Headaches Module

Cite this article as:
Anna McCorquodale. Headaches Module, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.27380
TopicHeadaches
AuthorAnna McCorquodale + Arie Fisher
Duration1-2 hours
Equipment requiredNone
  • Basics (10 mins)
  • Main session: (2 x 15 minute) case discussions covering the key points and evidence
  • Advanced session: (2 x 20 minutes) case discussions covering grey areas, diagnostic dilemmas; advanced management and escalation
  • Sim scenario (30-60 mins)
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

We also recommend printing/sharing a copy of your local guideline.

https://www.headsmart.org.uk/symptoms/sam-animation/ (2 min video) headsmart website contains around 20 min of reading around symptoms which could suggest an intracranial tumour

https://pemplaybook.org/podcast/pediatric-headache-some-relief-for-all/ (30 mins)
A good podcast including risk stratification, diagnosis and management of headache 

https://www.nice.org.uk
Quality standard 42 and clinical guideline 150

https://pemcincinnati.com/blog/headaches-in-the-pediatric-ed/

https://www.pemcincinnati.com/podcasts/?p=89

This is a lecture and a podcasts from PEM Currents which talks succinctly about the emergency management of migraine in ED and the likely treatment outcomes.

https://www.researchgate.net/publication/327473427_Cognitive_bias_in_clinical_medicine

https://miro.medium.com/max/800/1*yN2Xhv-M5PPerWzDVNt3sw.jpeg

Lecture by a US doctor specialising in headaches. Great review over the first 18 min of both the history and examination red flags and where she considers imaging. The second half is a question and answer session which is less useful.

(30 min video)

This is a lecture from a 2016 conference. It is pretty involved in the chronic management of headaches in children so quite advanced for the majority of attendees but might interest paediatricians who run follow up with outpatient clinics.

Headaches are common in children with 75% of children having experienced a headache by age 15. Our primary jobs in emergency are to provide effective symptom relief and filter out the headaches that are more likely to be concerning in their origin. The aetiology of headaches relies enormously on the history and, even in sinister causes, there are often few or no examination findings.

The most common cause of headache in children is a viral infection and the most worrying an intracranial space occupying lesion. Happily the latter is rare.

A good history is key:

  1. Onset, gradual or sudden?
  2. Location & severity, these questions will be incredibly age dependent. Younger children find localisation of pain difficult.
  3. Duration of the problem? How many times has this been reviewed and by who. Is there a lead professional. Be aware of cognitive bias created at this point by knowing what labels others have used. Here there should also be some investigation into what treatment strategies have been tried previously.
  4. Timing and associated symptoms? Compare a morning headache with some nausea/vomiting to one which worsens during the day and is relieved with sleep.
  5. Background medical history
  6. Family history sp of migraines. The presence or absence of this can be incredibly important when establishing aetiology. High prevalence of migraines running in families.

Full examination is necessary but here it should be stressed that abnormal neurological findings are rare in children with headaches. Where they exist there is a clear reason to pursue investigation by imaging, however, their absence cannot be wholly reassuring.

A 12 year old boy is brought to ED with a headache. He does not ordinarily suffer from headaches but today came home from school with a throbbing headache on the right side of his head. It is now 8pm and there has been no change. He has never been seen for headaches before but had a number of attendances for abdominal pain between the ages of 5 & 9 years.

On examination  you see an afebrile child, holding his head with his eyes closed. His neurology is otherwise normal (GCS 14 M 6 V 5 E 3).

What additional information would you consider important in the history?

What would be your next management steps?

Would you discharge this child?

With the additional history what are we trying to establish? Is this a primary or secondary headache. Here the presence of a family history of migraine can contribute to a likely ‘primary headache’ history. We also need to be clear about whether there is any possible infectious aetiology. How do we distinguish between a viral infection with a headache and meningitis? 

Clinical features suggestive of meningitis in children: a systematic review of prospective data, Curtis et al, Pediatrics 2010 – Having either a bulging fontanelle or neck stiffness (older child) increases the likelihood of meningitis by 8 fold

Without either of the above treating symptoms and re-evaluating seems reasonable.

