A5V4d

chest X-ray only if respiratory signs are present
stool culture, if diarrhoea is present. [2013]
Management by the paediatric specialist
50 Perform lumbar puncture in the following children with fever (unless
contraindicated):
infants younger than 1 month
all infants aged 1–3 months who appear unwell
infants aged 1–3 months with a white blood cell count (WBC) less
than 5 × 10 9 /litre or greater than 15 × 10 9 /litre. [2007, amended
2013]
51 When indicated, perform a lumbar puncture without delay and, whenever possible,
before the administration of antibiotics. [2007]
52 Give parenteral antibiotics to:
infants younger than 1 month with fever
all infants aged 1–3 months with fever who appear unwell
infants aged 1–3 months with WBC less than 5 × 10 9 /litre or greater
than 15 × 10 9 /litre. [2007, amended 2013]
53 When parenteral antibiotics are indicated for infants younger than 3 months of age,
a third-generation cephalosporin (for example cefotaxime or ceftriaxone) should be
given plus an antibiotic active against listeria (for example, ampicillin or amoxicillin).
[2007]
8.3 Children aged 3 months or older
Investigation by the paediatric specialist
Young children with fever will present to the paediatric specialist in three groups. The first group will
appear well, with no symptoms or signs of serious illness, the vast majority of these children having
viral or self-limiting illnesses (children with only ‘green’ symptoms/signs). A few of these children will
have bacterial infections but they will not be identifiable by clinical assessment alone. This is
particularly true of children less than 3 months of age and for this reason their management by the
paediatric specialist is covered in a dedicated section of this chapter (section 8.2). Information is
required regarding which serious illnesses occur in well-appearing children with fever, together with
evidence of which investigations may help to identify these children.
A second group of children will arrive appearing very unwell with symptoms and signs of serious
illness (mostly ‘red’ symptoms/signs) and will often be given immediate empirical antibiotic treatment.
The final group comprises those children with fever displaying symptoms and/or signs which may
indicate the presence of a serious illness (one or more ‘amber’ or ‘red’ symptoms/signs). Few
investigations will give results quickly enough to definitively identify serious illness in this group. For
example, bacterial cultures will identify those with bacterial meningitis or bacteraemia but these
results take 24–36 hours to become available. Treatment for these conditions should not be delayed
until these results are available. It may be that identification of serious infection comes from a
combination of signs and symptoms as well as simple tests such as WBC, etc. Markers of
inflammation (e.g. WBC, CRP) may help to identify children with serious illness.
One controversial area is occult bacteraemia. Well-appearing children with fever can have bacteria in
their blood, often pneumococcus. Most of these children will clear the bacteria without any antibiotic
treatment, whereas a few will go on to develop significant sequelae, such as persistent bacteraemia
and meningitis. Most information on this condition is from the USA and Australia, with little if any from
the UK. In the USA, meningococcal disease occurs much less frequently than in the UK. A raised
WBC has been used in the USA to identify those at increased risk of occult bacteraemia; however, in
the UK this might not detect cases of meningococcaemia, as only one-third of cases have a raised
WBC on presentation. US data on the prevalence and causes of occult bacteraemia need to be
viewed cautiously and UK data sought. The pattern of occult pneumococcal bacteraemia is also likely
155