Feverish Illness in Children — GP Assessment & Initial Management

Safety

Red Flags — Exclude life-threatening causes immediately

Done

Recognise and treat immediately life-threatening airway, breathing or circulation problems, reduced consciousness or status epilepticus, and arrange emergency transfer without delay. Perform only essential immediate interventions and investigations that do not delay transfer (airway support, oxygen where indicated, glucose, monitoring). Other NICE red features need urgent face-to-face assessment, generally within 2 hours — not every red feature is a 999 call.

New non-blanching petechial / purpuric rash Immediate emergency assessment and transfer to hospital (NICE NG240) → 999. Not synonymous with meningococcal disease (or septic shock), which can occur without a rash. Inspect the whole skin incl. nappy area and conjunctivae — harder to see on brown/black skin. If meningococcal disease is strongly suspected, give IV/IM ceftriaxone (preferred) or benzylpenicillin unless this delays transfer.

Suspected meningitis Judge the overall picture: fever, altered consciousness, irritability or abnormal behaviour, persistent vomiting, photophobia, headache, neck stiffness, bulging fontanelle, seizures, focal neurology, non-blanching rash. Absence of neck stiffness or classical meningeal signs does not exclude it, especially in infants. No LP in primary care → 999

Bulging fontanelle In infants — raised ICP → 999

Shock / poor perfusion Mottled / pale / ashen / blue skin, weak pulses, hypotension, altered mental state → 999. Capillary refill ≥3 s alone is a NICE NG143 amber feature — interpret with pulse quality, skin colour/temperature, mental state, BP, urine output, hydration and overall appearance.

Fever <3 months + temp ≥38°C High risk (red) → Urgent paediatric assessment (generally ≤2 h), usually in hospital. Emergency transport (999) if shock, respiratory compromise, reduced consciousness or seizure.

Seizure / status epilepticus Ongoing convulsion ≥5 min or breathing compromised → 999 (local paediatric seizure protocol). Focal/complex febrile seizure, persistent altered consciousness, meningism, recurrence within 24 h or atypical age → Urgent paediatric assessment

Altered consciousness / inconsolable GCS drop, not rousable or does not stay awake, weak, high-pitched or continuous cry → 999

Other NICE red features No response to social cues, appears ill to a healthcare professional, RR >60, moderate chest indrawing, reduced skin turgor, focal neurological signs or focal seizures → Urgent face-to-face assessment (generally ≤2 h). A weak, high-pitched or continuous cry, or severe chest indrawing → 999 (tiles above and below)

Respiratory compromise SpO₂ <92% in air, cyanosis, grunting, severe recession, apnoea or exhaustion → 999 / emergency management per clinical context; give oxygen if shock or SpO₂ <92%. SpO₂ ≤95% in air and nasal flaring alone are NICE NG143 amber features.

Fever ≥5 days Assess for Kawasaki disease, including incomplete Kawasaki — same-day paediatric advice/referral if suspected

Immunocompromised child Chemotherapy, severe neutropenia, haematological malignancy, central line, asplenia/sickle-cell disease, significant immunodeficiency or recent transplant → follow the child's specialist fever/neutropenic sepsis pathway: immediate specialist advice, usually Same-day hospital. Steroids alone do not automatically carry the same risk — assess dose, duration, indication and condition.

Features of leukaemia Pallor, persistent fatigue, unexplained fever, persistent or unexplained infection, generalised lymphadenopathy, unexplained bone pain, bruising or bleeding → Very urgent FBC (≤48h); unexplained petechiae or hepatosplenomegaly → immediate paediatric referral (NICE NG12 (updated April 2026) — children & young people). Unexplained fever is itself an NG12 trigger; fever with a clear source in an otherwise well child does not need an FBC; a petechial rash with fever also needs consideration of meningococcal disease.

Fever is the commonest presenting complaint in paediatric primary care, and a minority of febrile children have a serious bacterial infection (SBI). The NICE NG143 traffic light system (under 5s) stratifies risk; immediately life-threatening features need stabilisation and emergency transfer, and other red features need urgent face-to-face assessment.

