Assessing a Febrile Child: From the Common Cold to Meningitis

The differentials for a feverish child are extremely broad and can be anything from a common cold to more sinister causes, such as sepsis. This article aims to provide clinical students with an overview of how to approach history taking and examination in a febrile child.

When a child presents with a fever, alongside a comprehensive history, this must be accompanied by an appropriate and thorough examination to help establish the source of the fever.

Establish the child's age

• There should be a low threshold for admission to hospital for children aged under 3 months with a fever of >38 degrees Celsius. This is due to the high risk of serious illness in this group.
• Children aged 3-6 months with a fever of >39 degrees Celsius are known to be at intermediate risk of serious illness.
• The National Institute for Health and Care Excellence provide a clear traffic light system based on history and examination findings to help identify the risk of serious illness in children aged under 5 (1).

What do you need to know about the fever?

• How high?
• How long?
• Does it respond to calpol/ neurofen?
• When was the last dose of medication?
• Any associated febrile convulsions?

The next step is to explore the main presenting compliant/s. Then systematically work your way through other key systems. Included below is a head-to-toe review. Depending on the presenting complaint, you can tailor the depth of the system review that is required.

Common areas to enquire about:

Ears and Nose

• Pain in the ear or behind the ear
• Discharge (explore this further if present)
• Tugging on ears (depending on the age, children may not be able to tell you about pain, but tugging on ears is often associated with ear infections)
• Hearing difficulties
• Rhinorrhoea (runny nose)
• Clear fluid discharging from the nose or ears (this could indicate a CSF leak and a sinister cause of illness).

 Eyes

• Pain in and around the eyes
• Redness
• Swelling in and around the eyes (consider orbital cellulitis)
• Discharge
• Visual changes

Throat

• Is the child complaining of a sore throat?
• Is there any pus seen on the tonsils?
• Any difficulty swallowing or drooling? (Consider a peritonsillar abscess)
• Is the child able to eat and drink?

Respiratory & Cardiovascular System

• Any cough/ sputum production?
• Shortness of breath?
• Noises when breathing e.g. stridor/ wheeze/ grunting?
• Obvious breathing difficulties, e.g. intercostal recession?
• Cyanosis (blue fingers, blue lips and tongue)?
• Chest pain?

Gastrointestinal System

• Nausea?
• Vomiting?
• Diarrhoea?
• Abdominal pain? Where possible, elicit the site, onset, character, radiation, alleviating/ exacerbating factors, timing and severity.
• Bowel habits and any blood in the stool?

Genitourinary System

• Increased frequency of urination?
• Malodorous urine?
• Blood in the urine?
• Discomfort on passing urine?

Neurological System

• Headache?
• Drowsiness?
• Seizures?
• Limb weakness?
• Neck stiffness?
• Photophobia?
• Nausea and vomiting?
• Rashes (If present, ask about blanching, e.g. does the rash disappear with the pressure of a glass tumbler, versus a non-blanching rash, which does not disappear when pressed with a glass tumbler and could be a sign of sinister disease such as meningitis).

Musculoskeletal System

• Joint pain?
• Joint swelling?
• Reduced mobility/ unable to bear weight?

General areas to enquire about regardless of the presenting complaint:

• Eating and Drinking
• Passing urine to assess for dehydration/ number of wet nappies over 24 hours for babies and young children
• Bowel habits/number of dirty nappies over 24 hours in babies and young children
• Rashes
• Skin colour, e.g. pallor
• Change in activity level, e.g. not wanting to play.
• Change in conscious level, e.g. sleeping more than usual or very drowsy.
• Lethargy
• Irritability/ inconsolable crying
• Floppy limbs
• Recent injuries?
• Explore the parental ideas, concerns and expectations.

Take a General Paediatric History

Antenatal History

• Complications during pregnancy?

Birth History

• Type of birth
• Gestation
• Complications with birth e.g emergency Caesarian section/ assisted delivery
• Post-birth complication, e.g. Neonatal intensive care unit (NICU) admission?

Past Medical History and Drug History

• Any known medical conditions?
• Any previous hospital admissions?
• Drug History
• Allergies

Vaccination Status

• Is the child up to date with the vaccine schedule?
• When was the last vaccine given? (children may develop a fever after receiving vaccines, so it is important to ask this).

Growth and Development

• Discuss health visitor checks
• Any concerns about height or weight?
• Review the red book
• Review developmental milestones: social, sensory and motor functions

Feeding and Weaning

Depending on the age of the child, enquire about the following:

• Breast or bottle-fed
• Current diet, e.g. puree, solids
• Food intolerances/ allergies

Family History

• Are there any known medical conditions that run in the family?

Social History

• Who do they live with?
• Main care giver/s?
• Attend school or nursery?
• Any siblings?
• Recent exposure to unwell contacts?
• Any smoking, alcohol intake or recreational drug use in the household?
• Has the child ever been known to social services?
• Any relevant travel history?

Examination

The examinations undertaken should be guided by the history. If the child appears acutely unwell from the outset of the consultation, a focused history and examination is required.

• Take a set of observations and compare this to the age-appropriate normal ranges for children.
• Examine the key system/s that you have established as the likely source of the fever. Continue assessing additional systems if no clear cause of the fever has been identified.
• In young babies, assess the fontanelle for bulging or dehydration.
• In addition, even if unrelated to the key presenting complaint, review the cardiovascular, respiratory and gastrointestinal systems. systems for completeness.
• Also, check for any rashes.

Management

• Create an appropriate management plan based on the differentials or diagnosis that has been made.
• Explain the plan to the parent/guardian and child (if appropriate).
• Ensure the plan includes safety netting advice.
• Clearly document your history and examination. This should always include any pertinent negative findings, e.g. no rashes, if this was not present. Remember to clearly document the plan and any advice that has been given.

References

1. National Institute for Health and Care Excellence (2021) Fever in under 5s: assessment and initial management, NG143, https://www.nice.org.uk/guidance/ng143 (accessed 22 November 2023).

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