EM · Paediatric fever and serious bacterial illness
Paediatric fever and serious bacterial illness (the febrile child in the emergency department)
Also known as Febrile child · Paediatric fever · Fever without source · Serious bacterial illness · NICE traffic light system
The febrile child — NICE NG143 traffic-light system (green low, amber intermediate, red high). Children younger than 3 months with temperature 38 C or higher are a high-risk group. Infants younger than 1 month receive lumbar puncture and parenteral antibiotics; 1 to 3 months if unwell or white-cell count under 5 or over 15 times 10 to the 9 per litre. When parenteral antibiotics are indicated under 3 months: a third-generation cephalosporin (cefotaxime or ceftriaxone) plus a listeria-active agent (ampicillin or amoxicillin). Shock: 10 mL/kg 0.9 percent sodium chloride. Antipyretics for distress, not temperature. PECARN and Step-by-Step refine selected young infants. ACEM-primary.
Checked against its sources on 2 Sept 2026
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- NICE NG143: children younger than 3 months with a temperature of 38 C or higher are in a high-risk group for serious illness
- Infants younger than 1 month with fever: lumbar puncture (unless contraindicated) and parenteral antibiotics; 1 to 3 months if unwell or WBC under 5 or over 15 times 10 to the 9 per litre
- Under 3 months, parenteral antibiotics are a third-generation cephalosporin (cefotaxime or ceftriaxone) plus a listeria-active agent (ampicillin or amoxicillin) — NG143 does not forbid ceftriaxone
- Fever and shock: immediate 10 mL/kg intravenous 0.9 percent sodium chloride, then further boluses as necessary
- Fever lasting 5 days or longer: assess for Kawasaki disease; untreated coronary-artery aneurysms in about 25 percent (McCrindle AHA)
- Antipyretics for distress, never solely to reduce temperature; do not give paracetamol and ibuprofen simultaneously
Meet the patient
A 6-week-old ex-term infant is brought in by her parents with a single axillary temperature of 38.4 degrees measured at home. She is alert, pink, and smiling at you, feeding normally with her wet nappies unchanged; the pregnancy and delivery were uncomplicated and there is no maternal herpes history. She looks well — and that is exactly the trap. NICE NG143 classifies children younger than 3 months with a temperature of 38 C or higher as a high-risk group. Aronson documents large interhospital variation in how 61-to-90-day infants are tested, with invasive bacterial infection uncommon (median 0.3 percent) but not zero.[10][3]
Two questions decide her next hour and every febrile infant: what age band is she in? (the master variable) and what is the right empiric antibiotic for that band? Hold those two and the febrile child becomes manageable.[10]
References11ShowHide
- [1]Kerkhof E, Lakhanpaul M, Ray S, et al. The predictive value of the NICE "red traffic lights" in acutely ill children. PLoS One, 2014.PMID 24633015
- [2]Thompson M, Coad N, Harnden A, et al. How well do vital signs identify children with serious infections in paediatric emergency care? Arch Dis Child, 2009.PMID 19608555
- [3]Aronson PL, Mahajan P, Nielsen B, et al. Variation in Evaluation and Management of Febrile Infants 61 to 90 Days Old. J Pediatr, 2026.PMID 41921773
- [4]Gomez B, Mintegi S, Bressan S, et al. Validation of the "Step-by-Step" Approach in the Management of Young Febrile Infants. Pediatrics, 2016.PMID 27382134
- [5]Kuppermann N, Dayan PS, Levine DA, et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr, 2019.PMID 30776077
- [6]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med, 2020.PMID 32032273
- [7]Milcent K, Faesch S, Gras-Le Guen C, et al. Use of Procalcitonin Assays to Predict Serious Bacterial Infection in Young Febrile Infants. JAMA Pediatr, 2016.PMID 26595253
- [8]McCrindle BW, Rowley AH, Newburger JW, et al. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association. Circulation, 2017.PMID 28356445
- [9]Benito-Fernández J, Mintegi S, Pocheville-Gurutzeta I, et al. Pneumococcal bacteremia in febrile infants presenting to the emergency department 8 years after the introduction of pneumococcal conjugate vaccine in the Basque Country of Spain. Pediatr Infect Dis J, 2010.PMID 20592642
- [10]National Institute for Health and Care Excellence Fever in under 5s: assessment and initial management NICE guideline NG143, 2021.Source
- [11]National Institute for Health and Care Excellence Traffic light system for identifying risk of serious illness in under 5s NICE NG143 educational resource, 2019.Source