  • The ongoing management of this child is based around clinical judgement of the underlying cause. There aren’t any features of space-occupying lesion (SOL) so it seems reasonable to proceed with either simple analgesia (with an antiemetic if migraine seems likely).

Treatment of pediatric migraine headaches: a randomized, double-blind trial of prochlorperazine versus ketorolac, Brousseau et al, Annuls of Emergency Medicine 2004

  • Migraine symptoms more optimally treated with analgesia with additional antiemetic with >90% resolution of symptoms at 3 hours compared to either analgesia alone (55% symptom resolution) or antiemetic alone (85% resolution)
  • https://bpna.org.uk/uploads/pet/chat-pre-course-june-2017.pdf Offer combination therapy with an oral triptan and an NSAID,or an oral triptan and paracetamol,for acute treatment of migraine with or without aura.
  • https://www.rch.org.au/clinicalguide/guideline_index/Headache/ Acute migraine management on presentation to ED to consider is Chlorpromazine 0.25mg/kg (max 12.5mg) IV over at least 30 minutes with 10 – 20mL/kg sodium chloride 0.9% (max 1L); may cause hypotension, monitor BP.

A 2 year old girl is brought to your emergency with a headache. She has been unsettled at night and wakes slapping the back of her head. She has been seen on four previous occasions over a 5 month period with similar presentations (varying grades of staff involved including a paediatric consultant).

The first presentation was related to the appearance of her molars, an MRI was booked but cancelled as symptoms had resolved when the molars erupted. Subsequent attendances have been documented as teething.

The parents history corroborates the above. She is waking at night with increasing frequency and have come today because it has been worse over the past week. Full neurological examination is normal and she is developing normally. There are some areas of white bulging on the lower gums.

Are there any features here which suggest additional investigation is necessary?

  • If so, what would you plan?
  • If not, how do you proceed

What non-medical features of this cases should we be aware of?

  • There are red flags in this history, however, due to the ages of the child these are difficult to clearly elicit through the history. Waking at night holding the occiput would seem unusual and a primary headache at this age is less likely.
  • Given that clinical examination findings are unlikely even in sinister diagnoses, we should endeavour to find those red flags embedded in the history.
  • There are no neurological examination findings and the behaviour change is not sustained so here evidence would suggest that, although imaging is required, it should be of the most optimal type ie MRI

Children with headache suspected of having a brain tumor: a cost-effectiveness analysis of diagnostic strategies, Medina et al, Pediatrics 2001

  • Here is an optimal time to discuss cognitive bias. Many people had seen this child before, it is easy to ‘plan’ an MRI in a teaching session on headaches but in reality, if your consultant had seen and discharged this child with a diagnosis of teething how would you actually feel?
  • Much has been written on cognitive bias in business and it has been extrapolated to clinical medicine.  It could be useful to explore way we can individually become more aware of this as a process in day to day practice. (www.researchgate.net/publication/327473427_Cognitive_bias_in_clinical_medicine)

A 13 year old boy presents with a headache. He has been seen on four previous occasions spanning your hospital and another local emergency department over a 6wk period. His mother is particularly distressed by the headaches as she has previously lost a child. The boy’s mother clearly voices her anxieties and feels that things are worsening. This morning she reports witnessing an episode of vomiting with some ‘shaky walking’.

It is clear during your assessment that the boy is less concerned than his mother about these headaches. Neurological examination is normal while seated as he fears this will bring the headache back on lying down.

How do you proceed, is any further information required?

What investigations are indicated?

In practical terms this history and examination will need elucidating from both the mother and child independently being sympathetic to the overlying anxieties this mother is carrying from her deceased child. In saying this, there are already red flags appearing here:

  • Worsening headaches
  • Morning vomiting
  • Shaky walking (might indicated cerebellar signs)
  • Refusal to move to a supine posture

Again, we have a normal neurological examination (aside from the whole examination being conducted in a seated position).

How is imaging arranged within your department? This boy does require neuroimaging, but what would happen, CT or MRI? Does a refusal to lie down constitute enough information for a non-contrast CT head in emergency?

As you are deciding to neuroimage this child, you may wish to discuss:

  • Process of gaining CT at different times of day
  • Who reports this
  • If there are abnormalities on the imaging suggestive of raised intracranial pressure, what are the local arrangements to discuss this and where will definitive treatment be arranged?

