Any red feature, or a non-blanching rash, neck stiffness or reduced consciousness: treat as a medical emergency and meningococcal disease until proven otherwise. Immediate antibiotics per the sepsis pathway.
High-risk points
- Under 3 months with a temperature of 38 C or more: full septic screen and admit
- Measure temperature, HR, RR, capillary refill and oxygen saturations
- Parental concern and clinician gut feeling matter
- Do not rely on response to antipyretics to grade severity
Source hunting
- Urine sample in any fever without an obvious source
- Examine ears, throat, chest, abdomen, joints and skin
- Consider Kawasaki disease if fever 5 days or more
- Consider UTI, pneumonia, meningitis, septic arthritis, osteomyelitis
Green (low risk)
- Normal colour, responds normally, content or smiles
- Normal cry, stays awake
- Moist mucous membranes, normal skin and eyes
Amber (intermediate)
- Pallor reported, reduced activity, not smiling
- Nasal flaring, RR over 40, SpO2 95% or less, crackles
- Poor feeding, reduced urine, dry membranes, CRT 3 s or more
Red (high risk)
- Pale, mottled or blue; unrousable or weak, high-pitched cry
- Grunting, RR over 60, moderate or severe recession
- Reduced skin turgor, bulging fontanelle, non-blanching rash, status, focal signs
Assessment
1
1. Traffic light
Grade green, amber or red on colour, activity, respiratory, circulation and hydration, and other features.
Grade green, amber or red on colour, activity, respiratory, circulation and hydration, and other features.
↓
2
2. Investigate by risk
Red: bloods, cultures, urine, consider CXR and LP; admit. Amber: urine, observation, consider bloods. Green: usually no routine tests.
Red: bloods, cultures, urine, consider CXR and LP; admit. Amber: urine, observation, consider bloods. Green: usually no routine tests.
↓
3
3. Treat
Antipyretics for distress (not routinely to reduce fever alone). Antibiotics guided by source; immediate parenteral antibiotics if meningococcal disease or sepsis is suspected.
Antipyretics for distress (not routinely to reduce fever alone). Antibiotics guided by source; immediate parenteral antibiotics if meningococcal disease or sepsis is suspected.
↓
4
4. Safety-net
Written advice on warning signs and when to return. Same-day review if amber and uncertain.
Written advice on warning signs and when to return. Same-day review if amber and uncertain.
Antipyretic advice
- Paracetamol or ibuprofen if the child is distressed, not to prevent febrile convulsions
- Do not give both at once; consider alternating only if distress persists
- Encourage fluids, do not over- or under-dress
Pitfalls
- Under-investigating the under-3-month infant
- Missing a UTI (always check urine)
- Reassurance based on temperature response to antipyretics
- Missing Kawasaki disease in prolonged fever
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026