Urgent considerations

See Differentials for more details

The initial priority when a child presents with an acute fever is to assess the risk of a serious illness that requires initiation of urgent treatment. The ABCDE approach is used as the initial assessment in the acutely unwell child.[10]

The UK National Institute for Health and Care Excellence (NICE) guideline on fever in the under 5s recommends use of a traffic light system to aid in recognition of risk of serious illness in young children with fever.[11] Various other tools, such as pediatric early warning scores, are used to monitor for any deterioration in condition.[12] These tools use assessment of a wide range of factors, such as heart rate, respiratory rate, response to social cues, and capillary refill time, to assess the likelihood of a serious illness requiring urgent treatment.

Suspected sepsis

Sepsis is a spectrum of disease, where there is a systemic and dysregulated host response to an infection.[13]​ Presentation ranges from subtle, nonspecific symptoms (e.g., feeling unwell with a normal temperature) to severe symptoms with evidence of multiorgan dysfunction and septic shock. Patients may have signs of tachycardia, tachypnea, hypotension, fever or hypothermia, poor capillary refill, mottled or ashen skin, cyanosis, newly altered mental state, or reduced urine output.[14]​ Sepsis and septic shock are medical emergencies.

Risk factors for sepsis include: ages under 1 year, ages over 75 years, frailty, impaired immunity (due to illness or drugs), recent surgery or other invasive procedures, any breach of skin integrity (e.g., cuts, burns), intravenous drug misuse, indwelling lines or catheters, and pregnancy or recent pregnancy.[14]

Early recognition of sepsis is essential because early treatment improves outcomes.[14][15][Evidence C]​​​​​ However, detection can be challenging because the clinical presentation of sepsis can be subtle and nonspecific. A low threshold for suspecting sepsis is therefore important. The key to early recognition is the systematic identification of any patient who has signs or symptoms suggestive of infection and is at risk of deterioration due to organ dysfunction. Criteria to identify sepsis and septic shock in children and young people under the age of 18 years have been developed.[16]​ Several other risk stratification approaches exist. All rely on a structured clinical assessment and recording of the patient’s vital signs.​[14][16]​​[17][18]​​​[19]​​​ It is important to check local guidance for information on which approach your institution recommends. The timeline of ensuing investigations and treatment should be guided by this early assessment.[19]

Treatment guidelines have been produced by the Surviving Sepsis Campaign and remain the most widely accepted standards.[15] Within the first hour:[15]

  • Follow institutional protocols for management of sepsis/septic shock in children; these improve the speed and reliability of care.

  • Obtain blood cultures before administering antibiotics (provided this does not substantially delay antibiotic administration).

  • Administer broad-spectrum antibiotics.

  • Administer crystalloid fluids, titrated to clinical signs of cardiac output and stopped if there is evidence of volume overload. Consult local protocols.

Use trends in blood lactate levels to guide resuscitation. If the child’s hypotension is refractory to fluid resuscitation, consider use of vasopressors.[15]

For more detail on sepsis in children, including diagnosis and emergency management, see Sepsis in children. 

Differential diagnoses requiring specific urgent treatment

The list of differential diagnoses in children with fever is extensive. While a specific diagnosis can often be made with the use of ancillary testing, occasionally treatment must be initiated before establishing a definitive diagnosis. This is especially true for ill- and toxic-appearing children.

Because the most frequent cause of fever in children is infections, broad-spectrum antibiotic therapy (e.g., third-generation cephalosporins such as ceftriaxone) may need to be given empirically, ideally after obtaining blood, urine, and CSF cultures in children suspected of having bacterial infections.

Based on the practitioner's clinical assessment and the results of ancillary testing, a specific diagnosis may be further suspected. For some of these diagnoses, specific urgent treatment must also be initiated:

  • Pneumonia: supplemental oxygen

  • Septic arthritis: joint drainage

  • Hepatic/cerebral abscess: drainage

  • Meningitis: antibiotics with or without corticosteroids

  • Toxic shock syndromes: removal of infective material

  • Pulmonary tuberculosis: respiratory isolation

  • Dengue hemorrhagic fever or dengue shock syndrome: fluid replacement therapy

  • Kawasaki disease: aspirin and intravenous immunoglobulin (risk of coronary artery aneurysms)

  • Leukemia: hydration, induction therapy, correction of electrolyte abnormalities, blood product transfusion (risk of thrombosis, tumor lysis syndrome, bleeding)

  • Thyroid storm: beta-blocker, antithyroid medications, iodine compound, glucocorticoids, treatment of precipitating event

  • Serotonin syndrome: sedation, supportive care (especially control of hyperthermia)

  • Factitious disorder imposed on another (formerly known as Munchausen syndrome by proxy): removal from offending caregiver

  • Scarlet fever: prompt treatment of children with antibiotics is recommended to reduce risk of possible complications, including invasive group A streptococcus, and limit onward transmission. In countries such as the UK, where rapid antigen detection tests (RADTs) for scarlet fever are not readily available, test confirmation of group A streptococcus infection is not required before starting antibiotics in patients with a clinical diagnosis of scarlet fever.[20]​​ In countries where RADTs for scarlet fever are available, a positive test result may be required before starting antibiotics (patients with clear viral symptoms don't need testing for group A streptococcal bacteria).[21]​ If there is uncertainty about the diagnosis, obtain a throat swab prior to commencing antibiotics.[21][22][23]​​​​​​​​[24] Treatment of scarlet fever with antibiotics based on clinical diagnosis alone should follow in-country clinical guidelines. According to the UK Health Security Agency, notifications of scarlet fever and invasive GAS (iGAS) disease in England were higher than expected from September 2022 to February 2023, with the peak observed in December 2022.[22][25]​​​​​ The notifications have significantly reduced since then and are now in line with the expected number for the time of year.​[22] Other countries experiencing an increased incidence of scarlet fever and iGAS disease during this period include France, Ireland, the Netherlands, and Sweden. The increase was particularly marked during the second half of 2022.[26]

Coronavirus disease 2019 (COVID-19)

  • Although over 90% of children are asymptomatic or have a mild illness, moderate to severe illness has been reported in children.[27]​ It is important to note that children may have signs of pneumonia on chest imaging despite having minimal or no symptoms.[28]​ Coinfection with other respiratory viruses is common. 

  • Patients with suspected COVID-19 infection should be isolated from other patients. Contact and droplet precautions should be implemented until the patient is asymptomatic.

See Coronavirus disease 2019 (COVID-19). 

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