A5V4d

Clinical assessment of the child with fever
significant difference in the odds of serious bacterial infection when comparing children who had had
fever for longer than 48 hours with those who had had fever for less than 24 hours; however, a fever
duration of 72 hours or longer was significantly associated with serious illness.
As shown in Table 5.23, there were mixed results when comparing the duration of fever in children
with and without serious illness. Some studies reported that children with serious illness had had fever
for significantly longer than those without, whilst other studies reported that there was no significant
difference in the duration of fever.
Temperature of 38°C or higher at age 0–3 months, temperature of 39°C or higher at age 3–6
months (in 2007 traffic light table)
Thirty-six studies reported on the height of fever in children aged less than 5 years. As shown in Table
5.25, various cut-offs were reported, including 37.4°C or higher, 37.5°C or higher, higher than 37.5°C,
38°C or higher, 38.4°C or higher, 38.5°C or higher, higher than 38.5°C, 39°C or higher, higher than
39°C, 39.1°C or higher, higher than 39.3°C, 39.4°C or higher, 39.5°C or higher, higher than 39.5°C,
40°C or higher, higher than 40°C, 40.1°C or higher, and 41.1°C or higher. These were used to try to
detect urinary tract infection, serious bacterial infection, malaria or meningitis, serious illness, severe
illness requiring hospitalisation, bacteraemia, bacterial meningitis, bacterial infection, pneumonia,
sepsis and serious disease. Sensitivity and specificity ranged from high to low but were not correlated
with temperature. All of the positive predictive values were low. The negative predictive values ranged
from high to low, although also not in the expected pattern. Positive likelihood ratios were strong for
40°C or higher and for higher than 40°C, but were not strong for any other cutoffs. Negative likelihood
ratios were not strong for any cutoffs. As shown in Table 5.26, when comparing the mean or median
height of fever in those with and without serious illness, there were mixed results as to whether the
difference was significant or not.
Six of the 36 studies reported on the height of fever exclusively in children aged less than 3 months,
including 38°C or higher, higher than 39°C, 39.5°C or higher, 40°C or higher, and higher than 40°C for
detecting serious bacterial infection, urinary tract infection, occult bacteraemia, bacteraemia,
meningitis, bacterial meningitis, salmonella enteritis, sepsis and serious bacterial illness. Sensitivity
was high for 38°C or higher and low for all other cutoffs. Specificity was low for 38°C or higher,
moderate for higher than 39°C, moderate to high for 39.5°C or higher, and high for 40°C or higher and
higher than 40°C. Positive predictive values were low for all cutoffs, and negative predictive values
were high for all cutoffs. Positive likelihood ratios were not strong for 38°C or higher, higher than 39°C
and 39.5°C or higher. They were strong for 40°C or higher and higher than 40°C. Negative likelihood
ratios were not reported for 38°C or higher and were not strong for the other cutoffs.
No studies reported on the height of fever solely in children aged from 3 to 6 months.
Swelling of a limb or joint (in 2007 traffic light table)
No evidence was reported on the use of swelling of a limb or joint to detect serious illness.
Non-weight bearing limb/not using an extremity (in 2007 traffic light table)
No evidence was reported on the use of non-weight bearing limb or not using an extremity to detect
serious illness.
Non-blanching rash (in 2007 traffic light table)
Non-blanching rash was reported in seven studies, including ‘rash’, purpura, petechiae, purpura with
petechiae, more than 20 haemorrhages, haemorrhages greater than 1 mm in diameter, and
haemorrhages greater than 2 mm in diameter. The sensitivity, specificity and positive predictive
values ranged from high to low for detecting pneumonia, urinary tract infection, bacteraemia, serious
disease, serious bacterial infection, invasive disease, bacterial meningitis or meningococcal disease.
The negative predictive values ranged from high to moderate. The positive and negative likelihood
ratios ranged from not strong to convincing.
Bulging fontanelle (in 2007 traffic light table)
Bulging fontanelle was reported in three studies. The sensitivity was low for detecting serious
bacterial illness, bacterial meningitis, pneumonia, urinary tract infection or bacteraemia. The
specificity was high. The positive and negative predictive values ranged from high to low. The
likelihood ratios were not strong.
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2013 Update