Meningococcal disease can progress within hours. If it is strongly suspected, NICE NG240 recommends antibiotics outside hospital (IV/IM ceftriaxone or benzylpenicillin) unless this delays transfer; do not delay transfer to calculate a dose. Use the current weight/age-based regimen in the BNFC and local paediatric protocol.

Infants under 3 months have immature immune responses, and a temperature ≥38°C is a NICE high-risk (red) feature. Infants under 1 month with fever generally need parenteral antibiotics in hospital; unwell-appearing infants aged 1–3 months need parenteral antibiotics; well-appearing infants aged 1–3 months still need urgent paediatric assessment and investigation per the hospital pathway.

Diagnose

Assess — NICE NG143 Traffic Light System (Green / Amber / Red)

Done

Apply the NICE NG143 traffic light tool across colour, activity, respiratory, circulation/hydration and other features. NICE NG143 applies to children under 5 years. For children aged 5 years and over, use the same principles — appearance, circulation, respiratory status, hydration, neurological signs, source of infection and parental concern — but the NG143 table is not directly validated for this age group; follow local paediatric assessment pathways and sepsis/meningitis guidance.

🟢 GREEN — Low risk

Normal colour; responds normally; normal cry; moist mucous membranes; no red/amber features → Home with safety-net

🟡 AMBER — Intermediate

Pallor, decreased activity, nasal flaring, SpO₂ ≤95% in air, capillary refill ≥3 s, age 3–6 months with temp ≥39°C, fever ≥5 days, rigors, limb/joint swelling → Face-to-face review; same-day paediatric assessment per clinical picture

🔴 RED — High risk

Any red feature from Step 1 → urgent face-to-face paediatric assessment (generally within 2 hours); 999 if immediately life-threatening

Temperature

Under 4 weeks: electronic thermometer in the axilla; 4 weeks to 5 years: electronic or chemical dot thermometer in the axilla, or infrared tympanic. Do not routinely use oral or rectal routes, and do not add a correction (NICE NG143). Fever = ≥38°C. Height of fever does not reliably predict SBI.

Duration

Fever ≥5 days → assess for Kawasaki disease, including incomplete Kawasaki (see Step 6); features may have resolved — ask about the illness since onset. Document carefully — parents' history is key.

Focus found?

URTI, otitis media, tonsillitis, UTI, pneumonia → likely source. No focus = higher SBI risk.

The NICE NG143 traffic light system supports, but does not replace, clinical judgement — amber features in particular require clinical judgement. No single feature is pathognomonic; the gestalt of the unwell child matters.

Temperature height alone is a poor predictor of SBI. A child with 39°C who is alert, playful and well-perfused is far lower risk than a lethargic child with 38.2°C.

Diagnose

Age-specific risk stratification

Done

Age is an important risk modifier for serious infection in febrile children.

<28 days

Temp ≥38°C → urgent paediatric (hospital) assessment, generally within 2 hours, regardless of appearance; generally needs parenteral antibiotics in hospital. Emergency transport (999) if shock, respiratory compromise, reduced consciousness or seizure. Group B Strep, E. coli, Listeria.

1–3 months

Temp ≥38°C = high risk → urgent paediatric assessment, generally within 2 hours. Hospital investigation (blood tests, cultures, urine ± LP) per the hospital pathway; parenteral antibiotics if unwell-appearing. A well-appearing infant still needs urgent paediatric assessment.

3–6 months

Temp ≥39°C = amber → face-to-face assessment; consider same-day paediatric review based on appearance and other features.

6 months – 5 years

Viral illness most likely. Do not use temperature height alone — use appearance, activity, circulation, respiratory signs, hydration, neurological findings, source and parental concern. Test urine if UTI is suspected or the child is unwell without a clear alternative source (NICE NG224).

5–12 years

NICE NG143 does not apply — use the same clinical principles with local paediatric assessment pathways and sepsis/meningitis guidance. Consider EBV, mycoplasma if prolonged or with pharyngitis + rash.

