10.1 The Febrile Child, Sepsis & Meningococcal Disease

The Febrile Child, Sepsis & Meningococcal Disease

Fever is one of the most common presentations in paediatric acute care and general practice. While the vast majority of febrile episodes in children are self-limiting viral infections, acute systemic bacterial infections—such as meningococcal septicaemia, severe bacterial meningitis, urinary tract infections, and occult bacteraemia—can progress with terrifying rapidity. Clinical assessment requires a methodical approach that rapidly identifies high-risk red-flag features while avoiding unnecessary invasive procedures in low-risk children.

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The NICE Traffic Light System (NICE NG143)

NICE guideline NG143 (Fever in under 5s: assessment and initial management) provides a validated clinical risk stratification tool dividing children presenting with fever into three clinical risk tiers: Green (Low Risk), Amber (Intermediate Risk), and Red (High Risk). A child exhibiting any single red feature is classified as high-risk, and a child with any amber feature (and no red features) is classified as intermediate-risk.

Note that in NICE NG143 a capillary refill time of 3 seconds or more is an amber sign, not red; it becomes part of a red picture only alongside other features such as reduced skin turgor or signs of shock. Bile-stained vomiting is a surgical red flag (possible malrotation with volvulus) rather than part of the fever traffic-light table.

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Investigation and Management of the High-Risk Febrile Infant

When an infant younger than 3 months presents with a temperature ≥ 38.0°C, or any child exhibits red-flag features, immediate hospital admission to a paediatric facility is indicated.

Full Paediatric Septic Screen

In infants under 3 months, clinical examination alone cannot reliably rule out occult bacterial meningitis, bacteraemia, or urosepsis. The protocolized septic screen comprises:

• Blood Tests: Full blood count (FBC), C-reactive protein (CRP) or procalcitonin, and blood cultures.
• Urine Testing: Clean catch sample (or catheter specimen / suprapubic aspiration if clean catch unattainable) for urgent dipstick, microscopy, and bacterial culture.
• Lumbar Puncture (LP): Mandatory in all febrile infants aged under 1 month, all unwell infants aged 1–3 months, and any infant under 3 months with a peripheral white cell count < 5 × 10⁹/L or > 15 × 10⁹/L, unless absolute contraindications exist (severe respiratory compromise, haemodynamic instability, local infection at puncture site, or clinical signs of raised intracranial pressure).
• Chest Radiograph: Indicated if respiratory rate > 60/min, grunting, chest recession, crackles, or focal auscultatory signs are present.

Empirical Antimicrobial Regimens

• Infants < 1 month: Intravenous cefotaxime PLUS intravenous ampicillin (or amoxicillin) to cover Listeria monocytogenes, Group B Streptococcus (Streptococcus agalactiae), and Escherichia coli.
• Infants 1 to 3 months (unwell or high-risk): Intravenous cefotaxime (or intravenous ceftriaxone) PLUS intravenous ampicillin (if Listeria coverage remains clinically suspected).
• Ceftriaxone Caution: Ceftriaxone displaces bilirubin from albumin and can cause biliary sludging; hence, cefotaxime is the preferred cephalosporin in neonates and jaundiced infants.

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Symptom Control and Antipyretic Safety

Prescribing antipyretics in febrile children requires strict adherence to evidence-based safety principles:

• Purpose of Therapy: Paracetamol and ibuprofen are indicated only to alleviate discomfort and distress in a child who appears unhappy or in pain, never solely to achieve a normal temperature reading.
• Febrile Convulsion Myth: Antipyretics do not prevent febrile convulsions and must not be administered for this purpose.
• Single-Agent Rule: Start with either oral paracetamol (15 mg/kg every 4–6 hours; max 4 doses/24 hours) OR oral ibuprofen (5–10 mg/kg every 6–8 hours; max 30 mg/kg/day). Do not administer both agents simultaneously.
• Alternating Therapy: Consider alternating between the two agents only if distress persists or recurs before the next scheduled dose of the initial agent.
• Strict Contraindication of Aspirin: Aspirin must NEVER be given to children under 16 years of age (except in specialized conditions like Kawasaki disease) due to the risk of Reye's syndrome—a fatal condition characterized by acute non-inflammatory encephalopathy and hepatic microvesicular steatosis.

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Meningococcal Disease & Purpura Fulminans

Meningococcal disease, caused by Neisseria meningitidis (most commonly serogroups B, W, Y, and C in the UK), encompasses meningococcal meningitis and acute meningococcal septicaemia. Sepsis can trigger rapid microvascular thrombosis, extensive dermal necrosis, and disseminated intravascular coagulation (DIC), termed purpura fulminans.

Non-Blanching Rash & The Tumbler Test

• A non-blanching petechial (diameter < 2 mm) or purpuric (diameter ≥ 2 mm) rash that fails to fade under the pressure of a clear glass tumbler is the quintessential hallmark of meningococcal septicaemia.
• Petechiae confined strictly to the distribution above the superior vena cava (head and neck) can occasionally follow vigorous coughing or vomiting; however, any petechiae below the nipple line or generalized purpura must be treated as life-threatening meningococcal septicaemia until proven otherwise.

