Paediatric fever — febrile illness assessment, sepsis recognition

Overview

Fever is the cardinal presenting feature of infection in childhood, yet not every febrile child has an infection, and not every seriously unwell child is febrile (hypothermia < 36 °C is equally concerning and carries a poor prognosis). For the rural generalist, the challenge is threefold: accurately assess severity with limited diagnostic infrastructure, identify the small proportion of children at risk of serious bacterial infection (SBI) or sepsis, and make timely decisions about escalation and retrieval.

In remote and regional Australia, the clinical encounter may occur in an isolated clinic, a community health centre, or via telehealth. Distance from definitive paediatric care, limited point-of-care (POC) pathology, and the significant burden of serious infectious disease in Aboriginal and Torres Strait Islander (ATSI) communities make systematic, protocol-driven assessment essential.

Key definitions

SIRS is not synonymous with sepsis. A dysregulated host response causing organ dysfunction defines sepsis; SIRS criteria alone do not.

Assessment Framework

The Three Critical Points

For any child with fever, suspected infection, or sepsis:

1. Physiological assessment, systematic examination of key physiological markers at initial presentation and serially thereafter
2. Diagnostic assessment, history, examination, and targeted investigations to identify the site(s) of infection and likely causative organism(s)
3. Management assessment, link physiological and diagnostic assessments to key interventions (antimicrobials, fluids, oxygen, source control, retrieval)

In a haemodynamically unstable child, resuscitation takes precedence over a detailed history; in a stable child, a thorough history is the most important diagnostic tool.

Traffic Light Approach (Under 5 Years)

A structured green-amber-red framework (NICE CG160, 2013, updated 2017) is the practical cornerstone of assessment and must be applied consistently regardless of the clinical setting.

Any single red feature mandates immediate assessment, resuscitation initiation, and retrieval planning. Sick children do not always have fever, children with any red features but no fever still require immediate or same-day specialist review.

Paediatric Early Warning Scores (PEWS)

Rural generalists should be familiar with structured PEWS tools (e.g. ViCTOR in Victoria). These provide an objective escalation framework and improve communication with retrieval teams. Serial PEWS documentation over time demonstrates clinical trajectory, a rising score mandates escalation even when no single parameter is critically abnormal. Aggregated early warning scores (including NEWS2 in adults ≥ 12 years, and PEWS variants in children) are now preferred over isolated physiological parameters.

History Taking

A structured history should capture:

• Duration and height of fever, fever ≥ 5 days raises concern for Kawasaki disease, bacterial endocarditis, or occult deep-seated infection
• Intermittency, fever is often intermittent and may be absent at time of presentation; a reliable fever history from the carer is valid
• Source symptoms, URTI, ear pain, dysuria, diarrhoea, skin/soft tissue changes, bone pain
• Immunisation status, particularly Hib, pneumococcal (13-valent PCV + 23-valent PPV), and meningococcal vaccines; rates of incomplete immunisation may be higher in some remote communities
• Travel history, within tropical Australia (dengue, melioidosis, Ross River virus); overseas (malaria, typhoid, viral haemorrhagic fevers)
• Animal and environmental exposures, Q fever, leptospirosis, melioidosis (northern Australia), psittacosis, brucellosis; ask about soil/water contact, unpasteurised milk, animal bites/scratches, tick/mosquito bites, and occupation
• Sick contacts, household or community cluster
• Antibiotic use prior to presentation, may mask meningism and alter blood culture yield
• Underlying conditions, sickle cell disease, immunosuppression (including chemotherapy, steroids, asplenia, DM), malnutrition, prematurity

Any febrile episode in a neutropenic or immunocompromised child requires immediate specialist referral. Similarly, unexplained hepatosplenomegaly or unexplained petechiae require same-day hospital assessment to exclude malignancy.

Vital Signs, Age-Adjusted Thresholds

$$\text{Estimated minimum systolic BP (mmHg)} \approx 70 + (2 \times \text{age in years})$$

Persistent tachycardia disproportionate to the degree of fever, or any hypotension, is a red flag for sepsis. Fever is often intermittent, a normal temperature at presentation does not exclude serious infection.