A non-contrast CT head was undertaken which showed an obstructive posterior fossa mass requiring intervention by neurosurgery. The child required urgent transfer to a different unit for definitive treatment. Some further discussion points could be:

  • How is a time critical transfer arranged in you department?
  • What staff should go and what skills set would be required?
  • What would you prepare for if you were transferring this child (not ventilated, with a 6 week history of headaches but whom you now know has significant hydrocephalus)?

A 14 year old girl arrives immediately following an ophthalmology appointment for a general paediatric review. She has been suffering from mild headaches which have been controlled with simple analgesia for 2 months. These last from 1-4 hours, usually after school and have not worsened over this period. In the past 4 weeks she has become more aware of intermittent visual changes. She sees flashes of colour or ‘lego bricks’ which fall across her vision. This occurs daily, usually in the afternoon. Her ophthalmology appointment was unremarkable, including fundoscopy.

She is afebrile and lucid with no headache currently. Full neurological examination including co-ordination is normal.

Does this girl fit criteria for additional investigations?

What would you do?

You are intending to discharge her, what follow up should be arranged?

We refer back to:

Children with headache suspected of having a brain tumor: a cost-effectiveness analysis of diagnostic strategies, Medina et al, Pediatrics 2001

as an evidence base for imaging. She would not meet the criteria for urgent imaging. Consensus opinion from the American Academy of Neurology would suggest neuroimaging should be considered on the basis of new headaches with some features suggestive of neurological dysfunction. With a normal neurological examination, which here includes fundoscopy by an ophthalmologist, time is on our side so if imaging is pursued this should be MRI. Here it might be pertinent to consider other investigative strategies:

  • Would blood tests offer additional value? If not in this particular case then might they help in the context of low grade fever?
  • Would you consider an EEG?

In this case headaches aren’t really the major feature as they are easily controlled with analgesia. These do not sound epileptic – episodes are too frequent to not have a non-visual epileptic manifestation by now and the associated headache is not severe so an EEG may not be helpful. In childhood, migraine can encompass many other features and headache may not be the most prominent. Where patients are being discharged counselling/advice cannot be underestimated. A headache (or symptom in this case) diary can be a fast track to diagnosis in the outpatient setting and can easily be started from an emergency setting. Taking the time to talk about what your number one diagnosis is, and what environmental strategies might help and what features should prompt a further review, prior to discharge is vital.

A 10 year old boy presents with a 2 day history of a headache. He was referred by the GP to rule out meningitis. He appears uncomfortable but is alert and cooperative. The pain is throbbing and bilateral with a degree of photophobia. There is nausea but no vomiting. He is coryzal and has a temperature of 37.8C. The heart rate is 105 BPM and oxygen saturation rate 99% in room air. Neurological examination does not reveal any abnormalities and he has no problem lying flat for the exam. There is no meningism. On systemic examination there is only mild costophrenic tenderness.

What is the next best step in the management of this patient?

If a urinalysis is requested it shows microscopic haematuria and microscopic proteinuria but no pyuria.

What is the next step?

Participants may become fixated on headache characteristics at this point and may wish to ask additional questions about the character, timing and intensity and about associated symptoms. But these are vague and unspecific in this case. There is a heavy clue in the systemic findings including a mild tachycardia, low grade pyrexia and costophrenic tenderness. This is where the focus should shift towards investigating the cause of all of the patient’s findings, not just the headache.

The blood pressure was intentionally omitted from the vignette, an omission which also occurs frequently in real life. If it is requested it’s revealed to be 161/102. If it is not requested the vignette can continue with the patient developing seizures, which constitutes hypertensive emergency. The cause appears to be renal and the history, clinical findings and urinalysis are more in keeping with glomerulonephritis then acute infection. The most likely is IgA nephropathy. The management is behind the scope of this discussion – starting an anti-hypertensive and consulting a renal service is appropriate in the first instance. Here it is demonstrated that headache can be a sign of systemic illness and a thorough history and exam is always required including a full set of vital signs.