Emergency Pre-Hospital Intervention (GP & Paramedic)

If meningococcal disease is suspected in primary care or by ambulance crews:

1. Immediate Parenteral Benzylpenicillin: Administer a single dose of intramuscular or intravenous benzylpenicillin immediately (Age < 1 year: 300 mg; Age 1–9 years: 600 mg; Age ≥ 10 years: 1200 mg). If there is a history of severe penicillin anaphylaxis, use IV/IM cefotaxime or ceftriaxone.
2. Immediate Emergency Transfer: Call 999 for emergency transfer to the nearest emergency department. Never delay urgent transfer to give antibiotics if transfer is immediately available.

Hospital Resuscitation Protocol

• Resuscitation: High-flow oxygen, rapid IV/IO access, fluid bolus of 10 mL/kg of crystalloid given rapidly, reassessed after each bolus and repeated if needed, if there are signs of shock (prolonged capillary refill, tachycardia, hypotension).
• Empirical Antibiotics: Intravenous ceftriaxone 80 mg/kg once daily (max 4 g/day).
• Adjunctive Corticosteroids: Intravenous dexamethasone (0.15 mg/kg QDS for 4 days) administered before or with the first dose of antibiotics in children > 3 months with suspected bacterial meningitis to significantly reduce long-term sensorineural hearing loss and neurological sequelae.
• Public Health Notification & Prophylaxis: Meningococcal disease is a notifiable disease. Close household contacts must receive chemoprophylaxis with oral ciprofloxacin (single dose) or oral rifampicin to eradicate nasopharyngeal carriage.

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Kawasaki Disease (Mucocutaneous Lymph Node Syndrome)

Kawasaki disease is an acute, self-limiting systemic medium-vessel vasculitis that predominantly affects infants and children under 5 years of age (peak incidence at 1–2 years). Its major clinical importance lies in its predilection for the coronary arteries, causing coronary artery aneurysms in 20% to 25% of untreated patients, which can lead to myocardial infarction, ischaemic cardiomyopathy, or sudden cardiac death.

Classic Diagnostic Criteria

The diagnosis is clinical and requires persistent high fever for ≥ 5 days PLUS at least 4 out of the 5 following principal features:

1. Bilateral Non-Exudative Bulbar Conjunctivitis: Sparing the limbus (the avascular border around the cornea); painless and free of purulent discharge.
2. Oral Mucosal Changes: Injected, dry, fissured, bleeding erythematous lips; diffuse oropharyngeal mucosal erythema; prominent papillae creating a classic "strawberry tongue".
3. Polymorphous Exanthem: Diffuse erythematous maculopapular rash, primarily on the trunk and perineum; non-vesicular.
4. Extremity Changes: Acute phase: Erythema of palms and soles with indurative, painful, non-pitting oedema of hands and feet. Convalescent phase (2–3 weeks post-onset): Characteristically distinct periungual sheet-like desquamation (peeling) extending from under the nails.
5. Cervical Lymphadenopathy: Typically unilateral, firm, non-purulent, measuring > 1.5 cm in diameter.

Treatment Protocol

• Intravenous Immunoglobulin (IVIG): Single high-dose infusion of 2 g/kg over 10–12 hours, ideally administered within the first 10 days of fever onset to abort coronary arterial inflammation.
• High-Dose Aspirin: 30–50 mg/kg/day divided into 4 doses for its anti-inflammatory effects until the fever has resolved for 48 hours. This is one of the exceptionally rare clinical scenarios where aspirin is indicated in paediatric practice.
• Maintenance Antiplatelet Aspirin: Following defervescence, stepped down to low-dose aspirin (3–5 mg/kg/day once daily) for 6–8 weeks (or indefinitely if coronary aneurysms develop) to prevent thrombosis.
• Baseline & Surveillance Echocardiography: Performed at diagnosis, at 2 weeks, and at 6–8 weeks to screen for coronary ectasia or aneurysm formation.

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Febrile Convulsions

A febrile convulsion is an epileptic seizure occurring in a child aged between 6 months and 5 years provoked by a febrile illness, without evidence of intracranial infection (e.g., meningitis, encephalitis) or prior unprovoked afebrile seizures. They occur in 2% to 5% of healthy young children.

Acute Management and Parental Reassurance

• Emergency Resuscitation: Place child in the recovery position, clear airway, administer high-flow oxygen. If seizure activity continues beyond 5 minutes, administer buccal midazolam (0.5 mg/kg) or rectal diazepam.
• Investigation: Identify and treat the primary febrile focus (otitis media, viral tonsillitis, UTI). If the child is under 12 months, or if recovery is delayed, carefully exclude central nervous system infection with a lumbar puncture.
• Safety-Netting: Reassure parents that simple febrile seizures do not cause brain damage, intellectual disability, or death. Provide verbal and written instructions on seizure first aid and emergency ambulance activation if a future seizure lasts longer than 5 minutes.