Fever in Children: History Taking and Differential Diagnoses

Fever in Under 5s

Fever is common in babies and young children. In some cases, it can be hard to elicit the cause of a fever and it may be an initial sign of a serious illness such as pneumonia, sepsis, or meningitis.

NICE has created guidelines that use a ‘traffic light system’ for risk stratification in children <5 years old with fever.

History Taking

Overview

With each symptom, always (if relevant) ask about:

• When did it start?
• Did it come on suddenly or gradually?
• Is it continuous or intermittent?
• Has this ever happened before?

Fever

• Onset and duration:
  • When did the fever start?
  • How long has the fever been ongoing?
• Characteristics:
  • Do they have any temperature measurements?
  • How hot does the child feel?
• Associated symptoms – see systems review below
• Timeline:
  • Is the fever present at all times or intermittent?
• Exacerbating/alleviating factors:
  • Does taking antipyretics help with fever?
    • Whether they reduce fever or not does not differentiate between serious and non-serious causes

In general, acute and high fevers suggest acute infection and low-grade, prolonged fevers may suggest chronic infection, inflammatory disorders, and malignancy.

Paediatric systems review

Briefly screen for the following, and adjust where appropriate:

• Screen for general features:
  • Fever, chills, rigours, sweating
  • Crying – is it consolable or inconsolable?
  • Growth, weight loss 
  • Behaviour, appetite, alertness, activity, sleeping
• Screen for skin rashes:
  • Viral infections can have non-specific maculopapular rashes
  • Is the rash non-blanching? – a red flag for sepsis, vasculitis, and malignancy
  • Purpura and petechiae can suggest sepsis (including meningococcal septicaemia), malignancy, and vasculitis
• Screen for cardiorespiratory features:
  • Cough, shortness of breath
  • Noisy breathing (stridor, wheezing), rapid breathing
  • Cyanosis
• Screen for gastrointestinal features:
  • Vomiting, diarrhoea, constipation, stool character (e.g. mucus, blood, melaena etc.)
  • Abdominal pain, abdominal distension
• Screen for genitourinary features:
  • Urine output and hydration – number of wet nappies, number of times using the toilet
  • Dysuria, frequency, urgency, enuresis, loin pain
  • Haematuria
  • Scrotal swelling
• Screen for neurological features:
  • Headaches, neck stiffness, photophobia
  • Level of consciousness
  • Seizures, fits, falls, or ‘funny turns’
  • Changes in gait, abnormal movements
  • Vision changes, hearing changes
  • Hypotonia (floppiness), hypertonia (stiffness, spasticity)
• Screen for ear, nose, and throat features:
  • Ear: pain, discharge, hearing changes
  • Nose: epistaxis, discharge, congestion
  • Throat, mouth, and neck: sore throat, neck swelling, limited neck movement, mouth ulcers
• Screen for haematological features:
  • Bleeding, bruising, gum bleeding, fatigue, pallor 
• Screen for musculoskeletal features:
  • Limp, limitation in movement
  • Joint pain, joint swelling, joint stiffness

Birth

• How was the pregnancy?
  • Any abnormal scan results or extra scans? Why?
  • Any problems? – including maternal illness, diabetes, alcohol, drinking, drug use
• What happened during birth?
  • Number of weeks gestation?
  • Weight at birth?
  • Birth location? – such as in hospital, at home?
  • Mode of delivery? – vaginal delivery, caesarean section?
  • Any complications to both the mother or child during or after birth?
  • Did they need to stay in hospital for longer/was there any admission to neonatal intensive care?

Feeding and toileting

• Ask about diet and appetite:
  • What is their diet and appetite usually like and what is it like now?
  • Breastfed or formula milk?
  • When and how did weaning start?
• Ask about toileting:
  • Are they toilet trained?
  • How often do they go to the toilet/how many wet nappies?

Growth

• How is their weight?
  • Are they gaining weight, staying the same, or struggling to gain weight?
  • Do they have their personal child health record (PCHR, the ‘red book’)
• Have they started puberty?
  • Usually 8-13 for girls, 9-14 for boys 

Development

• Is the child meeting developmental milestones?
• Are there any concerns with development?
• How is school/nursery progress and attendance?
• Perform a developmental assessment if necessary

Immunisations

• Are they up to date with their immunisations?

General past medical history

• Do they have any other medical conditions?
• Have they ever had any previous surgery?
• Do they take any regular medications?
• Do they take any over-the-counter medications, herbal remedies, or supplements?

Family History

• Is there any family history of anything similar?
• In some autosomal recessive inherited diseases, consanguinity may be possible, ask about this sensitively if necessary

Allergy History

• Are they allergic to anything?
  • What happens during the allergic reaction?