A 12 year old girl presenting with a 2 month history of headache. The pain is throbbing, bilateral, worse at night and is accompanied by nausea. She is anxious as the headache is now affecting her sleep. The GP started her on Amitryptiline but she stopped it due to daytime somnolence. She has a history of chronic abdominal pain. There is a family history of essential hypertension and diabetes. She has long been bullied about her weight. Her BMI is >99th centile.

Her fundscopy examination is shown.

Are there any red flags in the history?

What is the most likely diagnosis and the differential diagnosis?

What are the most important aspects of the exam?

This patient has symptoms which could suggest increased intracranial pressure. Given the history idiopathic intracranial hypertension is probably most likely but other causes like mass or syringomyelia must be considered. If these are ruled out than a primary headache disorder is most likely. Participants will likely list important aspect of the neurological examination. Visual fields and extraocular movements are of particular importance to screen for complications of ICP and a thorough screen for lateralizing signs to outrule mass. Ultimately this patient will need a scan prior to lumbar puncture but these findings will determine urgency.

A bedside fundoscopy can be used as a test for papilloedema but is it really possible? Most children are not fully cooperative and most ED are equipped with direct ophthalmoscopes which give a very small field of view (a panoptic ophthalmoscope is better). Additionally, the exam is usually undilated, adding another layer of difficulty. Overall a reliable ophthalmoscopy under these conditions requires significant expertise, so it should not be relied on unless a specialist is available. If the history is concerning, than the child should be worked up.

Which of the following is not a sign of raised intracranial pressure when co-existing with a headache?

A: Increasing head circumference in <1 year old

B: Vomiting

C: Behavioural change/irritability

D: Fever

E: Waking from sleep with pain

The correct answer is D.

Fever may suggest meningism but not raised ICP. All the others are concerning features of raised ICP.

What is the investigation of choice in headaches with clinical neurological signs?

A: MRI

B: Non-contrast CT

C: EEG

D: Bloods including infection markers/clotting profile

The correct answer is B.

Children who present with headaches and clear neurological signs are the cases where an in department non-contrast CT is indicated. Where there are no clinical findings MRI is the preferred imaging modality.

In paediatric migraine, what is the most effective single treatment for children presenting to emergency?

A: Analgesia

B: Rest and reassess

C: Modify environmental factors

D: Antiemetic

E: Keeping a headache diary

The correct answer is D.

All of the above have a role in the treatment of migraine, however, in the acute setting evidence points to antiemetics are most effective in symptom relief. Analgesia and antiemetics together are even more beneficial. Modification of environmental factors, including rest/exercise/diet and keeping a diary of symptoms will not help acutely but hand some control to the patient in the long term management of symptoms.

https://www.headsmart.org.uk/

Clinical features suggestive of meningitis in children: a systematic review of prospective data, Curtis et al, Pediatrics 2010

Treatment of pediatric migraine headaches: a randomized, double-blind trial of prochlorperazine versus ketorolac, Brousseau et al, Annuls of Emergency Medicine 2004

https://bpna.org.uk/uploads/pet/chat-pre-course-june-2017.pdf

https://www.rch.org.au/clinicalguide/guideline_index/Headache/ www.researchgate.net/publication/327473427_Cognitive_bias_in_clinical_medicine

Children with headache suspected of having a brain tumor: a cost-effectiveness analysis of diagnostic strategies, Medina et al, Pediatrics 2001

https://pemplaybook.org/podcast/pediatric-headache-some-relief-for-all/

https://pemcincinnati.com/blog/headaches-in-the-pediatric-ed/

https://dontforgetthebubbles.com/non-specific-symptoms-in-the-emergency-department-are-you-headsmart/



Please download our Facilitator and Learner guides

Febrile Child Module

Cite this article as:
Team DFTB. Febrile Child Module, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.27356
TopicFebrile child
AuthorSarah Timmis
DurationUp to 2 hours
Equipment neededNone
  • Basics (10 mins)
  • Main session: (2 x 15 minute) case discussions covering the key points and evidence
  • Advanced session: (2 x 20 minutes) case discussions covering grey areas, diagnostic dilemmas; advanced management and escalation
  • Sim scenario (30-60 mins)
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

We also recommend printing/sharing a copy of your local guideline.

The expectation is for the learners to have watched or read one of the basic links before the session.