Immunocompromised

Follow the child's specialist fever/neutropenic sepsis pathway. Chemotherapy, severe neutropenia, haematological malignancy, central line, asplenia/sickle-cell disease, significant immunodeficiency or recent transplant → immediate specialist advice, usually same-day hospital assessment. Steroids alone do not automatically carry the same risk.

Age-based thresholds reflect immuno-developmental physiology. Neonates lack maternal IgG for many pathogens and have immature neutrophil function.

UTI is easily missed in infants and young children — it often causes no localising symptoms. Under 3 months: paediatric referral and urgent microscopy and culture; 3 months to under 3 years: dipstick (leukocyte esterase + nitrite) with culture when indicated; send culture for high/intermediate risk, upper or recurrent UTI, positive dipstick or treatment failure (NICE NG224).

Diagnose

Targeted Examination — systematic head-to-toe

Done

Full examination every time. Never assume it's a simple viral illness without excluding other sources.

General impression

Responds to parent, maintains eye contact, consolable → low risk. Lethargic, glassy-eyed, high-pitched cry → high risk.

Skin

Rash: blanching (often viral) vs non-blanching (petechiae/purpura → emergency assessment for meningococcal disease). Inspect the whole skin incl. nappy area and conjunctivae — petechiae are harder to see on brown/black skin. Jaundice in neonate = urgent. Scarlatiniform rash = strep.

ENT

Ears: erythematous TM / effusion (AOM). Throat: tonsillar exudate (use Centor/FeverPAIN). Lymphadenopathy: anterior cervical = local infection; generalised = EBV/malignancy.

Respiratory

RR >60 at any age = red; >50 at 6–12 months or >40 over 12 months = amber (NICE NG143). Recession, nasal flaring, grunting, wheeze, focal crackles.

Abdomen

Tenderness, guarding, rebound → surgical emergency. Right iliac fossa = appendicitis. Hepatosplenomegaly = EBV.

Fontanelle

Infants only — bulging = raised ICP → 999. Sunken = dehydration.

Perfusion

Cap refill <3 s (≥3 s = NICE amber), warm peripheries, normal HR for age, normal BP. Tachycardia can be fever-driven — interpret in context; response to an antipyretic does not distinguish serious from non-serious illness.

Urine

Test urine when symptoms or signs suggest UTI; consider it in an unwell child where UTI remains possible without urinary symptoms. Do not routinely test children aged 3 months or over with a clear alternative infection and no diagnostic uncertainty (NICE NG224). Under 3 months: paediatric referral + urgent microscopy and culture; 3 months to under 3 years: dipstick (leukocyte esterase + nitrite), culture when indicated; 3 years and over: dipstick. Offensive urine / frequency increase suspicion but do not establish UTI. Obtain urine before antibiotics when feasible, but do not delay treatment in a seriously unwell child.

A child with an apparent viral illness can still have a concurrent UTI — test urine when the child remains unwell or diagnostic uncertainty persists. Systematic examination often identifies a source that changes management.

The "general impression" — how sick does this child look? — remains the highest-yield clinical decision tool and is what parents mean when they say "they just don't seem right." Trust parental concern: it correlates with illness severity.

Diagnose

Investigations — targeted, not blanket

Done

Most febrile children with green features and an apparent viral illness need no investigations in primary care. Investigate only when it will change management.

Urine dipstick / MSU

First-line When UTI is suspected, or the child is unwell without a clear alternative source (NICE NG224). Under 3 months: urgent microscopy and culture + paediatric referral. Send for culture if high/intermediate risk, upper UTI, recurrent UTI, positive dipstick or treatment failure. Obtain urine before antibiotics where feasible; do not delay treatment in a seriously unwell child.

Throat swab

Do not routinely swab — use FeverPAIN/Centor to guide prescribing (NICE NG84). Most sore throats are viral.

FBC + CRP

Amber: investigations guided by the suspected source and local pathway. Red: hospital FBC, blood culture, CRP and urine ± LP/CXR per clinical situation. Very urgent FBC (within 48 h) if leukaemia features (NICE NG12). Do not use FBC, CRP or response to antipyretics to rule out serious infection.

Blood cultures

Hospital only — not in primary care. Taken before IV antibiotics.

