The febrile or unsettled child with non-specific symptoms
The febrile or unsettled child with non-specific symptoms
Background
Children often present with a fever and a parent or carer looks to you for answers. You may or may not be able to find a cause but if you do then this will help you to reassure that parent about their child’s symptoms.
Your agenda should be to:
•Try to find a cause that you can treat.
•Exclude possible serious explanations for the child’s symptoms.
•Provide an explanation of the symptoms or, if you find none, refer where appropriate.
•Recognise that you are only able to assess the child as they are. Some children who have minor infections later develop serious infections, so safety-netting well and arranging observation where appropriate are vital.
This may seem a challenge in the context of a busy emergency department and virtually impossible in the context of a general practice consultation. However the odds are in fact on your side. Most of these children do not have serious infections. Furthermore, if you listen to the warnings you will most likely recognise the child with more significant illness.
This group of patients constitute a significant chunk of children who present to primary care. The aim should be to manage the vast majority of them in primary care, since unnecessary referral causes considerable anxiety and inconvenience.
How to assess
•Ask about what symptoms the child has, when the symptoms started and whether the symptoms are getting better, worse or staying the same.
•Ask about contact with any infections and letters which have come home from school about outbreaks of contagious illnesses.
–How ill do the parents feel their child is?
–Does the child seem like their normal self? If not, then how are they different?
–What is the child is doing and not doing that they normally do? Playing and eating are children’s favourite pastimes so if these activities have stopped, you should see that as significant.
•Ask about fevers and ask for specific numbers if they have taken their temperature.
•Ask specifically about coughs, diarrhoea, vomiting, pain and urinary symptoms.
•Examine the child fully.
•It is essential to gain a good look at both of the ear drums as well as the pharynx (not just the palate) in order to confidently diagnose or rule out an upper respiratory tract infection (URTI). If you haven’t seen tonsils and ear drums, then you haven’t finished examining the child.
•Even if an URTI is found, this does not exclude other concurrent and possibly related illnesses. It is still therefore important to examine the heart, lungs, abdomen and make a neurological assessment.
•Look for a rash. Ideally, this means full exposure of the child.
•Unless a clear focus for infection is found, obtain a urine specimen for testing.
In fact, have a low threshold for doing this whenever in doubt. Though inconvenient to obtain, it is a harmless test, and urine infections can be easily missed.
If the tonsils are visualised, this is the indication that an adequate view of a child’s throat has been achieved.
Figure 5.1 Throat examination of a 13-year-old child
From birth to six months
Possible condition | Characteristics, symptoms and signs |
Upper respiratory tract infection (URTI) | •Coryzal, or inflamed pharynx or ear drums. •No signs of sepsis. •Be very hesitant to diagnose this in children under three months old if febrile. |
Lower respiratory tract infection (LRTI) | •Uncommon at this age. •Usually has cough and respiratory distress – these accompanying a significant fever equal a LRTI unless proven otherwise. •Auscultation signs are variable and unreliable. There can be crepitations with no infection and an infection with no crepitations. |
Urinary tract infection (UTI) | •Presents with unsettled babies, who may or may not be unwell. •Have a very low threshold for excluding UTI in this age group, as sepsis can develop rapidly. •There are usually no specific signs and the absence of an explanation of a fever or for an unsettled child should make the exclusion of UTI mandatory. |
Meningitis | •Unsettled, lethargic babies who feed poorly. •Classically they have a high pitched ‘irritable’ cry. •Instead of neck stiffness, these babies have increased tone and do not respond kindly to being handled. •There may be a bulging fontanelle, even when not crying. |
Sepsis (which may be due to any of the above) | •Presents as an unwell baby but not always dramatically so. The baby may just seem ‘not their normal self’ or be ‘off their feeds’. •Usually, either the parent, the doctor or the nurse get a sense of foreboding about a child with sepsis. •Suspect sepsis if heart rate is high, capillary refill is prolonged or the baby is subdued. •Pure sepsis may present without a focal infection. As a result, absence of a good explanation for a baby’s unwellness leaves early sepsis as a possibility. In other words, the child with fever who is unwell and has no focal findings is presumed to be septic. |
Table 5.1 Characteristics, symptoms and signs from birth to six months