What is the deal with fever? a good overview of the approach to a febrile child

NICE fever guidelines for kids • LITFL covers the NICE guidelines, plus a bit more

If you prefer to listen rather than read, there is a podcast that although long, is worth listening to and covers the approach to a febrile child: (1hr 14 minutes)

Pediatric Fever Without A Source

Fever is one of the most common presentations to the paediatric emergency department; it scares parents and it makes children miserable. So why does fever occur? A fever is a natural physiological response to infection. It occurs when either an exogenous (eg micro-organisms) or endogenous (eg TNF, interleukin-1 or 6) pyrogen is activated. These pyrogens, via a number of mechanisms, activate the anterior hypothalamus which ultimately results in an increase in body temperature (The pathophysiological basis and consequences of fever).  

This is crucial to understand – your body is in control of your temperature. This is not something an infection is doing to your body; it is something your body is doing to the infection. Of note- this is different from pathological hyperthermia, where your temperature is elevated by either hypothalamic dysfunction or external heat. These are extremely rare. (Hot Garbage: Mythbusting fever in children)

The process of having a fever is believed to be a beneficial response to an infection. The mechanisms by which a fever helps protect you from infection include:

  1. Higher temperatures inhibiting growth/replication of pathogens
  2. Higher temperatures promoting the immune response to infection
  3. It is also worth noting that bacteria are killed more easily by antibiotics at higher temperatures, so there is also a potential third mechanism.

With all this considered, it is not the presence of the fever that is the issue, but what the reason behind the fever is. This is what we, as clinicians, need to discern. First of all, is it infection (most likely in the paediatric population), if so, is this a serious infection? Or is the fever caused by something else (malignancy, drugs, autoimmune, endocrine)?

A father attends the ED with his 4 year child, who has a 2 day history of fever, his most recent temperature was 39.9oC and this has prompted his visit to the emergency department. The father describes his child as being otherwise well, but is extremely concerned about the height of the fever.

Describe how you would assess the child?

What investigations and treatment options would you consider?

You are happy with your assessment of the child, and would like to discharge him, however his temperature is 38.5oC. How do you proceed?

Is this child sick?

The Paediatric Assessment Triangle (from DFTB)

In some instances it will be fairly obvious if the child is unwell, they just ‘look unwell’. A tool that can help you put a system to this assessment is the paediatric assessment triangle. Which considers the childs: appearance, breathing and circulation. This will let you consolidate what you are worried about and allow you to communicate this to your colleagues. 

If all these appear to be in order, this is a reassuring sign. A happy child playing in the waiting room, whilst eating a packet of crisps is much less likely to be unwell with a serious bacterial infection than one that is quiet. Remember to write what you have observed in your notes. 

NG143 Traffic light tool (from NICE)

Once you have some observations you can also use the NICE traffic light table – which helps categorise children into green (well), amber or red (potentially unwell). If they score red, you know they need further workup, and potentially quickly. Green, then they can probably wait a bit to be seen. 

Take a full paediatric history, specifically asking about:


Normal self?
Eating and drinking?
Passing urine?
Bowels opening?
Drowsy?
Pulling at ears?
Vomiting?
Rash/ lumps and bumps?
Siblings, anyone else unwell?
Travel?
Immunisations?

This should also give you an idea about how worried the parents are, is it just the temperature, or is it something else? A high fever with a child who seems their normal self is far less concerning than a child with a normal temperature that just isn’t right.

This needs to be thorough, given that the majority of these kids will be discharged without further investigation. This means looking in ears and throats, looking at the skin hidden under clothing, looking at joints, feeling pulses. So undress the child. You may find a petechial rash, a lump, or more likely, some very enlarged tonsils. Get the child to walk if they are old enough, and stand on one leg and then the other. And when it comes to ears and throats get the parent on board and show them how to hold the child properly. 

Whilst you are hunting for the source, also note the absence of one- look for the signs of the scary infections, the petechiae, the reduced air entry on a lung base, the red knee.