COVID/RSV/flu swab

Consider in community if affects isolation / cohorting decision or in at-risk groups. Not routine for every febrile child.

Kawasaki screen

Fever ≥5 days: assess clinically for Kawasaki disease, including incomplete Kawasaki. Principal features: bilateral non-exudative conjunctival injection, oral mucosal changes, hand/foot changes, polymorphous rash, cervical lymphadenopathy — do not require 4 or 5 before referral. FBC, CRP, ESR, LFTs, ECG and echocardiography via the paediatric pathway; do not delay referral to obtain them.

Do NOT order

Routine CRP/FBC/CXR in an otherwise well child with a clear viral illness. Blood cultures in community. LP in primary care. Routine repeat bloods as a general primary-care rule.

CRP and FBC are context-dependent and not diagnostic; they can give false reassurance or prompt unnecessary referral. Use them to support, not replace, clinical judgement — never to rule out serious infection. NICE NG143: lack of response to an antipyretic should not be used to distinguish serious from non-serious illness.

Urine testing is a high-yield investigation in primary care when UTI is suspected — UTI is easily missed in infants because symptoms are non-specific.

Refer

Referral Criteria — who needs hospital assessment today?

Done

999

Immediately life-threatening illness: shock, respiratory compromise, reduced consciousness, ongoing seizure ≥5 min / status epilepticus, strongly suspected meningococcal disease or bacterial meningitis. New non-blanching rash with fever → immediate emergency assessment.

Urgent (≤2 h) / same-day

NICE NG143 red features not needing 999 (see the red-flag tiles above) — urgent face-to-face assessment, generally within 2 hours. This includes age <3 months with fever ≥38°C (urgent paediatric assessment, generally within 2 hours). Other reasons for urgent assessment (clinical judgement, not part of the NICE traffic-light table): unable to tolerate oral fluids; suspected appendicitis/surgical abdomen. Immunocompromised child (also not a traffic-light feature): immediate specialist advice per the fever/neutropenic sepsis pathway, usually same-day hospital.

Same-day paeds

Amber features — face-to-face review; same-day paediatric assessment per clinical picture. Fever ≥5 days with suspected Kawasaki disease (including incomplete). Suspected septic arthritis / osteomyelitis (limb swelling + fever + refusal to weight-bear). Suspicious rash + fever (parvovirus B19, HHV-6, varicella complications).

Urgent GP / OOH

Parental concern overriding your assessment — trust it. Child deteriorating or not improving. New symptoms developing. Unable to assess adequately.

Primary care manage

NICE NG143 green features. Clear viral source (URTI, hand-foot-mouth). Adequate fluid intake. Parent confident with safety-net. Age >3 months.

Kawasaki disease

Fever ≥5 days + suspected Kawasaki (conjunctival injection, oral mucosal changes, polymorphous rash, cervical lymphadenopathy, hand/foot changes) → same-day paediatric advice/referral. Do not wait for 4 or 5 criteria — consider incomplete Kawasaki. Missing Kawasaki = coronary aneurysm risk.

The decision to admit is the most important clinical decision in paediatric fever. Under-referring risks missing SBI; over-referring exposes children to nosocomial infection, unnecessary procedures, and parental anxiety. The NICE NG143 traffic light system guides but does not replace clinical judgement.

Parental concern is a validated risk factor for SBI independent of clinical findings.

Treat

Treatment — antipyretics, antibiotics, and supportive care

Done

Antipyretics treat discomfort — they do not prevent febrile seizures or alter disease course.

Discomfort / distress

Paracetamol Either agent

Dose by age/weight per the licensed product information and BNFC/local paediatric dosing guidance, which take precedence. Check the product concentration — multiple liquid strengths and combination products risk dosing errors. Continue only while distress is present.

Discomfort / distress — alternative

Ibuprofen Either agent

Dose per the product information and BNFC. Age ≥3 months and weight ≥5 kg, subject to the product information. Avoid if dehydrated, significant renal impairment or chickenpox/varicella.

