Paediatric Pathways

CHILDREN WITH A FEVER AND PETECHIAL RASH OR PURPURA PRESENTING TO HOSPITAL

Presenting Features

Temperature >38°C and non blanching rash (any size or formation)1

DIFFERENTIALS

  • Viral infections such as enterovirus and parechovirus
  • Idiopathic thrombocytopaenic purpura (ITP) - will need blood tests to confirm or refute
  • Henoch-Schonlein Purpura (HSP) / IgA vasculitis - is a clinical diagnosis with rash normally buttocks and below +/- abdominal pain
  • Non accidental injury
  • Haematological malignancy

RED FLAGS

  • Appears unwell +/- clinically shocked (including CRT >4s or hypotensive)
  • Rash spreading within department
  • Purpura (>2mm)

Red flag(s) present

 

ASSESSING SEVERITY

Potential evolving Meningococcal Disease or Disseminated Intravascular Coagulation secondary to sepsis

Prompt medical assessment & senior review

[Purpura alone, no fever & well appearing must have senior review if decision not to treat secondary to HSP/Vasculitis]

INVESTIGATIONS

Blood Tests including
FBC, U&Es, Clotting, Meningococcal PCR, CRP, Blood Culture and Blood Gas.
Virological investigations including throat swab and stool/rectal swab for enterovirus / parechovirus.

MANAGEMENT

Oxygen as Required. Escalation of care depending on haemodynamic status.
IV 3rd generation cephalosporin (as per local guidance).
If confirmed meningococcal disease, management as per national guidelines - for 7 days IVAbx, notification to public health and prophylaxis of close contacts.2

No red flag(s) present

 

ASSESSING SEVERITY

Clear mechanical cause e.g. forceful vomiting, coughing or trauma resulting in a rash in SVC distribution

Yes

 

Home with clear safety netting advice if no other reason for admission
Always discuss with senior if any uncertainty.

No

 

INVESTIGATIONS

Blood Tests may include:
FBC, U&Es, CRP, Blood Culture Virological investigations may include throat swab and stool/rectal swab for enterovirus / parechovirus.

CRP≥20mg/L or clinical deterioration1
(isolated increased WCC is not a useful predictor if used in isolation and must be taken in clinical context)

MANAGEMENT

If bloods suggest alternative diagnosis (i.e. ITP, HSP etc), manage as per local protocols. Otherwise commence empirical IVAbx.
Consider early ambulation3 on IVAbx from ED / assessment unit (admission avoidance) after 4 hours observation unless:

Ensure robust clinical governance systems and documentation in place for children being ambulated
Provide verbal and written safety netting information
Review Abx at 36-48 hours. If invasive bacterial infection unlikely / alternative diagnosis, stop Abx. If presumed invasive bacterial infection but cultures and/or PCRs negative, stop Abx after 5 days if clinical improvement and improvement in CRP.
If confirmed meningococcal disease, management as per national guidelines - for 7 days IVAbx, notification to public health and prophylaxis of close contacts.2

Normal bloods (inc. CRP<20mg/L)1

MANAGEMENT

Home with clear safety netting advice if bloods and observations reveal no abnormality or concerns. Ensure family understand the nature of condition and potential for change. Always discuss with senior if any uncertainty.

The development of this pathway involved a systematic review of the literature, collaborative development of the pathway with relevant national groups followed by formal national consultation. For more information, click here

REFERENCES
  1. Waterfield T, Maney JA, Fairley D, Lyttle MD, McKenna JP, Roland D, Corr M, McFetridge L, Mitchell H, Woolfall K, Lynn F, Patenall B, Shields MD; Paediatric Emergency Research in the UK and Ireland (PERUKI) Group. Validating clinical practice guidelines for the management of children with non-blanching rashes in the UK (PiC): a prospective, multicentre cohort study. Lancet Infect Dis. 2020 Nov doi: 10.1016/S1473-3099(20)30474-6. Epub ahead of print.
  2. NICE Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management https://www.nice.org.uk/guidance/cg102
  3. Patel S, Abrahamson E, Goldring S et al. Good practice recommendations for paediatric outpatient parenteral antibiotic therapy (p-OPAT) in the UK: a consensus statement. J Antimicrob Chemother 2015; 70: 360-73.