Are you happy examining a child? https://vimeo.com/60599216 gives some top tips on how to examine different age groups

Also read https://dontforgetthebubbles.com/finding-fever/ for a step by step fever focussed examination guide

This step depends very much upon your assessment of the child. If you have found a source-treat that as appropriate. If full history and examination does not provide you with an answer, you have a fever with an unclear source. NICE helpfully has a set of guidelines for these: (NICE fever guidelines for kids • LITFL)

  • Investigate fever with no source if they have any red features –  this includes FBC, CRP, B/C and urine.  Consider LP, CXR, UEC and gas if indicated. 
  • Investigate fever with no source if there are any amber features unless deemed unnecessary by an experienced paediatrician. (this is the bit that could cause you to become unstuck, and you may want a senior to look over these)
  • Check urine for all children with fever (over 37.5) and no source, even if they are green (on the NICE traffic light systemt).

Consider the use of paracetamol or ibuprofen to bring down a high temperature in a hot and miserable child. If it makes the child feel better, it will make the examination process easier for everyone. NICE advises alternating antipyretics.

In many children with fever, the cause will be viral, the source of which may be obvious, or may still be unclear. If they are in a low risk group with a normal urine, they may be ok to go home with advice and a leaflet on the use of antipyretics, fluid management and safety netting advice. However as stated above these are only guidelines, if you are not happy you can always investigate, or admit for observation, and parents can always come back.

If the child has a fever but you have a well child that you have no concerns about then you do not have to wait for the temperature to come down before discharge. 

Give the parents advice on recognising red or amber signs by providing written information and/or arranging follow-up- most EDs will have a ‘fever’ leaflet to give to parents. 

Educating the parents about the nature of fever is important. Explain that “We treat fever with anti-pyretics because it makes the child feel bad, not because fever itself is bad.” Fever is due to a functional immune response. It is what is causing the fever that has the potential to do harm. As a result what the fever is, is not nearly as important as how the child looks or behaves. (The caveat being an under 6 month old where the height of fever is relevant)

On discharge tell them If the fever lasts for more than 5 days, the child should at least have a repeat physical exam by a clinician.

Finish with “But come back if you are worried about the child, even if you have only made it to the car park/ house/ doors of the ED”  
A good summary in video form on seeing a feverish child: https://rolobotrambles.com/listen-look-locate-an-approach-to-the-febrile-child-tipsfornewdocs/

A 5 week old girl has been brought in by her mother. Her mother reports the child seemed irritable so she took her temperature and it was 38.2oC. Pregnancy and birth was unremarkable and there have been no concerns since her birth. The child is feeding well and the history and examination are unremarkable, observations in the ED have been within normal limits, apart from her current temperature which is 38.5oC. Your initial assessment has not provided you with an obvious source for the infection.

When is a temperature classed as a fever?

How would you investigate this child?

How would you manage this child if they had a white cell count of 17 x109/L?

NICE consider >38oC to be a fever

RCEM considers a temperature of 37.5-38oC to be a low grade fever 

However, most people would agree that the difference between .1 of a degree is not significant, therefore infants with a temperature of 37.9 vs 38oC should be managed in the same way.

This child is under 3 months old

Any child with a fever >38oC that is under 3 months old is at ‘high risk’ of serious illness (‘red’ on NICE’s traffic light table NICE fever guidelines for kids • LITFL). If they have a history of fever, but none on assessment remember to ask about antipyretics.

According to NICE this child requires bloods (FBC, CRP, Blood cultures), a urine sample and if the history and exam suggests, a chest X-ray and/ or a stool culture.

A lumbar puncture should be considered and is indicated if the child is:

  • less than 1 month 
  • 1-3 months and unwell; 
  • or 1-3 months with WCC<5×109/L or >15×109/L.

The discussion here is if the child is ‘unwell’, or not. You have a few tools that can help you – the paediatric assessment triangle and the NICE traffic light table (referenced in the above case) can help you decide. However if in doubt, the child will be investigated, and you should be speaking to the paediatric seniors.


If this child had a WCC of 20 then this is an indication for IV antibiotics. 

IV antibiotics are required for children under the same criteria that a lumbar puncture is indicated: 

  • if less than 1 month; 
  • 1-3 months and unwell; 
  • or 1-3 months with WCC<5×109/L or >15×109/L.

The choice of antibiotic will come down to trust guidelines.