Alternating (controversial)

Alternate paracetamol + ibuprofen

Do not give both simultaneously. Consider changing to the other agent if distress is not relieved; only consider alternating if distress persists or recurs before the next dose is due (NICE NG143). Do not use antipyretics solely to reduce temperature or to prevent febrile seizures.

Prescribing check

Antibiotics only when a bacterial diagnosis or high-risk indication justifies them. Check every dose and duration in the SPC, your local paediatric antimicrobial guideline and local formulary.

Antibiotics — AOM

Most AOM is self-limiting — give analgesia; consider no antibiotic or a delayed prescription for most children. Under 2 years with bilateral AOM, or any child with otorrhoea: immediate, delayed or no antibiotic depending on severity and context. Immediate antibiotic if systemically very unwell, at high risk of complications, or complications such as mastoiditis. If prescribed: amoxicillin 5–7 days (7 days for more severe or recurrent infection), dose per NICE/SPC (children: BNFC) (NICE NG91). Allergy: clarithromycin.

Antibiotics — URTI

Do not prescribe antibiotics for viral URTI. Sore throat: use FeverPAIN/Centor; do not routinely swab. Lower scores: no antibiotic or a delayed prescription; higher scores or systemically unwell/high risk: immediate or delayed phenoxymethylpenicillin (5–10 days). Check the paediatric dose and course length in the local antimicrobial guideline (NICE NG84).

Antibiotics — UTI

Lower UTI, 3 months and over: trimethoprim or nitrofurantoin for 3 days (NICE NG109; dose per NICE/SPC (children: BNFC)). Fever with bacteriuria = possible upper UTI, not lower UTI. Upper UTI / acute pyelonephritis, 3 months and over: cefalexin for 7–10 days, or co-amoxiclav only if culture shows susceptibility (NICE NG111; dose per NICE/SPC (children: BNFC)). Need for paediatric referral depends on age, appearance, risk and ability to tolerate oral treatment. Obtain urine for culture before antibiotics where possible. Under 3 months → paediatric referral for IV antibiotics.

Antibiotics — Pneumonia

Amoxicillin for 3 days in non-severe community-acquired pneumonia in children aged 3 months to 11 years without complications or underlying disease, dose per NICE/SPC (children: BNFC) (NICE NG250, 2025). Extend beyond 3 days only if not clinically stable; stop by 5 days unless microbiology indicates longer or the child remains clinically unstable. Macrolide (clarithromycin) only if clinical assessment makes atypical infection sufficiently likely. Under 3 months corrected age or severe: paediatric referral/hospital.

Pre-transfer antibiotics

If meningococcal disease is strongly suspected: transfer immediately; give IV/IM ceftriaxone (preferred where available) or benzylpenicillin as soon as possible unless this delays transfer or there is severe allergy (NICE NG240). Use the current weight/age-based emergency regimen in the BNFC and local paediatric protocol (benzylpenicillin: <1yr 300mg, 1–9yr 600mg, ≥10yr 1.2g). Do not give for an isolated non-blanching rash without clinical suspicion of meningococcal disease; do not delay transfer to calculate a dose.

Next steps: see UTI in children · Acute cough and chest infections · Suspected neutropenic sepsis · Otitis media and externa

Antipyretics improve child comfort but do NOT prevent febrile seizures or their recurrence (Cochrane 2017). Do not wake a sleeping child to give antipyretics. Fever itself is not harmful — it is part of the immune response.

Antibiotic prescribing for viral URTI is the commonest source of unnecessary antibiotic use in paediatrics and drives resistance. The RCGP TARGET Toolkit supports delayed prescription strategies.

For UTI: trimethoprim resistance is rising in some areas — check the local antibiogram. Send urine for culture before treatment where possible — culture results guide any switch if the child is not improving.

Lifestyle

Supportive Care & Parental Guidance

Done

Clear verbal and written advice to parents reduces re-attendance, prevents complications, and builds confidence.

Hydration — key priority Encourage regular fluids: breast milk / formula in infants; water, diluted squash, oral rehydration solution in older children. Regular wet nappies / urination is reassuring — interpret against the child's age, usual pattern, fluid intake and other dehydration features.