Age-Specific Risk Assessment

Examination Red Flags

• Non-blanching petechial or purpuric rash, meningococcal septicaemia until proven otherwise; administer benzylpenicillin immediately regardless of setting
• Bulging fontanelle, meningitis in infants (in the absence of crying)
• Neck stiffness, meningitis; note that signs may be non-specific in children < 18 months
• Altered consciousness or irritability, encephalitis, meningitis, septic encephalopathy
• Prolonged capillary refill (≥ 3 sec), impaired perfusion
• Grunting respirations, severe respiratory compromise or sepsis, particularly in neonates and young infants
• Joint swelling and restricted movement, septic arthritis (orthopaedic emergency)
• Hypothermia, may indicate serious infection, particularly in neonates and malnourished children

Investigation

Point-of-Care Options in Remote Settings

Full Pathology (If Accessible or Pre-Retrieval)

Blood culture yield is approximately 50% during the acute febrile phase. Shaking rigors (not fever alone) more strongly suggest bacteraemia.

Management

General Principles, The Rural Sepsis Response

Three parallel priorities (proceed concurrently, not sequentially):

1. Resuscitate the physiology
2. Identify and treat the source
3. Arrange retrieval if indicated

Fever Management

• Antipyretics reduce discomfort but do not prevent febrile convulsions
• Paracetamol 15 mg/kg orally every 4-6 hours
• Ibuprofen 5-10 mg/kg every 6-8 hours (avoid in infants < 3 months, dehydrated children, or renal impairment)
• Focus on identifying the cause; do not use fever reduction as a substitute for clinical assessment

Fluid Resuscitation in Sepsis

For children with suspected sepsis and signs of poor perfusion:

$$\text{Initial bolus} = 10\text{-}20 \ \text{mL/kg IV/IO of 0.9\% NaCl over 15-30 minutes}$$

Reassess after each bolus. Repeat up to 40-60 mL/kg total in refractory shock, with careful monitoring for fluid overload (hepatomegaly, pulmonary oedema). In resource-limited settings without ICU backup, cautious titrated fluid resuscitation is preferred, high-volume bolus resuscitation has been associated with increased mortality in some low-resource settings (FEAST trial data).

If IV access cannot be obtained promptly, intraosseous (IO) access is the preferred alternative (proximal tibia or humeral head). All IV drugs and fluids can be administered IO.

The Sepsis Six Bundle

Initiate as soon as sepsis is suspected:

1. High-flow oxygen
2. Blood cultures
3. IV/IO broad-spectrum antibiotics
4. IV/IO fluid resuscitation
5. Serum lactate measurement
6. Monitor urine output (catheter if shocked)

Empirical Antibiotic Therapy

Administer as soon as cultures are collected, do not delay antibiotics for investigations.

Pre-transfer benzylpenicillin for suspected meningococcal disease:

Airway and Oxygen

• High-flow oxygen to maintain SpO₂ ≥ 94% in all children with suspected sepsis
• Prepare for intubation if GCS ≤ 8, respiratory failure, or impending airway loss; bag-mask ventilation must be immediately available
• CARPA Standard Treatment Manual protocols guide pre-hospital RSI considerations for appropriately trained practitioners

Febrile Convulsions

• Prevalence: 3-5% of children aged 6 months to 5 years (peak 18 months); often a family history
• Common causes (in order of frequency): viral infections, otitis media, tonsillitis, UTI, gastroenteritis, LRTI, meningitis, post-immunisation
• Most are brief (< 5 minutes) and self-limiting
• Prolonged seizure (> 5 minutes): midazolam 0.2 mg/kg buccally or intranasally (max 10 mg); repeat once after 5 minutes if no response
• Antipyretics do not prevent febrile convulsions but provide symptom relief
• Do not assume a febrile seizure is benign without excluding serious pathology, especially in children < 18 months (meningitis may present non-specifically), those with complex features, or where the fever source is unclear

Arrange immediate paediatric assessment if:

Decision to Transfer, Retrieval Criteria

Mandatory Retrieval Indications

Pre-Transfer Stabilisation Checklist

• IV/IO access secured and fluid resuscitation initiated
• Empirical antibiotics administered (cultures drawn first, do not delay antibiotics for results)
• Oxygen commenced; airway secured or management plan in place
• Temperature, BGL, SpO₂, HR, RR, BP documented and trending
• SBAR handover prepared for RFDS or retrieval team (include PEWS trend)
• Notifiable disease reported if applicable (meningococcal, measles, dengue, malaria, per state/territory legislation)
• Family briefed with culturally sensitive communication; interpreter engaged if required

Contact the relevant RFDS base or state retrieval coordination service early, early notification allows optimal aircraft and crew preparation.