A 7 week old has been brought in by her mother because she felt very hot today, and has been ‘a bit grizzly’. Mum has given paracetamol and brought her to ED. Her temperature is 37.6oC on triage. On initial assessment you have no concerns and remaining observations are within normal limits. 

How should a temperature be taken? 

How would you investigate and manage this patient?

NICE has recommendations on this:

Do not routinely use the oral and rectal routes to measure the body temperature of children aged 0–5 years.

They advise in infants under 4 weeks: 

  • measure body temperature with an electronic thermometer in the axilla 

In children aged 4 weeks to 5 years use one of the following:-

• electronic thermometer in the axilla

• chemical dot thermometer in the axilla

• infra-red tympanic thermometer

It’s worth checking what your department uses and what the parent has been using. 
There are some small studies with low numbers of patients that suggest that layers of clothing can raise the skin temperature by up to 2.5°C with a minimal rise in rectal temperature in the very young (Feel the heat). Therefore undress children who seem inappropriately overdressed.

For this patient, guidelines are helpful, but they will not tell us what to do.

We know that 

1. Any child with a fever >38°C under 3 months old is a ‘red’ on NICE’s traffic light system, and this makes them at high risk of serious illness.

2. NICE guidelines suggest that the parents subjective perception of a fever should be considered valid and taken seriously by healthcare providers. 

There is a temptation to treat a child who is apyrexial in the department differently to one that does have a fever. Consider:

  • Has this child had an antipyretic? 
  • In the young, mums are usually right (There is a study from 1984 that shows in children under 2 yrs, mums were correct 90% of the time when they thought their child had a fever, although this dropped to 50% accuracy in over 2 year olds.)
  • Those with fever at home are equally at risk as those with fever in the department (A BMJ study reports that infants <60 days of age, with a history of documented fever are at equal risk for bacteraemia or meningitis as those with fever in the department. https://adc.bmj.com/content/103/7/665.)

So in summary, we have an infant with a normal temperature, who probably had a fever this morning. There are at least two ways of managing this, one is to treat as a fever which therefore means bloods (FBC, CRP, B/C), urine and if history suggests, a CXR and or stool culture. Given that there was parental concern this is probably the preferable option. The other is a period of observation to see how the child progresses, and see whether or not they spike a fever. 

Given that there are no clinical concerns at present, antibiotics prior to blood results are not indicated.

For a debate surrounding overtreating infants read https://dontforgetthebubbles.com/fever_under_60_days_of_age/

A 3 year old boy has returned to ED with a history of 6 days of fever, they have seen the GP twice, two and four days ago, and told it was a viral illness. However the fever is persistent and his parents are concerned. His past medical history includes two admissions for viral wheeze when he was younger, but is otherwise unremarkable. All immunisations are up to date, he goes to nursery and lives with his parents, he has no siblings but his mother is 9 weeks pregnant. On examination the child seems grumpy, he has a fever of 38.8 and a HR of 150 he has a rash across his face and torso and evidence of conjunctivitis.

You think the rash looks morbilliform, what are your concerns and how will you proceed?

What other differentials should you consider, and what examination findings would you be looking for?

How would you work this patient up?

Measles – A brief historical & clinical review

The MMR in the UK is given at 12 months and 3yrs 4 months, so this child will have had the first immunisations affording him 80-95% protection, https://em3.org.uk/foamed/15/7/2019/lightning-learning-measles. Measles therefore is unlikely but possible. Once he has had the second vaccination, this is quoted to afford 99% protection.  

Hopefully you are seeing this child in a side room, as measles can survive for up to 2 hours in air and is very contagious in the un-immunised population. 

It is likely wherever you are in the world, you will need to report this to your public health body. 

His mother is pregnant, check her vaccination status, if this is not complete and she has no history of disease, you need to advise her to see her GP ideally today, she may need a measles titre and, if this does not show previous exposure to the disease, human normal immunoglobulin (HNIG). You also need to enquire about other immunosuppressed/ non immunised contacts. 

A patient is infectious from 4 days before the onset of rash to 4 days afterwards, therefore he will need to be isolated until this period is up and nursery and other contacts need to be informed. 

Serum and saliva testing for measles is available.

