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SA: Hello, and welcome to Master the MRCPCH. In this series, we tap into the expertise here at Great Ormond Street Hospital to give you an overview of a topic on the RCPCH exam curriculum. So whether you're revising for an exam or just brushing up on a need to know topic, hopefully this podcast can give you the information that you need.
I'm Dr. Sarah Ahmed, a paediatric registrar and the current digital learning education fellow here at GOSH.
In today's episode, we're going to be talking with Dr. Alexis Bouvier, a consultant in general paediatrics at Great Ormond Street Hospital. We're going to be talking about managing the child who presents with fever.
Alexis, thank you very much for coming back and talking to us.
AB: Pleasure as always.
SA: So we're going to talk about approaches to fever. So what would you like people to get out of listening to this podcast?
AB: Exactly that, an approach to fever. It's so common that it's important to tackle it the same way every time, to ensure that we pick up the ones that we should be worried about and are able to not excessively worry or excessively manage the ones that we don't.
Before I forget and get too far down into the podcast, I think it's important to remind the listeners that we're doing an approach to fever podcast. Although we may mention some specific situations or patient cohorts, this isn't a podcast about septic shock, Kawasaki's disease – I did that one in 22 – febrile neutropenia, pyrexia of unknown origin, fever in the under three months old cohort, meningitis, encephalitis, meningococcal sepsis, any of those. Those either have had or may in future have their own podcasts, will probably have their own guidelines either on NICE or locally. But really at this call, this podcast is about the approach to a child presenting in front of you on the ward, in A&E with a fever.
SA: Yes. Thank you for clarifying that Alexis.
So I want to start really basic with what is going to seem like a silly question, but I think it's important to go over. What is fever?
AB: That is neither a silly nor a stupid question because different people will potentially tell you different things. Parents would often cal in saying my child's had a fever, but actually they never checked for temperature, it was just feeling hot. So to them, that's a fever. But to us, I would generally say that although the normal range is 36.5 to 37. 5, from a practical perspective 38 degrees is the threshold we would use in paediatrics for it being a fever. And then as to what a fever is in of itself, it's essentially an immune response or an inflammatory response to something going on. And in children, that's generally an infection, but it could be a rheumatological problem, a non-infectious inflammatory problem, for example. But it's a, it's a response to something happening. The fever itself is not the problem.
SA: Yes. And I think that's really important to differentiate. Which leads me onto my next question, is a fever normal?
AB: A fever can definitely be normal if it's the body responding to an infection. It's part of the body's immune response. It's an associated sign of inflammation. You would expect to see that – for example it’s not uncommon to see a one-off fever after surgery due to expected inflammation. Similarly, some of the drugs that we might give might cause inflammatory reactions, some of the autoimmune disorders that children have might have fevers. So whilst it's not good to have a fever per se, the fact that your child has a cold or your child has a cough and they have a fever is almost expected and therefore is not worrying in and of itself.
SA: Yeah, and a really important thing to try and explain to parents as well, because it can be very worrying seeing your child have a fever and it can seem abnormal, but it is often important to explain that it is your body's response to, to fighting an infection.
AB: And that is a good point because parents are going to be worried. Children who have fevers become what I call hot and bothered. They don't look as happy. They don't want to do anything. They don't want to eat and drink as much. They're clingy and their heart rates go up and their respiratory rates go up and therefore their orbs spike and everybody worries about them. A lot of that is just due to the fever. It is a normal associated response for the heart rate to get tachycardic and for respiratory rates and often the work of breathing to go up. However, then when the temperature comes down, either just with time or with some magic medicine, which we'll get to later, often you see a much happier, much more settled looking child and some much more reassuring numbers. But at the time of a proper fever, it's understandable that parents and sometimes staff can be worried, even if with hindsight there wasn't actually that much else going on underneath it.
SA: Yeah, very, very understandable why people react the way they do when you see a child who is hot and bothered with a fever. So you mentioned that it's common and it does sometimes feel like every patient that you see in A&E has got a fever and that's the reason that they came in. Do we have a sense of how common it actually is?
AB: It does mean that we'll always have a job. It's probably about 30 percent of paeds A&E attendances are related to a fever. And that's discounting how many go to GP and are appropriately managed or how many are just managed at home. Children get infections all the time, and that can still be within normal and a lot of the infections that children get being viral will have fevers. So it's a very common thing to see.
SA: Very common, although 30 percent is much lower than, a much lower number than I thought you were going to say.
So what is your approach to managing that child that presents with a fever?
AB: So, as with anything, it's about the assessment, first and foremost and probably, whereas I would start with history, generally speaking, in a fever child, have a look at them, do they look well or unwell, is the big bit to start off with cause generally speaking that will be able to guide you as to how worried you need to be, how likely it is that something else is going on, and how much escalation you need to do. And that's something that you'll get from experience. If you're a junior junior doctor, seeing them with your seniors and getting their perspective on it as well, and their explanations of why they're worried and why they're not. But either way, just practice. Everybody eventually gets to the point of being able to tell you look unwell versus actually you look okay.
