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Fever in Under 5s

NICE guideline [NG143] Fever in under 5s: assessment and initial management. Last updated: Nov 2021.

Diagnosis Guidelines

Recommended methods:
  • <4 w/o → axilla measurement with electronic therometer
  • 4 w/o - 5 y/o → axilla measurement (electronic / chemical dot therometer) or infra-red tympanic measurement

 

Do not routinely use the oral and rectal routes to measure body temperature of 0-5 y/o children.

NICE specifically mentioned the following causes of fever in under 5s:
 
Cause of fever When to consider
Meningococcal disease and bacterial meningitis Any of the following:
  • Non-blanching rash
  • Bulging fontanelle
  • ↓ Level of consciousness
  • Convulsive status epilepticus
  • Capillary refill time ≥3 sec
Herpex simplex encephalitis Any of the following
  • Focal neurological signs
  • Focal seizure
  • ↓ Level of consciousness
Pneumonia Any of the following:
  • Tachypnoea
  • Nasal flaring
  • Chest indrawing
  • Cyanosis
  • SpO2 <95%
  • Crackles on auscultation
UTI Features that increase the likelihood of UTI:
  • Dysuria / frequent urination
  • Malodorous / darker / cloudy urine
  • Frank haematuria
  • New bedwetting 
  • Reduced fluid intake
  • Abdominal pain / loin tenderness / suprapubic tenderness
  • Shivering
  • Capillary refill time >3 sec
Septic arthritis / osteomyelitis Any of the following:
  • Limb / joint swelling
  • Not using an extremity
  • Non-weight bearing
Kawasaki disease Fever for >5 days, and possible additional features (CRASH):
  • Conjunctival injection (bilateral without exudate)
  • Rash
  • Adenopathy (cervical lymphadenopathy)
  • Strawberry tongue
  • Hands and feet oedema
 

Work-Up and Management Guidelines

  Green (low risk) Amber (intermediate risk) Red (high risk)
Colour
  • Normal colour
  • Pallor
  • Pale / mottled / ashen / blue
Activity
  • Responds normally to social cues
  • Content / smiles
  • Stays awake or awakens quickly
  • Strong normal cry / not crying
  • Not responding normally to social cues
  • No smile
  • Wakes only with prolonged stimulation
  • Decreased activity
  • No response to social cues
  • Appears ill
  • Does not wake / not stay awake if roused
  • Weak / high-pitched / continuous cry
Breathing
  • n/a
  • Nasal flaring
  • Tachypnoea (>50/min in 6-12 m/o, >40/min in >12 m/o)
  • SpO2 ≤95%
  • Crackles on auscultation
  • Grunting
  • Tachypnoea (>60/min)
  • Chest indrawing
Circulation
  • n/a
  • Tachycardia (>160bpm in <12 m/o, >150bpm in 12-24 m/o, >140bpm in 2-5 y/o)
  • Capillary refill time ≥3 sec
  • Dry mucous membranes
  • Reduced urine output
  • Poor feeding in infants
  • Reduced skin turgor
Temperature
  • n/a
  • 3-6 m/o + ≥39°C
  • Fever for ≥5 days
  • <3 m/o + ≥38°C
Other
  • n/a
  • Rigors
  • Swelling of a limb / joint
  • Non-weight bearing / not using an extremity
  • Non-blanching rash
  • Bulging fontanelle
  • Neck stiffness
  • Focal neurological signs
  • Focal seizures
  • Status epilepticus
 

  • Any red features → refer urgently to paediatric specialist
  • Any amber features → safety netting with follow-up or refer to paediatric specialist
  • No amber or red features → care at home with safety netting

Investigations Indications
  • FBC
  • Blood culture
  • CRP
  • Urine testing  (clean catch method if possible)
 Perform routinely (all patients)
  • Chest X-ray
 Only if respiratory signs are present
  • Stool culture
 Only if diarrhoea is present
  • Lumbar puncture
 Almost routinely...

Only in the following:
  • < 1 m/o (routinely)
  • 1-3 m/o who appear unwell
  • WBC <5x109/L or >15x109/L
 

Traffic light group Investigations
Red (any) Perform the following routinely:
  • Blood tests (FBC, blood culture, CRP)
  • Serum electrolyte and blood gas
  • Urine testing  (clean catch method if possible)
  • Chest X-ray
  • Lumbar puncture
Amber (any) Perform the following routinely:
  • Blood tests (FBC, blood culture, CRP)
  • Urine testing  (clean catch method if possible)

Other conditional tests:
  • Chest X-ray if >39°C and WBC >20x109/L
  • Lumbar puncture (if <1 y/o)
Green Perform the following routinely:
  • Examination for pneumonia features
  • Urine testing  (clean catch method if possible)

Do NOT perform the following routinely:
  • Blood tests (FBC, blood culture, CRP)
  • Chest X-ray

Management should be guided by the working diagnosis and investigation findings. The following are important points outlined by NICE.
 

IV antibiotic is indicated if:
  • Fever, and
  • Shocked / unrousable / signs of meningococcal disease

Choice of antibiotics (until culture results are available):
  • <3 m/o → 3rd generation cephalosporin (ceftriaxone / cefotaxime) + amoxicillin / ampicillin (to cover Listeria)
  • Otherwise → 3rd generation cephalosporin (ceftriaxone / cefotaxime)

Suspected sepsis (fever + shock):
  • 0.9% NaCl bolus of 10mL/kg​​​​​​, and
  • IV antibiotics

Suspected herpes simplex encephalitis:
  • IV aciclovir

Antipyretics are only indicated to relieve distress from the fever (but NOT just to reduce body temperature):
  • Paracetamol / ibuprofen
  • Continue as long as the child appears distressed

Oxygen therapy is indicated in:
  • SpO2 <92% + signs of shock
  • Consider if SpO2 >92% as clinically indicated

References

Author: Adams Lau
Reviewer:
Last edited: 26/08/25