Initial assessment of any febrile child

For all febrile children the following should be undertaken:

• Fully undress and examine systematically. Make a thorough search for a focus of infection: think about the ‘hidden sites’ such as meninges, urinary tract and bloodstream (septicaemia). Mildly pink tympanic membranes or throat do not constitute a focus.
  
  
  
• If a rash is found, it is important to decide whether it is non-blanching. All febrile children with haemorrhagic rashes must be taken very seriously. Although many children with fever and petechiae will have viral illnesses ^{17 28 29} there is no room for complacency when assessing these children. They must all have their vital signs measured, a decision made as to whether they have signs of meningitis or septicaemia and given intravenous antibiotics. A senior paediatrician should be informed immediately. Some hospitals in the UK may have local protocols on action to take when a haemorrhagic rash if found, depending on whether the rash is petechial or purpuric, and there is work underway to consolidate this⁴⁸.
  
  
  
• Children without a rash or with a blanching rash can still have MD. The rash may appear later or not at all if the child has pure meningitis and occasionally with septicaemia. Thorough clinical assessment should ascertain whether there are physical signs of serious systemic illness.
  
  
  
• If initial assessment of airway, breathing and circulation reveals that you are dealing with a seriously ill child, ABC should be rectified in line with APLS guidelines³⁰ before proceeding with the detailed examination.

The following clinical signs must be measured and recorded to complete a full assessment:

• Temperature
• Heart rate
• Respiratory rate
  
• Blood pressure
  
  
• Capillary refill time or toe-core temperature gap
  
  Standard technique for measurement of CRT is to press for 5 seconds on a fingertip or toe, or on the centre of the sternum, and count the seconds it takes for colour to return. (Capillary refill shown here on dorsum of foot to facilitate capture on film.)
  
• Oxygen saturation measurement (normal value is >95% in air)
  
  
• Assessment of conscious level (AVPU)
• Pupil size and reaction
• If rash present record whether it is blanching, extent of rash, speed of development and whether it is petechial or purpuric (Petechial <2mm diameter, purpuric >=2mm diameter). Purpura are highly predictive of meningococcal disease and should be treated as an emergency, with immediate antibiotics and admission. Petechiae alone are less predictive, but must be taken very seriously and especially in combination with other features of septicaemia should provoke urgent action.

Full-blown non-blanching haemorrhagic rash*