Social History

• Ask about their home situation:
  • Who’s at home?
    • Ask about parents/carers, siblings, and other people at home
  • What support does the child and parent/carer have?
  • What is their housing situation? – e.g. cramped housing
  • What are the parent’s occupations?
  • How is the parents’/carers’ mental health?
• Ask about the child’s activities including school and nursery:
  • Does the child go to school/nursery?
  • Has the child had to stay home from school/nursery?
• Ask about smoking, drinking, and illicit drug use sensitively:
  • Does anyone smoke inside or outside of the house?
  • Does anyone drink alcohol inside the house?
    • If relevant, does the young person drink alcohol?
  • Does anyone at home use illicit drugs?
    • If relevant, does the young person use illicit drugs?
• Ask questions regarding safeguarding:
  • Are they known to social services?
  • Are there any safeguarding concerns?
  • You may need to separately ask the child about safeguarding concerns including:
    • Are they at risk of harm?
    • Are they being made to do things they don’t want to do?
• Ask about possible infectious contacts:
  • Is anyone else at home ill?
  • Has anyone in school/nursery been ill?
  • Has there been any recent foreign travel?

Assessment and Referral

Overview

The following should be recorded and assessed in all children with fever:

• Temperature:
  • If <4 weeks old – use electronic thermometer in the axilla
  • If 4 weeks – 5 years old – use electronic thermometer in the axilla, chemical dot thermometer in the axilla, or an infrared tympanic thermometer
• Heart rate
• Respiratory rate
• Capillary refill time
• Signs of dehydration, which may include:
  • Prolonged capillary refill time, abnormal skin turgor, abnormal breathing, weak pulse, cool extremities
• Signs of specific illnesses, discussed below

Risk Stratification

Overview

The traffic light system for risk stratification is as follows:

Management

Overview

Management of fever is guided by risk as mentioned above. In general:

• Green features only present:
  • Manage child at home with advice for parents/carers and advice on when to seek further help such as if:
    • The child has a seizure
    • The child develops a non-blanching rash
    • The parent/carer feels the child is less well than when they last sought advice
    • The parent/carer is worried
    • The fever lasts ≥5 days
    • The parent/carer is distressed or concerned that they cannot look after their child
• Any amber features are present, but no red:
  • Safety-net parents with details on when to seek further help (e.g. specific signs and symptoms) or refer to urgent paediatric care
    • Safety-netting may include written information on when to seek further help, how further care can be accessed, a follow-up appointment etc.
• If any red features are present, immediately admit the child to hospital for assessment by a paediatric specialist

Other points include:

• If there is no obvious source of infection, test urine for an infection
• Oral antibiotics should not be given in children with fever without an identifiable source
• If pneumonia is suspected but the child does not need a referral to hospital, a chest x-ray does not need to be routinely performed
• If a child has been given antipyretics and their temperature decreases or there is no longer a fever, this does not rule out serious illnesses

Management in secondary care

After referring to secondary care using the traffic light system, paediatric specialists examine the child, arrange tests, and initiate treatment.

Signs of Specific Illnesses

Meningococcal septicaemia

Consider meningococcal septicaemia if any of the following are present alongside fever:

• Ill-looking child
• Lesions ≥2 mm in diameter (purpura)
• Capillary refill time ≥3
• Neck stiffness

Bacterial meningitis

Consider bacterial meningitis if any of the following are present alongside fever:

• Neck stiffness
• Bulging fontanelle
• Decreased consciousness
• Status epilepticus
• Classic features (e.g. neck stiffness, bulging fontanelle, and high-pitched cry) are often absent in infants with bacterial meningitis

Herpes simplex encephalitis

Consider herpes simplex encephalitis if any of the following are present alongside fever:

• Focal neurological signs
• Focal seizures
• Decreased consciousness

Pneumonia

Consider pneumonia if any of the following are present alongside fever:

• Tachypnoea:
  • 0-5 months: >60 /min
  • 6-12 months: >50 /min
  • >12 months: >40 /min
• Chest crackles
• Nasal flaring
• Chest indrawing
• Cyanosis
• Oxygen saturations <95% or less when breathing in air
  • Be aware that pulse oximeters can overestimate oxygen saturation in people with darker skin

Urinary tract infection (UTI)

Consider UTI in any child <5 years old with fever.

Septic arthritis or osteomyelitis

Consider septic arthritis or osteomyelitis if any of the following are present alongside fever:

• Limb or joint swelling
• Not using an extremity
• Non-weight bearing

Kawasaki disease

Consider Kawasaki disease if any of the following are present alongside fever:

• A fever that has lasted ≥5 days
• Bilateral conjunctival injection without exudate
• Erythema and crackling of the lips, strawberry tongue, or erythema of the oral and pharyngeal mucosa
• Erythema and oedema of the hands and feet
• Polymorphous rash
• Cervical lymphadenopathy

These features may have been resolved by the time of assessment. Ask parents about the presence of these features since the fever started. Children <1 year old may have fewer features of Kawasaki disease but are at higher risk of coronary artery problems than older children.