Another one is how the child responds to you and responds to parents. Are they miserable and clingy, but allow you to examine them? Are they crying and unhappy, but are consolable or distractible in the older child? Or are they full blown irritable? Just touching them sets them off. Parents can't settle them. Anything you do, just noises, anything really sets them off as being irritable. And that's a important distinction that I always try and make or recommend because we use irritable probably too much. We've all learned it initially in sort of meningism and meningitis, and I try and keep it for those really, really will be set off by anything children and really, really will not settle down children. Most children, even with a fever will settle with parents. Will settle with time and in the older group, we'll be able to be distracted with the help of parents and some magic medicines and stuff. And nowadays YouTube.
So then into examination since we're on that, what did they present with? They usually have an associated symptom. So is it a cough, cold, runny nose? Is it some ear pain, some ear discharge? Is it some vomiting and diarrhoea? Is it a rash? Is it in an older child, perhaps some smelly urine, some stinging or, something like that? Look at that one first and foremost. That's probably the reason why you've got a fever. Then look at the other ones. So if they came with a cough look at the rest of it and think about it anyway. And then move into the history just take a history. So when did the fever start? Is it every day? How high is it? So more for us to determine whether we consider it a fever compared to parents saying, Oh, they felt really hot, but it was 37.4. How long has it been going on for? Is anybody else at home been unwell? Have they had any recent travel? So there you're thinking about things like some of the nastier travel ones like TB, or just depending on where you've gone, malaria, typhoid, those kind of things, especially if you haven't been adequately protected from other vaccinations or, or regular medicines whilst you’re doing it.
And then with all of that, once you've taken your history and you've taken your examination, I'd be looking to do something like a risk stratification, including with your observations. And for that, the NICE guidelines have a really good traffic light system which is essentially borrowed from the sepsis
picture, but can be used just as well and there will be different criteria and ranges for age, both in terms of their activity, the ranges for their obs, for example, with their circulation and their breathing, but the important distinctions around age often relate to how high the fevers have to be to be of concern or what they're doing or not doing. And that can give you low risk green, amber intermediate risk or red high risk.
SA: So you mentioned observations, and recording a fever, and we talked a little bit about parents coming in and saying that the children felt hot. I want to talk about the best way to go about measuring a temperature.
AB: Yeah, so that's key. It's different for different age groups. Your safe go to across age groups is your electronic auxiliary armpit thermometer. That works basically for everyone. Um, and that's the only one that you should be using for your neonates under four weeks old. So if parents are trying to do ears or foreheads or forehead guns or forehead strips or kind of stuff like that, we don't really take that. We would do our own one. Between one month to five years, then you can start using some of the auxiliary temper dot, sort of the the skin contacts sticks essentially or the infrared tympanic eardrum ones. And then once you're five years old, you can add the electronic oral ones. We wouldn't recommend, and in fact, we would recommend to avoid using rectal thermometers. I think you're far more likely to cause discomfort, plus or minus accidental injury, and fear of assessment in children from using that than you are from doing a, from holding them still for an auxiliary one or even a quick tympanic one.
SA: I'm really glad that we went over that because it is one of those things that you're not necessarily taught, but it's important to know where the fever came from when the parents present and how they recorded that fever to see if it is quote unquote a genuine fever or not.
AB: But having said that, if the parents feel that their child felt hot, believe that.
SA: Yes.
AB: Your job is then to determine how hot they are now, because you can't tell how hot they were then if they, if parents didn't measure it, how hot they are now and what else is going on and therefore how worried or not worried you're going to be about it. The parents’ recollection of felt hot is your starting point. That's essentially their presenting complaint.
SA: Yeah. Parental intuition is so important and I think something that we forget and reassuring parents and even doing things to reassure parents is an important part of practicing good paediatrics.
AB: Yeah. Your full MOT works really well to help parents see and believe that you have understood their concern, that you have acted on that concern and that therefore if you're going to do nothing, which is a lot of what we do in paediatrics actually is reassurance and trying not to do tests or, or medications, because most children have viruses and will get better. Um if you're going to not do anything, having done a proper thorough assessment gives you that weight for them to believe that you know what you're doing.
SA: So say you have a child, they have a temperature that's over 38, that's been recorded appropriately, but you just can't find a source, which happens to all of us. What do you do in that situation?