Six months to three years
| Possible condition | Characteristics, symptoms and signs |
| Upper respiratory tract infection (URTI) | •Extremely common in this age group, especially if at nursery or has older siblings in which case URTIs may occur more than once a month. •Coryzal, or inflamed pharynx or ear drums. •No signs of sepsis in uncomplicated URTI. If the child is significantly unwell, consider concurrent or complicating infections. |
| Lower respiratory tract infection (LRTI) | •More common at this age but if present is usually viral. •Classical triad of fever, cough and respiratory distress – these equal an LRTI unless there is a better explanation. •Auscultation signs are variable and unreliable. There can be crepitations with no infection and an infection with no crepitations. |
| Urinary tract infection (UTI) | •Presents with miserable children, who may or may not be unwell. •There are usually no specific signs and the absence of a focus for infection should make the exclusion of UTI mandatory. |
| Meningitis | •Presents with irritable children. •Suspect meningitis in the subdued child who will not settle. •Neck stiffness or increased tone may be present. |
| Sepsis (which may be due to any of the above) | •This will be a noticeably unwell child. There is also an absence of reassuring signs (cheerfulness, playfulness etc). •Usually, either the parent, the doctor or the nurse get a sense of foreboding about a child with sepsis. •Suspect sepsis if heart rate is high, capillary refill is prolonged or the child is subdued. •Assume that sepsis is present when a child is unwell and no focus can be found. •May be accompanied by a progressive petechial or purpuric rash. |
Table 5.2 Characteristics, symptoms and signs from six months to three years
Three years to adulthood
| Possible condition | Characteristics, symptoms and signs |
| Upper respiratory tract infection (URTI) | •Continues to be the most common cause of fever. •Coryzal, or inflamed pharynx or ear drums. May also now complain of specific symptoms such as earache or sore throat. •If signs of sepsis, then this is evidence of systemic bacterial infection in addition to the URTI. |
| Lower respiratory tract infection (LRTI) | •Bacterial infections become increasingly common in the older child. •Usually has a cough and respiratory distress – these accompanying a significant fever equal a LRTI unless proven otherwise. •Auscultation signs are variable and unreliable. There can be crepitations with no infection and an infection with no crepitations. |
| Urinary tract infection (UTI) | •Presents with vague abdominal pains. Sometimes also age-appropriate urinary symptoms: enuresis in the younger child and frequency/dysuria in the older child. •There are still usually no specific signs. •Tenderness in the renal angles suggests kidney involvement. |
| Meningitis | •Presents with headache, photophobia or just being quite unwell. •Suspect meningitis in the subdued child who does not seem their normal self. •Neck stiffness or increased tone may be present. By this age, it is possible to test for Kernig’s sign. |
| Sepsis (which may be due to any of the above) | •This will be a noticeably unwell child. •Usually, either the parent, the doctor or the nurse get a sense of foreboding about a child with sepsis. •Suspect sepsis if heart rate is high, capillary refill is prolonged or the child is subdued. •Assume that sepsis is present when a child is unwell and no focus can be found. •May be accompanied by a progressive petechial or purpuric rash. |
Table 5.3 Characteristics, symptoms and signs from three years to adulthood
The ‘must do’s
Significant effort spent on gaining a good look at both ear drums and the pharynx is time well spent. Unless the child is able to co-operate (and many children do surprisingly well at this), you require an adult who is willing to hold the child tight no matter how much they fight. Then to complete your side of the bargain you need to look swiftly, yet accurately. Firm but gentle is the way to gain a good view humanely. Remember though that being too gentle is no good to anyone. The likelihood is that the child who is going to get upset will be upset regardless, so make sure that you make a good effort and don’t be too put off by a child who doesn’t want to be examined. If the child is really too combative and the adult isn’t managing to hold the child still, you may need to stop, suggest that another adult tries holding the child and show them exactly how to do so again, before having another attempt. Giving up without obtaining a view should not be necessary.
Listen to the parents’ anxieties. If you have made an assessment and explained your findings then it is part of the safe completion of your consultation to ask the parents if they still have any worries. If they do, then it may be because there is something wrong with the child that they have been unable to articulate or you did not fully appreciate. If you cannot reassure the parents, do not be too quick to dismiss these anxieties.