Dress lightly Remove excess clothing. Tepid sponging is NOT recommended — NICE NG143 advises against. Avoid over-bundling.

School / nursery exclusion Keep the child away from nursery or school while they have a fever or are too unwell to participate. For vomiting or diarrhoea, follow UKHSA exclusion advice — usually 48 hours after the last episode. No need to exclude for mild URTI without fever. Inform school of Kawasaki / invasive GAS if applicable.

Vaccination check Is child up to date? Fever after vaccination is common; assess according to the child's clinical condition and the timing/type of vaccine. Do not automatically attribute persistent, severe or unusual symptoms to vaccination.

Avoid aspirin Never give aspirin to children under 16 (Reye's syndrome risk) — except under specialist guidance in Kawasaki disease.

Febrile seizure first aid Place the child on their side; remove nearby hazards; do not restrain; put nothing in the mouth; time the seizure; call 999 if it is the first seizure, it reaches 5 minutes or breathing is compromised.

Written safety-net Provide written advice: when to call 999, when to re-attend. Consider NHS 111 leaflet. NHS "fever in children" information available online.

Dehydration is the primary complication of fever in children and is prevented by consistent oral fluid intake rather than temperature management. Signs of dehydration (dry mucous membranes, sunken eyes, reduced urine output) should trigger urgent reassessment.

Parental anxiety is the primary driver of re-consultation for fever. Written fever advice for parents is freely available on the NHS website.

Safety

Follow-up, Safety-Netting & Monitoring

Done

24–48 hrs

Review if amber features present. Check urine result if sent. Confirm child improving. If worsening → reassess urgently.

Not improving

Repeat face-to-face assessment and look for a new focus. Delayed antibiotics only for selected infections (e.g. AOM, sore throat) — not for an undifferentiated febrile illness.

Fever ≥5 days

Assess for Kawasaki disease, including incomplete Kawasaki; ask about features since onset as they may have resolved. Seek same-day paediatric advice/referral if suspected — do not require 4 or 5 criteria. Bloods, ECG and echocardiography via the paediatric pathway; do not delay referral to obtain them.

Document

Clinical appearance, observations, traffic-light features, source (or absence of source), urine testing and results, treatment and dosing advice, exact safety-netting advice, planned review or referral.

UTI follow-up

Renal USS within 6 weeks for a first UTI responding to treatment in infants <6 months, and for recurrent UTI; USS during the acute infection for atypical UTI (NICE NG224). DMSA / MAG3 if recurrent or atypical UTI (specialist).

Call 999 if:

Non-blanching rash develops or a rash changes. Seizure. Child less responsive, unusually sleepy or difficult to wake. Weak, high-pitched or continuous cry. Stiff neck, bothered by light or a bulging soft spot. Breathing difficult, rapid or noisy. Pale, mottled, blue or cold.

Same-day if:

Cannot keep fluids down or passing markedly less urine than usual. Child deteriorating or parent more concerned. Fever lasting 5 days or longer. Persistent limb/joint swelling, refusal to weight-bear or severe pain. New or worsening symptoms.

Febrile seizure follow-up

Simple febrile seizure, back to baseline, no concerning features → routine EEG or neuroimaging generally not needed. Focal/complex seizure, persistent altered consciousness, meningism, recurrence within 24 h or atypical age → urgent paediatric assessment; specialist assessment if the diagnosis is uncertain or the event atypical (NICE NG217). Teach seizure first aid (on side, remove hazards, do not restrain, nothing in mouth, time it, 999 if ≥5 minutes or breathing compromised). Review 1–2 weeks.

Safety-netting reduces medicolegal risk and improves outcomes. NICE NG143 specifies that all children discharged from primary care with fever must receive written or verbal safety-net advice. Document that this was given.

Renal tract imaging after UTI detects vesicoureteric reflux and renal scarring. Missed reflux leads to recurrent UTIs and chronic kidney disease. NICE NG224 recommends ultrasound within 6 weeks for infants under 6 months with a first UTI that responds to treatment and for recurrent UTI, and ultrasound during the acute infection for atypical UTI.