AB: So once you've done your proper assessment, you risk stratify them. Because not having a source isn't in of itself a bad thing, nor an automatic predictor that something will turn out worse, or that you need to escalate and do bloods and antibiotics to be on the safe side or anything like that. Most fevers are viruses. And I apologize if I've said that before, and I probably will say it again. Most fevers are viruses. They will generally get better by themselves with supportive management. Don't need blood tests, don't need antibiotics, etc. So use the traffic lights. If necessary, show those to parents for why you're reassuring them. Your child, yes, has a fever, but their breathing is normal. Their heart rate is normal. Their hydration is good. They're not showing this, this, this sign, for example, and that's why I don't think we need to do anything at the moment. And then build on that towards safety netting and red flags. And often your A& Es, if that's where you're working, or your wards will have information leaflets. If they don't, it's a very nice and quick and easy QI, by the way for anybody listening to say, this is some information about fevers about viruses for example, this is the kind of stuff we can expect to see – not as happy, breathing fast, et cetera, et cetera. And this is what you should look out for and when to come back either via GP or via A&E or to call 1 1 1 again. So things like proper lethargy, listless, floppy, ragdolly kind of thing, as opposed to they're happy watching TV, but don't want to do anything else. Is it that they're working really hard, chugging away like they're running the marathon and looking like they're getting tired? Is it that they've not even had two wet nappies in a 24-hour period, for example, despite little and often fluids? Those kind of things. Try to be specific. Information leaflets are really good because parents will nod and say yes a lot in A&E and then will forget half of it once they've walked out of A&E, which is not their fault, which is normal. And if you give them the information leaflet, they can review that at home and also for next time. Because next time their child has a fever, which will happen because they will get another virus or another infection of some description, they may not need to come to A&E because they can see these are the normal things we can keep an eye on at home and how to manage the basics. And we will not go to A&E until or unless this happens. So it's useful both for this acute instance and the future ones. And that can include stuff like advice around hydration, little and often, addition of dioralyte, difflam, topical back of throat spray to help food and liquids go down, antipyretics, which we'll get to, and the ability to discuss with 111 or, or GPs.
One big thing I tend to advise about in safety netting is that, although most things are viruses, if a fever lasts for more than five days consecutively, I would suggest that a child get reviewed in person by somebody, whether that be a GP or A&E doctor. And that's because five days is the point at which I would look for and think about some less common causes or more easily missed sources of fever. These could include Kawasaki's disease, which I think we covered actually in my first podcast, what feels like ages ago. But it could be that a simple ear infection has now turned into mastoiditis, an upper respiratory tract infection into sinusitis, or a perhaps fever without source may have now declared itself as a septic arthritis. So even though most fevers of five days are not Kawasaki's or anything serious – they’re still probably viral and likely self-limiting – five days would be a specific cutoff that I would advise parents to take their children to get them reviewed just to make sure. And that's because also I'm seeing them at this point in time, tomorrow, somebody seeing them might see, oh, their tonsils now look obviously gunky, or now they've got obvious signs of this particular viral skin rash or this particular bacterial problem that they didn't have at the point that you or I have seen them. So all we can do is go by what we've got our assessment now, what we think might happen and safety net them appropriately.
SA: And document that you've safety netted as well. I think it's really important.
AB: Absolutely.
SA: I will link down below the episode that you did for us on Kawasaki's. If anyone wants to go there to find out a little bit more information about that.
AB: A vintage one from the archives.
SA: Um, so you've taken history, you've examined the baby, child, you plus or minus have found a source and you've risk stratified. How do you manage the fever? Should you be giving antibiotics is my slightly facetious question?
AB: That was an easy toss volleyball wise. The answer is probably not. Most are viruses. If I, if one of my juniors came and suggested giving antibiotics, I would want to know why they were doing that. Is it because there is enough evidence of an obvious bacterial infection. So their tongue and skin and history are very strongly suggestive of something like scarlet fever, for example. Is their urine dip very strongly suggestive of a UTI? Have they recently had a swab or been known to be colonized by something and they've now got a cough, which could very well be related to that. I would want some evidence to give antibiotics rather than the other way around. Most things are viruses. Most things will get better with time, support, rest, hydration, et cetera.
Now how to manage the fever in and of itself. Unfortunately, I can't predict how long the fever will go on for or how unhappy the kid will be. And actually the height of fever and or whether it responds or not to antipyretics is not automatically linked or proportional to the severity of the illness or the likelihood that it will be or become a severe, for example, bacterial septic infection, especially once you've gone out of that first six-month age range. But generally I would be recommending them to give hydration, to give rest, to focus on fluids rather than food, and to give antipyretics more for distress and discomfort rather than to bring the numbers down. Often through no fault of their own and through understandable parental anxiety, they want to see normal numbers, thinking that that will prevent things. And parents are sometimes concerned about the potential things like febrile convulsions, where you get very hot, often very quickly, and you have a seizure as a result. That in and of itself is not automatically going to cause sepsis or automatically going to cause brain damage, unless you're into the hyperpyrexias of sort of 42 degrees, which we very rarely see. And even regular paracetamol and ibuprofen isn't automatically going to prevent you from, from having a febrile convulsion, for example. So I would be suggesting, personally, ibuprofen over paracetamol. And I think there's some evidence out there that children react slightly better to ibuprofen than to paracetamol. And generally I recommend to alternate them if they want to be giving regular stuff rather than giving together, especially because generally it's paracetamol four times a day, ibuprofen three times a day to alternate them. So give one and then a few hours later, give another and a few hours later, give the first one. And that way across the course of a day, they've usually got something available to them if necessary.
