This is the 170th #WILTW
As a result of a recent twitter mediated discussion (and resulting project), along with an influx of new doctors into our Children’s Emergency Department, I’ve had cause to dwell on ‘fever‘. Having been asked to solidify the key practice points to consider when managing the child with a raised temperature I couldn’t resist the opportunity to formalise an appropriate mnemonic.
The challenge with fever is that both professionals, and parents, forget that fever is a body’s response to an infection, not the infection’s response to the body. A fever, apart from in infants less than 3 months old or lasting longer than 5 days, is essentially irrelevant. You are worried about the cause of the infection not the fever. Fever often causes distress, which you should treat, but in, and of itself, isn’t really an issue. This can be a difficult to comprehend but should focus your attention on the really key issues. Could this child have sepsis and is there an investigation or intervention I need to perform? This is only determined by a thorough..
There is a two fold process here. The first to make a global assessment – is this child unwell? And the second to ensure you have ticked off potential sources with a thorough systems review. Make sure the child is undressed to look for relevant rashes and that an Ear, Nose and Throat examination has occurred. (Ear drums can appear red secondary to temperature induce vasodilation – this isn’t otitis media). A fundamental part of the process is…
Forehead thermometers cause far more anxiety than they are worth and I think should be banned. Sadly, while not always cheap to purchase, an electronic or chemical dot thermometer in the axilla or infra-red tympanic thermometer are the only devices that should be used. Parental concern should always be considered valid (see later) but this involves exploring with them why they thought there was a temperature not just accepting there must have been one. Once a source has been found there is always an opportunity for…
A fundamental part of all emergency care consultations with children and young people, and especially those which concern fever, should be safety net advice. This process allows for education, not just for the current illness episode, but for future episodes as well. The core construct of safety net advice is to explain what the parents should expect to happen if your diagnosis is correct and what they need to seek further help for if the situation should change. Personally I aim to ensure the parents understand I’m far more concerned about the behaviour of their child than the temperature they have. It’s also important to de-mystify appropriate use of anti-pyretics, namely paracetamol and ibuprofen do not need to be given together. Families should not leave consultations thinking fever on its own is causing harm. Having said this it is important to…
The nature of illness. You don’t need to respect fever, you do need to respect its cause.
The concerns of parents. Judging parents for having fever phobia is a sure fire way to get burnt. While the outward manifestation of concern may appear to be the fever, active listening may reveal other far more dangerous symptoms the parents may not be as concerned about.
What have you learnt this week? #WILTW