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Guidance for the diagnosis and management of children presenting with a non-blanching rash. It includes a management algorithm and photos to aid the clinician.
Children presenting with a non-blanching rash.
Medical and nursing staff in the Emergency Department and Acute Care Environments.
Management of the Child with a Non-Blanching Rash Algorithm go straight to algorithm if patient unwell.
It is not uncommon for children to present to the Emergency Department with a non-blanching rash (accounting for approx. 2% of all attendances) +/- fever and other systemic features of illness. 1, 2
The minority of children with invasive bacterial infections, such as meningococcal disease (MCD), must be distinguished from the majority of individuals presenting with a non-blanching rash secondary to a benign self-limiting illness (90% of paediatric hospital presentations with NBR do not have MCD; furthermore petechiae can be found in up to 3% of well infants). 3, 4, 5
Meningococcal disease remains the leading infectious cause of death amongst the paediatric population within both the UK and the developed world. The highest rates of invasive infection are in children < 5yrs (particularly those under 1yr of age); a second peak occurs amongst 11 – 22yr olds. Early recognition & treatment has been shown to improve outcome. 6, 7
If in any doubt – Treat as Meningococcal disease
Once the above differentials have been excluded, this leaves us with a further group of children in whom we need to distinguish invasive meningococcal disease and other underlying bacterial sepsis from self- limiting viral illness or a traumatic / mechanical cause.
The algorithm in this guideline is based on observation & investigation of these children and acts as a guide to their initial assessment and management.
* Children who have received pre-hospital IM / IV Benzylpenicillin:
**The “ILL” Criteria:
Children should be considered unwell when they have the following features:
***ESSENTIAL PROCESS PRIOR TO DISCHARGE FROM RHC:
Ensure clear & appropriate indications for return advice given to child’s parent / guardian.
Indicators of meningococcal disease (or other serious bacterial infection) include:
Evidence is based on both retrospective and prospective observational studies; the salient points include:
Where there are concerns that a NBR may be due to non-accidental injury:
Last reviewed: 23 November 2020
Next review: 30 November 2023
Author(s): Dr Aoife Ryan (Paediatric Medicine Trainee, RHCG)
Co-Author(s): Link clinician for general paediatrics: Dr Ruth Bland (Consultant in General Paediatrics, RHCG) on behalf of Department of Paediatrics, RHCG; Correspondence author: Dr Steve Foster (Consultant in Paediatric Emergency Medicine) on behalf of Department of Paediatric Emergency Medicine, RHCG.
Approved By: Paediatric Emergency Medicine & Acute Paediatric Medicine Clinical Governance Groups
Reviewer Name(s): Paediatric Clinical Effectiveness & Risk Committee