Most parents who call about a fever have already done the right things. The paracetamol has gone in, the room has been cooled, the temperature has been checked more times than anyone will admit to. The question by the time the phone is picked up is rarely about the number on the thermometer. It is whether this is the ordinary kind of unwell, or the other kind.
A child with a fever is usually a virus. That sentence is true and it is also not the sentence a parent can use at 11pm. The useful question is how the child looks between the spikes, and whether anything in the picture belongs on the other list.
Chest pain, signs of a stroke, severe breathlessness, heavy bleeding, a severe allergic reaction or symptoms of sepsis need 999 or A&E immediately. In a child, a floppy body, a rash that does not fade under a glass, severe work of breathing, or a baby under 3 months with a fever belongs on that same list.
When a child with a fever needs to be seen today
The number on the thermometer is information. It is not the decision. Children run high temperatures with ordinary viruses. They also look surprisingly well in between. What I care about more is colour, activity, breathing, hydration, and whether a rash or a neck or a soft spot has joined the party.
NICE sets this out for children under 5 as a traffic light: green features that can wait and be watched, amber features that mean we should be seen today, red features that mean 999 or A&E now. I use that skeleton. I also use the parent. A parent who says “this is not my child” is giving me a clinical sign. I listen to that before I listen to the gadget.
Same day, at this clinic, means an examination. It does not mean a guess about tonsils from a description of drool. Throats look different in the room. Ears look different in the room. Work of breathing looks different in the room. If you need a decision today, bring the child.
Babies under 3 months with a fever are a different conversation. Their immune systems do not advertise well. I have a low threshold for sending those children in, even when they look not too bad in a warm living room. That is not panic. That is how this age group behaves, and how NICE treats it.
It is worth saying plainly. Most of these children go home with a virus, a plan, and a parent who has been told what would change my mind. Some do not go home from here. Both outcomes are the clinic working.
What I look at when a child is hot
What I look at in clinic starts at the door. How they are being carried. Whether they look at me. Whether they object to being undressed, which is a good sign, or lie there and let it happen, which is not. Colour of the lips and the skin. Mottling. A rash, and whether it fades when I press a glass or the side of a tumbler on it. That glass test is crude and it is still one of the most useful things a parent can do at home. If it does not fade, you are not waiting for us. You are dialling 999.
Then breathing. Rate. Effort. Recessions under the ribs. Flaring of the nose. Grunting. Wheeze. A pause that is too long. I count when the child is quiet if I can, not while they are screaming at the otoscope, because a scream wrecks a respiratory rate. Oxygen saturation if we need it. In a baby, feeding is part of the respiratory exam: an infant who cannot feed because they cannot breathe is telling you the chest, not the appetite.
Then hydration. Wet nappies in the last 12 hours. Tears. How the mouth looks. How quickly colour returns after I press a finger on the skin. A child who is drinking little sips and still passing urine is in a different place from a child who has gone 12 hours with a dry nappy and a dry mouth.
Then the rest, in a sensible order. Neck stiffness in a child old enough to show it. The soft spot in a baby, whether it is bulging. Ears. Throat. Chest. Tummy, because a pneumonia in a child can present as abdominal pain, and appendicitis can present as a fever. Limbs, because a limp with a fever is a joint until someone has looked, and a hot joint is not a wait and see. Urine, if the story fits, particularly in infants who have fever without a focus.
I ask what has already been given, and when. Paracetamol and ibuprofen are ordinary tools. They make a child more comfortable. They do not, on their own, tell you the infection is settling. A child who looks well once the paracetamol has worked, and looks like themselves in between doses, is often the ordinary kind. A child who never returns to themselves between doses is not. The pattern matters more than the single reading.
Fits. A brief febrile seizure in a child of 1 to 3 who recovers quickly is usually a conversation and a look, not an automatic admission, but I still want to see them, and any fit that is long, repeated, or on one side of the body is 999. Do not wait for a slot.
The second layer, when this comes up, is the parent. Sleep debt. The other child at home. The grandparent on the phone with a meningitis story from 1989. None of that is silly. Meningitis is rare and it is why we do the glass test and the neck and the colour. Naming the rare thing, and then showing what I am looking at so it is not a ghost, is part of the work. Reassurance that has not been specific is just a pat.
I also ask about immunisations, recent travel, who else is unwell in the house, and whether there is a surgical history or a child who already has a chest or heart problem. A child with asthma who is hot and working hard is not “just a virus” until the chest has been treated as asthma as well.
If I do not know yet, I say so. Let us look again in 24 hours, or in 6 hours if amber features are sitting there, is a legitimate plan. It needs a parent who can get back, and a list of red features they can act on at 2am without ringing us first.
When to come in sooner
Some of this should skip us. Some of it should come today.
- A rash that does not fade under a glass, a floppy child, severe work of breathing, a blue or mottled colour, or a baby under 3 months with a fever: 999.
- A fit that lasts, repeats, or looks one sided, or a child who does not wake properly afterwards.
- A hot swollen joint, or a limp with fever.
- No wet nappy for 12 hours, no drinks at all, or bile stained vomiting.
- A parent who says this is not their child, and the child is not returning to themselves between medicines.
- A child who already has a serious medical condition, and this fever is not behaving as their usual virus behaves.
If you are in between those lists, book today if you can. Watching a child overnight is reasonable when they are drinking, they have no red features, and you have a plan for what would end the watch. Watching without a plan is just hoping.
How we see children here
Clinique Alpa in Palmers Green can see children, subject to the diary. A 30 minute appointment is £100. We will undress them, look, and tell you what we think, including when I think this is A&E and not us. If the child is too unwell to travel, or you have other children and no spare adult, a home visit is £250 on a weekday, £325 at weekends and on bank holidays, and £450 for a start from 20:00, up to an hour. Ask for that if the house is the safer room.
Same day slots exist when the diary has them. They are not a promise we will squeeze everyone in. Ring 020 8882 8088 early and say it is a child with fever. If we cannot take you, we will say so, and we will tell you whether 111, your NHS GP, or A&E is the better next door. Read the same day GP page if you want the practical bit before you call.
If a urine test or bloods would change the decision, we say so. Blood-test prices include the £20 collection fee, and in small children we only draw if it earns its place. If a paediatrician is the next step, a referral letter is included in the consultation fee after the assessment, or we send you to A&E if that is the honest destination. Fees are on the fees page.
With your consent we write to the NHS GP. Children accumulate notes. The next doctor needs today’s examination, not a parent’s memory of it from a corridor.
If this is the ordinary kind, you will leave with a review window in actual hours, not with a vague instruction to see how they go. If it is the other kind, you will leave towards hospital, with that said plainly.
Get the child examined rather than guessing from the thermometer. Read our fees page, or call 020 8882 8088. 30 minutes £100. Home visits £250 weekday, £325 weekend and bank holiday, £450 from 20:00. Published in full. In an emergency call 999. Subject to availability.
Written by Dr Mitesh Parmar, MBBS MRCGP, GP and founder of Clinique Alpa, 466 Green Lanes, Palmers Green, London N13 5PA. This article is general information, not personal medical advice. In an emergency call 999. For NHS advice call 111 or visit nhs.uk.