You should take high temperatures (>39°C) seriously but in the context of the whole child. Septic children do not usually look well. In other words, a cheerful child with a high temperature is less likely to have a serious illness than a miserable or very subdued child with the same temperature. However you should feel more obliged to justify your opinion that the child is well the higher the temperature is that is recorded.
Likewise any ‘fever effects’ should be taken seriously. A rigor potentially implies a more serious infection. While it is possible for a child with a simple viral infection to have a conscious shaking episode, the presence of a rigor in the history should make any clinician more wary, have a lower threshold to investigate and more keen to observe the child.
Pitfalls to avoid
Mastoiditis is easy to miss. This is because it may be hidden by hair or the ear and so needs examining for specifically. Have a look at the child’s face and ask yourself if one of the ears is pushed forwards. Then look for redness and swelling behind the ears. Finally, at the same time as you examine for lymph nodes in the neck, palpate the mastoid bone behind the ear. It may be tender or there may be a boggy swelling.
How to be a know-it-all
The majority of children with febrile illnesses have one of the common (or less common but more serious) infections listed above. There are however a few children who present with fevers who have less common causes. While it is unnecessary to know these conditions in detail, knowing how to spot them is extremely valuable. A child who presents without a straightforward history and examination should have the following problems considered.
•Complications of bacterial upper respiratory tract infection are thankfully rare but do occur and catch out the unwary clinician. Peritonsillar abscesses (‘quinsy’), mastoiditis and brain abscesses are three such invasive infections. These will usually make the child more unwell and may present with specific symptoms (unable to swallow in quinsy, neurological symptoms in brain abscesses) or signs (see pitfalls). However note that children who have recently had an oral broad spectrum antibiotic may have these conditions partially treated. It is useful in such children to examine them more thoroughly, than for a child presenting at the beginning of an illness and who has been well for the preceding few weeks. If there are signs or symptoms that a recent infection has become invasive, refer.
•Septic arthritis will usually present with localising symptoms in older children. However in preverbal children or if no focus has been found, the only way to rule an infected joint out as the source of the fever is to examine arms and legs. The simplest way to do this is to get the child to use their limbs and be confident that there is no restriction. A child will not allow movement of an infected joint.
Also worth knowing
Kawasaki’s disease has many of the features of a viral illness but is an important diagnosis to make because early treatment may reduce cardiac complications. Important features to look for are:
•A really miserable child. Children with viral illnesses are often miserable but settle with medication and there is a steady improvement over the space of a few days. Children with Kawasaki’s are more consistently and persistently miserable.
•There will be a fever that persists for five days and does not improve with antibiotic treatment.
•Most will have conjunctivitis but no discharge.
•Most will have a non-specific rash.
•Most will have inflammation of the oral mucosa.
•About half will have lymphadenopathy which will be more dramatic than that expected for a viral URTI.
•While peeling skin on hands and feet are the sign that most people associate with Kawasaki’s, it is a late occurrence and not always present.
Children who continue to be febrile five days into an infection that was originally felt to be viral are still more likely to have a bacterial infection, so all the possibilities must be considered. However, children with a fever for five days and who fulfil the diagnostic criteria should be referred as soon as the diagnosis is significant possibility.
General management of the febrile or unsettled child
Temperature control
There are two aspects to managing these children. While treatment of the underlying infection is important (where it is possible), the second goal is the treatment of the pain and fever associated with the infection. Fever control is important to help the child feel better and to give you a true picture of how unwell the child is. Treating a high temperature and the associated misery is achieved both through medication and other means. In order to achieve maximum temperature control, consider the following:
•Is the child able to shed heat? Children are often wrapped up very warmly to come to be seen by the doctor. They should be stripped down to a minimum of clothing as long as the room temperature is not cold. Don’t overdo this though. Cold air and fans, like sponging, can cause vasoconstriction and cause the core temperature to paradoxically rise. If the skin is cooled too much the child may shiver which will also raise core temperature.