Special Considerations

Aboriginal and Torres Strait Islander Children

• Higher baseline burden of: invasive pneumococcal disease (IPD), group A streptococcal (GAS) disease (rheumatic fever risk), melioidosis (tropical north), scabies-related sepsis (impetigo → cellulitis → sepsis), and TB
• Malnutrition and anaemia increase sepsis risk and may blunt fever response, a normal temperature does not exclude SBI in a malnourished child; hypothermia is equally concerning
• Verify vaccination history carefully, pneumococcal and meningococcal vaccines are particularly important
• Community MRSA is prevalent in remote communities, use clindamycin or cotrimoxazole if MRSA is suspected in skin/soft tissue infections
• Rheumatic fever: consider in school-aged ATSI children with fever + joint pain (migratory polyarthritis), fulfil Jones criteria before diagnosis; benzathine penicillin is first-line treatment and secondary prophylaxis is mandatory
• Cultural safety: engage family, use Aboriginal Health Workers and interpreters, explain procedures clearly, and centre family in decision-making
• Notify Aboriginal Health Workers at the receiving hospital to facilitate continuity of care

Neonates (< 28 Days)

• Fever ≥ 38.0 °C mandates full sepsis evaluation and empirical antibiotics without delay
• Clinical signs may be subtle: poor feeding, temperature instability (including hypothermia, temperature < 36 °C), lethargy, grunting, or simply "not right"
• Examine for omphalitis (umbilical infection), skin pustules, bulging fontanelle, nasal flaring, severe chest indrawing, or difficult-to-rouse state
• IMCI criteria for possible serious bacterial infection in young infants (0-2 months) include: seizures, tachypnoea > 60/min, severe chest indrawing, nasal flaring, grunting, bulging fontanelle, fever or hypothermia, many/severe skin pustules, or inability to be calmed within 1 hour
• All neonates with fever require transfer to a facility with neonatal capabilities

Returning Travellers and Tropical Australia

• Malaria must be excluded in any child with fever who has visited or lives in a malaria-endemic area (Queensland, NT, WA coastal regions); use RDT and blood films; empirical treatment may be warranted if high suspicion and delays are anticipated
• Melioidosis (Burkholderia pseudomallei) is endemic in tropical northern Australia, consider in any febrile child with soil/water exposure during or after the wet season; presents as sepsis, pneumonia, or localised infection; meropenem is first-line treatment
• Dengue fever, consider with fever + severe myalgia + thrombocytopenia + northern Queensland/tropical exposure; secondary infection (different serotype) is the major risk factor for dengue haemorrhagic fever; management is supportive; watch for the critical phase (plasma leakage, haemorrhage, shock) occurring on days 3-7
• Ross River virus and Barmah Forest virus, arthralgia + rash + fever; rarely serious in children; supportive management
• Leptospirosis, fever + jaundice + AKI + conjunctival suffusion + thrombocytopenia; treat with penicillin, ceftriaxone, or doxycycline
• Q fever, psittacosis, brucellosis, consider with animal/occupational exposure and an atypical pneumonia or undulant fever pattern; detailed exposure history is essential
• Notify public health authorities for notifiable conditions (meningococcal disease, measles, dengue, malaria, and others per relevant state/territory legislation)

Prolonged Fever / Fever of Undetermined Origin (FUO)

FUO criteria (Petersdorf-Beeson modified): fever > 38.3 °C on multiple occasions, lasting ≥ 3 weeks, undiagnosed after one week of intensive study.

The longer the duration of fever, the less likely an infectious cause, fevers persisting > 6 months are rarely infectious (< 6%).

Common causes to consider:

Children with FUO in definite need of further investigation include: infants < 3 months, children with fever > 40 °C, the immunocompromised, those with diabetes, and returned travellers.

Summary: Rural Generalist Decision Framework

``` Febrile child presents ↓ Apply Traffic Light / PEWS (serial assessment) ↓ RED features? → Resuscitate + Sepsis Six + Empirical Antibiotics → Immediate RFDS/retrieval activation AMBER features? → PO

Sources

• Royal Flying Doctor Service clinical resources
• CARPA Standard Treatment Manual
• Therapeutic Guidelines (eTG)