This is a UKMLA-centred history guide about fever in children.
Introduction
Fever is one of the most common presenting complaints in children. The causes range from benign and common to rare and life changing.
Fever is defined as a temperature of 38 degrees centigrade and above. In infants aged up to 4 weeks you should measure temperature with an axilla thermometer. In infants aged 4 weeks to 5 years use either an axilla measurement or a tympanic thermometer. Parental perception of a high temperature (measured or not) should be taken seriously.
Presenting Complaint
Fever
Duration – you should suspect Kawasaki disease in any child with a fever lasting 5 days or more.
Height of temperatures – Can help risk assess in infants < 3 months and 3 – 6 months (see traffic light system below)
Timing – intermittent fevers may be suggestive of diseases such as malaria or TB.
Method of measurement – to check accuracy of reported temperatures.
Risk assess – using the NICE traffic light tool below
Next ask about associated symptoms to identify a source of the infection.
Respiratory
There is significant overlap in symptoms affecting different areas of the respiratory tract. Some symptoms may be hard to elicit from younger children and infants.
Upper respiratory tract – dry cough, runny nose, sore throat, sneezing, wheeze, sinus pain.
Lower respiratory tract – productive cough, pleuritic pain in older children.
Respiratory distress – sucking in tummy when breathing, taking breaths one per second, see-sawing chest, tracheal tug, difficulty completing sentences, tripoding.
DDx: URTI, LRTI, pneumonia, bronchiolitis, viral induced wheeze, croup
Ears / Nose / Throat
Ears – Infants may tug on their ears to indicate otalgia, parents may notice reduced hearing in small children by lack of response from one side or turning the TV up louder than normal, discharge may be noted on the child’s pillow, older children may describe otalgia, discharge, tinnitus or itching.
Sinuses – Headaches, runny nose, watering eyes.
Throat – Sore throat, refusing feeds, increased or decreased fluid intake, hoarse voice, cough.
DDx: Acute otitis media, acute otitis externa, sinusitis, tonsillitis, URTI
Urinary
Urinary tract infections are more common in girls than boys, but should be considered in both. Strongly suspect a urinary source in febrile infants with no other clear source of infection.
Older children – burning or stinging when going for a wee, increased urinary frequency, nausea, lower abdominal pain, flank pain, blood in the urine, discharge
Infants and small children – Vomiting, irritability, foul smelling urine, crying, drowsiness.
DDx: UTI, pyelonephritis, nephrotic syndrome, sexually transmitted infections, pelvic inflammatory disease
Gastrointestinal
Diarrhoea, foul smelling stools, nausea, vomiting, abdominal distention, reduced appetite, weight loss.
DDx: gastroenteritis, appendicitis, mesenteric adenitis
Other systems
Neurological – confusion, seizures, neck stiffness, photophobia, headache
Eyes – red eyes, purulent discharge, watery discharge, itching
Skin – rashes
MSK – limping child, weakness of limb, painful joint, swollen joint
Differentials
There is a large amount of overlap between the symptoms seen in the differential diagnoses for febrile children. These differentials all present with fever and often with lethargy and reduced intake. The other ‘typical’ symptoms are summarised below. This list is not exhaustive.
