 |
>12 | 15–20 | 60–100 | 65–70 |
The key elements of initial assessment of a child
involve:
Appearance: The TICLS (“tickles”) mnemonic summarises the main components of assessment of the general appearance of a child:
Tone
Interactiveness
Consolability
Look/gaze
Speech/cry
Work of breathing: abnormal positioning; abnormal airway sounds; retractions; nasal flaring.
Circulation to skin: pallor; mottling; cyanosis.
Recognition of increased work of breathing in children
Abnormal airway sounds: altered voice; wheeze; stridor; grunting
Abnormal positioning: head bobbing; tripoding
Chest wall retractions: supraclavicular, intercostal, subcostal and sternal
Nasal flaring
Causes of reduced level of consciousness in childhood
Shock (hypovolaemic, distributive, cardiogenic)
Sepsis
Metabolic diseases
Intracranial infections
Raised intracranial pressure
Convulsions; post-ictal state
Intoxication/poisoning
Trauma
Hypertension
Stroke
Acute hydrocephalus
Causes of incessant crying in infants and young children
Infantile colic: characterized by paroxysmal episodes of incessant crying (usually daily), high-pitched cry, generalized hypertonicity and inconsolability. The onset is at 1–4 weeks of age, and there is spontaneous improvement by the age of 3–4 months
Infections: otitis media; meningitis; encephalitis; systemic sepsis; urinary tract infection, osteomyelitis, septic arthritis, pneumonia, gastroenteritis
Trauma: limb fracture; shaken baby
Gastrointestinal: intusussuception; gastro-oesophageal reflux; constipation; anal fissure; incarcerated inguinal hernia; testicular torsion; appendicitis
Metabolic: hyponatraemia; hypernatraemia; hypoglycaemia; hyperglycaemia
Skin: nappy rash; atopic eczema
Red flags with incessant crying
Fever: temperature greater than 38 degrees Centigrade in infant less than 12 weeks’ age
Paradoxical irritability: unwillingness to be held
Poor feeding
Cyanotic or apneic spells
Bilious or projectile vomitingRelated posts:
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