•Has the child been receiving antipyretics at home? If so, how much? Parents often hold back for a variety of reasons. They do not want to ‘fill their children with too many medicines’ and many over the counter medicines advise that they are not to be given for more than three days without consulting a physician.
The management of fever is therefore best achieved by ensuring that the child is adequately exposed and that they have received the maximum allowed dose (according to weight or age) of at least one antipyretic medication.
Specific management of the febrile or unsettled child
The management of each condition depends on what it is. URTI has been covered already in Chapter 3. The following sections outline an approach to the other conditions that may be encountered.
Lower respiratory tract infection (LRTI)
Assessment
As mentioned previously, diagnosing LRTI is far from straightforward. Most children with a cough and crackles heard on auscultation do not have a LRTI. Also, many children with LRTI do not have obvious signs in the chest. Because of this difficulty many doctors develop a policy of treating with antibiotics whenever a LRTI might be present. Unfortunately this means that any child with a cough is treated with antibiotics, and the vast majority of these children are being put at risk of antibiotic side effects unnecessarily.
Note that the term ‘lower respiratory tract infection’ essentially means any infection of the respiratory system within the thoracic cavity. This could mean a viral or bacterial infection and could mean bronchitis or pneumonia. I have intentionally used the rather vague LRTI to reflect the uncertainty that we all have as doctors when making the diagnosis of a ‘chest infection’. However, with a child who has focal signs and is clearly unwell and in distress, the term pneumonia is obviously more medically appropriate.
My approach to diagnosing LRTI is one which I think allows the clinician to treat ‘in case’ where appropriate but is likely to ensure as accurate a ‘hit rate’ as possible in this tricky condition. I believe that a healthy mix of suspicion and scepticism are needed to assess children regarding the possibility of LRTI.
Of course, the child as a whole needs to be the factor that truly makes your mind up regarding the diagnosis. However, I think that ‘unpacking’ the various factors and considering how much weight to give them is important. The following is a guide to the factors which may help to make a diagnosis, according to how significant I think that they are:
Unlike in adult medicine, blood tests and chest X-rays are not a routine part of diagnosing or managing pneumonia in children. Irradiating children should be avoided unless truly needed and should never be done ‘routinely’. Children are vulnerable and the benefits of a test should be clear before a child is subjected to the distress associated with venepuncture. In general, blood tests and X-rays should not be needed to diagnose LRTI and may even confuse the diagnosis as changes lag after clinical signs of infection. Investigations do have a role but mainly in the management of LRTI severe enough to require admission to hospital. Therefore as a rule, investigations should not be needed to make a decision to refer to the paediatric team.
Signs that are significant and suggest possible LRTI | Signs which may suggest LRTI | Signs which are non specific for LRTI |
•Respiratory distress without wheeze •Focal reduced breath sounds on auscultation •Localised dullness to percussion •Localised bronchial breathing on auscultation | •Focal crepitations on auscultation •Fever •Unwell child | •Cough, even if productive •Scattered crepitations on auscultation •Respiratory distress with wheeze |
Table 5.4 Significant factors to consider for diagnosis
Generally, children fall into one of the following three categories:
1. A child who has a cough and crackles in the chest, but is not in respiratory distress and is not unwell, is unlikely to have a significant LRTI.
2. A child who has cough and fever and focal crepitations in the chest, but no distress, probably has a LRTI.
3. A child with cough, fever and respiratory distress has a LRTI until proven otherwise, particularly if there is a focal finding in the chest.
Management
Most children with LRTIs are managed with oral antibiotics at home. Below is a list of factors which should prompt you to consider referral or to seek advice from a paediatrician:
•Age under two years old. If a child of this age has pneumonia, they are usually unwell.
•Moderate respiratory distress. These children often benefit from supplemental oxygen.
•Any signs of sepsis or dehydration ie tachycardia, pale, or significantly unwell.
•Any floppy episodes or blue episodes.
•Poor fluid intake or any vomiting, as this will make it unlikely that oral medication will be successful.
•Fevers >39°C, or fevers unresponsive to adequate doses of antipyretics.
•Oxygen saturations of <93%.