| Differential | Features |
|---|---|
| URTI | Coryzal symptoms including sneezing, cough and scratchy throat. |
| LRTI | Productive cough and shortness of breath. |
| Croup | Characteristic barking cough and shortness of breath. |
| Bronchiolitis | Age under 2yrs. Coryza, cough, reduced feeding and increased work of breathing. |
| Viral induced wheeze | Diurnal cough, wheeze, interval symptoms and shortness of breath. |
| AOM / AOE | Ear pain, ear discharge, tugging at ear, hearing loss. |
| Tonsillitis | Sore throat, hoarse voice, vomiting and difficulty swallowing. |
| UTI | Dysuria, abdominal pain, urinary frequency, vomiting and foul smelling urine. |
| Pyelonephritis | Loin to groin pain, haematuria, dysuria. |
| STIs / PID | Sexually active, discharge, pelvic pain, and dysuria. |
| Gastroenteritis | Vomiting, diarrhoea, cramping generalised/epigastric abdominal pain. |
| Appendicitis | Abdominal pain that migrates from periumbilical to RIF, nausea. |
| Mesenteric adenitis | History of resolved viral illness in past two weeks, intermittent abdominal pain. |
| Post immunisations | It is normal to have fevers 48 hours post immunisations. |
| Cellulitis | Spreading erythema, warmth and pain on the skin. |
| Transient synovitis | Limping child, history of viral infection, self resolves. |
| Septic arthritis | Limping child, hot and swollen joint, painful joint. |
| Meningitis | Neck stiffness, photophobia, non-blanching rash, difficulty rousing from sleep. |
| Kawasaki Disease | Cracked lips, strawberry tongue, erythema on soles and palms, bilateral conjunctivitis. |
| Roseola (6th disease) | Coryzal symptoms in baby for 3-5 days followed by erythematous rash that starts on trunk before moving to the face. |
| Slapped cheek (5th disease) | Coryzal symptoms, characteristic erythematous rash on cheeks, may later cause spotty rash on trunk. |
| Hand, foot and mouth | Sore throat, mouth ulcers, erythematous spots on hands and feet. |
| Chickenpox | Itchy erythematous rash that starts with macules which turn to vesicles before bursting and crusting over. Lesions at all three stages are pathognomonic for chickenpox. |
| Measles | White spots in mouth (Kolpik spots), pinprick rash that starts behind ears before spreading to face and trunk. |
| Mumps | Bilateral parotid swelling, often painful. |
| Scarlet fever | Sandpaper erythematous rash, strawberry tongue, sore throat, cervical lymphadenopathy. |
Red Flags
There are serious causes of fever in children and it is important to demonstrate that you are considering them and asking red flag questions to screen for them:
Meningitis – neck stiffness, photophobia, difficulty rousing from sleep, non-blanching rash
Sepsis – lethargy, floppy, reduced urine output, confused, cool peripheries
Kawasaki – cracked lips, strawberry tongue, rash, erythema on soles and palms, bilateral conjunctival injection
Septic arthritis – swelling of joint, limp, not using limb
Pneumonia – cough, difficulty in breathing, sucking in tummy or chest when breathing, > 1 breath per second
Febrile neutropenia – history of chemotherpy or haematological malignancy
Background
In any history you will ask about past medical history, medications, allergies, social history, and family history. In a history around fever in children, you can show how much you know about the various causes by explicitly asking about the following things:
Past Medical History
– Prematurity is a risk factor for more severe bronchiolitis. As the child ages the clinical relevance of prematurity becomes reduced.
– Chemotherapy and haematologicalmalignancies are causes of neutropenia.
Drug History
- Has the child being taking antipyrexials such as Calpol (paracetamol) or Neurofen (ibuprofen)?
If so, what doses? - Are the child’s immunisations up to date? Missing certain vaccines can expand your differential list.
- It is normal to have fevers 48 hours post immunisations.
- Is the child taking chemotherapy or other immune supressing medications such as methotrexate.
Family History
Any family history of asthma, atopy and allergies can increase the risk of children having VIW or asthma.
Social History
- Does the child attend nursery or school? Has there been any illnesses going around that the parents are aware of?
- Has anyone in the household been unwell recently
- Does anyone in the household smoke? (this can trigger/worsen respiratory conditions)
- Travel history can expand your differentials to include conditions such as malaria, TB, yellow fever etc.
Examination
When examining the patient, you should keep your differentials in mind and look for signs that confirm or refute your potential diagnoses. You should fully expose all children under the age of 2, and examine all children top to toe including an ENT examination.
Author and Editor – Dr James Mackintosh
Last updated 17/02/24