Lastly we now advise against stripping down or sponging down febrile children – rather we’d recommend still dressing them reasonably, so a babygro, t-shirts and shorts or skirt, light dress etc).
SA: Yeah, that idea of alternating antipyretics is a great trick and can make such a difference as well. Just making sure kids are covered over the day.
I think it can be quite hard for parents for you to turn around as a doctor and say, I'm not going to give antibiotics and you don't need to chase the fever because it's hard seeing your child like that. But this is the time for you to really sit down and explore their concerns and to try and alleviate some of it with good reassurance and good paediatric communication care.
AB: Absolutely. You hit the nail on the head there. This is one of those communication stations that skipping ahead could come up in an exam, but even if not, this is some of the bread and butter. Paediatrics is so much about reassurance and telling parents why we're not going to do stuff. More so than adults, where actually you do stuff most of the time. Also is my experience from what I recall.
And the last bit I would say about antipyretics and a little bit of a little helpful advice nugget you can give to parents is don't bother buying Calpol and Nurofen. Just go to Sainsbury's. Other shops are available, Boots, Asda, wherever, and buy own brand stuff. Legally, it has to be the same and it does the same stuff and it's so much cheaper.
SA: It's the same thing in every bottle.
You've led us really nicely onto the part where we wrap up a little bit. So exam questions, you've already mentioned one of them, but are there any other exam questions that could pop up about fevers?
AB: So I mentioned Kawasaki's. So your sort of fever over five days and so it, being able to know the criteria that might come up in a in either communication or probably a written question. Another one again, probably a written question, would be a fever in an under three month old and how you manage that potentially slightly differently. This is an approach to fever podcast rather than the specifics. But for example, a three month, an under three month old would generally have antibiotics and a full septic screen, but they've just had their routine immunizations today and have therefore spiked a fever. Or we know their mum or dad has got COVID and they're a little bit coryzal. So being able to rationalize how you'd still assess them but why you might hold off the immediate full septic screen, including lumbar puncture, why you might perhaps admit them for observation and, and hold off, for example, as opposed to just jumping straight to this baby's six weeks old, they've got a fever, they get everything. And it's that, it's that nuance that would probably be something coming out in a question like that.
SA: Yeah. That nuance is really important.
So are there any resources that you would recommend?
AB: Absolutely. As with most of my podcasts, I go back to the NICE guidelines. The fever under five years old one, the suspected sepsis one, which covers children, the UTIs under 16, which is a really useful one because we do too many urine dips as a whole. It's often one of those that gets done as a screen, but actually, unless you think it's a UTI or you have no idea what the source is, you shouldn't be doing it. And neonatal infection. There's probably before big, NICE ones. And then locally, your trust will have febrile neutropenia guidelines, sepsis guidelines. It will have fever in the under three month old guidelines. It will probably have a Kawasaki's guideline. It will probably have a pyrexia of unknown origin, et cetera, et cetera, et cetera, guidelines. So for those specific conditions or specific patient groups, look for your local guidelines.
SA: Guidelines are actually a really good way of revising as well. So if you want to go find out more about fever under three months, then go and find a nice guideline about it. It's a very good launch point.
And so finally, what are your takeaway learning points?
AB: You'll be happy I've actually kept these down to three for once. So fevers are common and mostly viral. They do not need antibiotics for the vast majority. They do not need investigations for the vast majority. The key is a thorough assessment and MOT, history and examination, more so than investigations.
Use risk stratification to determine how worried you should be and why, and therefore what you're going to do about it, or more likely what you're not going to do about it, and be able to then reassure parents, which is so key.
And using safety net and red flag advice ideally through an information leaflet that parents can take home and review when they're in a more calm state of mind so that they know how to manage and when to worry about it in this episode, but possibly more importantly for you in the future episodes, because not all fevers need to be going to the GP or to A&E. And if we can help parents safely and appropriately, self-assess and self-manage at home, then we've done them a really good service that day.
SA: Yes, I absolutely agree. Alexis, thank you so much for talking to us about an approach to fever today.
AB: Always a pleasure.
SA: Thank you for listening to this episode of Master the MRCPCH. We would love to get your feedback on the podcast and any ideas you may have for future episodes. You can find link to the feedback page in the episode description, or email us at
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