•Any underlying chronic lung disease, not including asthma. If a child has a LRTI and an exacerbation of asthma, then it is still reasonable to manage both without referral as long as each of the two aspects would have been treated outside of hospital independent of each other.
•Parental anxiety despite a full explanation.
Children who can be managed at home on oral antibiotics are usually those who have a cough, fever and focal chest signs but have not yet developed respiratory distress or become particularly unwell. Although there are many factors to take into consideration, you can usually tell who is well enough to be managed at home just by looking at them.
Unlike with adults, a follow-up is not often needed. If a parent is advised that the cough will improve with the antibiotics and may take a couple of weeks to go altogether, then they should also be advised to seek a review if one of those two things does not happen.
How to be a know-it-all
As mentioned previously, over-reliance on chest signs can be very misleading in trying to decide who does and doesn’t have a chest infection. One sign that does seem to point towards a bacterial LRTI in younger children in particular is grunting. Children grunt when there is an element of collapse in the lungs. The grunt is an involuntary partial closure of the glottis which keeps a small amount of pressure in the airways so that they do not collapse at the end of expiration.
It is not uncommon to see a child with what would otherwise seem to be an upper respiratory tract infection yet who grunts intermittently. The presence of grunting should prompt a careful examination to look for signs of LRTI.
What do I tell the parents?
When I do not think their child has a ‘chest infection’:
‘Most coughs in childhood are not due to chest infections. Even when children are ruttly with a cough, it is usually due to mucous produced by a viral infection. When I examined your child I couldn’t find any of the things that would indicate a chest infection. Because of this it is better if they don’t have antibiotics. As you are probably aware, antibiotics can cause problems such as diarrhoea, thrush, urine infection and allergic reactions, so we always try to make sure a child really needs them rather than just giving them “just in case”.’
‘Instead, you should concentrate on giving medicines for fever if they have one. I don’t think that it worth spending your money on cough medicines, because they don’t work well at all.’
‘Most viral coughs last a few days as a severe cough and then become mild, but can stay as a nuisance cough for quite a while. However, if you think it is not getting better you should get your child seen again. Sometimes, a minor infection can come before a more significant infection, so if your child becomes worse, I would want your child to be seen again quickly.’
When I think that a child has a ‘chest infection’ but does not need to be admitted:
‘When I examined your child, some of the things that I found suggest that they have a chest infection. This is something that lots of children get at some point in their childhood and mostly they respond well to antibiotic medicine.’
‘I think that your child is well enough to have their medicine at home. It may take a day for any improvement to be noticeable. If they are no better then, or if they are significantly worse at any point then they need to be seen again to see if they need to have any different treatment. You should not hesitate to get your child seen again if you are worried.’
When I think that a child has a ‘chest infection’ and I feel that they need admission:
‘Your child has the signs of a chest infection. As doctors, we call this pneumonia*. Pneumonia is not as dangerous to children as it is to old people, so you shouldn’t worry about it in the same way. Most children respond very well to antibiotics including children who are poorly enough to need hospital treatment.’
‘Because your child is quite unwell with their infection, I would like them to be seen by the paediatricians. They will decide what treatment your child needs to have.’
*NB. I always try to make sure that I use the word ‘pneumonia’ with parents early on. It carries a real fear of death and they will hear it used later on. If you don’t explain it to them, no one else might. When parents are not spoken to openly, they often assume that this is because the doctors do not want to tell them that their child might die. Of course, they may have someone explain things well to them later, but they may still be upset that you only told them that their child had a chest infection when the ‘specialist’ diagnosed pneumonia!
Flowchart for managing lower respiratory tract infection
Figure 5.2 Flowchart for managing lower respiratory tract infection
Summary for lower respiratory tract infection (LRTI)
•LRTI usually manifests as cough with fever and respiratory distress. Focal chest signs make the diagnosis more likely but are not always present.
•Children with cough and bilateral crackles without fever or respiratory distress probably have a viral illness and are therefore unlikely to benefit from antibiotics. Focal crackles in a child without other features of LRTI can be due to the mucous produced by viral infections.
•Most children with LRTI can be managed at home on oral antibiotics. Those who require assessment with a view to admission can usually be identified by looking at them. They look unwell, tired or significantly distressed.
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