Most children with measles can be discharged home

UK guidelines on managing measles exposure : Guidelines on Post-Exposure Prophylaxis for measles June 2019 

Poster: https://em3.org.uk/foamed/15/7/2019/lightning-learning-measles

Recurrent or Periodic Fevers – investigate or reassure? 

Think infection, inflammation or neoplastic. We know infection is common in paediatrics, and the other two are less so. The list of differentials is probably almost endless. There is a good article which lists a whole heap of causes of fever in children, and investigations which can be performed. 

However with this presentation, it is important to consider Kawasaki disease with this time scale of fever and measles. Other conditions worth considering are listed below: 

• Streptococcal disease (e.g. scarlet fever, toxic shock syndrome)

• Staphylococcal disease (e.g. scalded skin syndrome, toxic shock syndrome)

• Bilateral cervical lymphadenitis

• Leptospirosis and rickettsial diseases

• Stevens-Johnson syndrome and Toxic Epidermal Necrolysis

• Drug reactions

• Juvenile Chronic Arthritis

Kawasaki Disease 

You are looking for evidence of Kawasaki disease: The diagnosis is made on the basis of the following clinical criteria (A + B):

A. Fever ≥5 days

B. At least 4 of the 5 following physical examination findings:

  • 1.Bilateral, non-exudative conjunctivitis
  • 2.Oropharyngeal mucous membrane changes – pharyngeal erythema, red/cracked lips, and a strawberry tongue
  • 3.Cervical lymphadenopathy with at least one node >1.5 cm in diameter
  • 4.Peripheral extremity changes 
    • acute phase: diffuse erythema and swelling of the hands and feet
    • convalescent phase: periungual desquamation (weeks 2 to 3)
  • 5.A polymorphous generalised rash – Nonvesicular and nonbullous. There is no specific rash that is pathognomonic for KD

This child has had a fever for 6 days, is tachycardic and the source currently is unclear. It may be measles, however this is not clear cut. He is therefore not going home. Depending on other findings on examination he may also fit the criteria for Kawasaki disease he certainly needs bloods, FBC, U+E, LFTs, CRP, ESR, cultures and a urine dip. He does not require IV antibiotics at this point.

Kawasaki Disease the first 4 minutes covers the presentation and investigation of Kawasaki disease

Communication: Septic screen , taken from  Simulation Library, PaediatricFoam

Which of these is true, a 60 day old with a temperature of 38.5oC:

A: Fulfils the criteria for a lumbar puncture

B: Can be discharged without further investigation 

C: Needs IV antibiotics

D: Needs urine sent for urgent microscopy and culture

The correct answer is D.

This child will need further investigation, at the least bloods and serum cultures, however if they are well they may not necessarily need antibiotics or a lumbar puncture. All children under 3 months need urine sent, not dipped. Use dipstick testing for infants and children 3 months or older.

Which of these is false?

A: The height of the fever can make a difference to the how the child is managed

B: If a fever doesn’t reduce with an antipyretic the child needs admission to hospital

C: A 28 day old with a temperature of 38.5oC will need FBC, CRP and Blood cultures

D: It is recommended that children aged 4 weeks to 5 years have their temperature taken with an axillary probe or tympanic thermometer

The correct answer is B.

A is true because the height of the temperature does make a difference to the management of those under 6 months old

Presence of a fever, even one that does not reduced with an antipyretic is not an indication of a serious infection. It is perfectly acceptable to discharge a well child with a fever, with good safety netting. 

Which of these is true?

A: Kawasaki disease can be diagnosed with fever for > 5 days plus 3 of the B symptoms

B: Fever of over 39oC in a 3-6 month old automatically needs a full septic screen 

C: The higher the fever, the more likely it is to be a serious bacterial infection

D: Measles is infectious from 4 days before the onset of the rash to 4 days afterward

The correct answer is D.

Kawasaki disease is diagnosed with fever >5 days and 4 out of 5 B symptoms

A fever of >39 in a 3-6 month may need a full septic screen, the temperature alone would push them into NICE’s ‘amber’ category. However it depends on a few factors, including whether there is an obvious source and NICE recommends a review by an experienced paediatrician before performing a septic screen automatically on these patients. 

C is not true, there is no good consistent evidence to suggest a higher fever means a more serious infection 



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