Cases/Patient < 19 years old

Fever in a Seven Week Old Baby — Free SCA Practice Case

Mother calling about her 7 week old's fever

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

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Patient Profile

Full Name

Arlo Treharne

Age

0 years

Consultation Type

Telephone

Age

7 weeks

Situation

Telephone Consultation. Same day call booked by Arlo's mother.

Reason for Encounter

"Arlo felt hot this afternoon and measured 38.3. He's feeding a bit less. Can I give him Calpol?"

Medical Records (Arlo)

●PMH: Born at term, vaginal delivery, 3.4 kg. 6 week check normal, weight 4.9 kg.
●Medications: Vitamin D drops.
●Allergies: NKDA.
●Immunisations: First set due at 8 weeks.
●Social: Lives with his parents and sister aged 4.

Caller context

Gwyneth Treharne, aged 35, registered at the practice. Nothing relevant in her records.

Patient Script

For the friend playing the patient role

Character Overview: You are Gwyneth Treharne, a 35 year old dispensing assistant at a community pharmacy, phoning the surgery about your son Arlo, who is 7 weeks old. You are on maternity leave and live with Arlo, your daughter Seren, who is 4 and in reception class, and your partner Dafydd, a wind farm technician who works offshore and is away for another three days with very little phone signal. Your mother Nerys lives ten minutes away. You are capable, dry and matter of fact, and pride yourself on not fussing; people ask you about Calpol every day at work. You speak in short, tidy sentences and sound calm, but you are quietly worried and a little defensive about being thought a worrier. You answer what you are asked and do not elaborate.

Opening Sentence: "Hello, it's Gwyneth Treharne, I'm ringing about my son Arlo, he's seven weeks. He felt hot this afternoon and I took his temperature and it was 38.3. He's not feeding quite as much as usual but he's smiling and he seems himself. I just wanted to check about giving him some Calpol, and I'd rather not end up in A&E if I can help it."

History if Asked (Data Gathering Phase)

●How it started: "I picked him up at about four this afternoon after his nap and he felt hot against my chest. He was fine this morning."
●How the temperature was taken: "Our digital thermometer, under his arm. It said 38.3. I checked again half an hour later and it was 38.2. I know forehead strips are useless, so I didn't use one."
●What has been given: "Nothing. I wanted to ask first. I know the Calpol box says from two months, and he's seven weeks and a couple of days."
●Feeding: "I'm breastfeeding. He normally feeds fifteen to twenty minutes each side about every three hours. The last two feeds he came off after five or six minutes and wasn't interested in the second side."
●Wet nappies and stools: "Three wet nappies since this morning. Normally it would be more like six by now. His last dirty one was at lunchtime, normal yellow and soft."
●Vomiting and cough: "No vomiting, just a tiny bit of milk back up after feeds as usual. No cough."
●How he is in himself: "He smiled at me just before I rang. He's looking around and cries normally when he's hungry. He wakes for his feeds, though he's been a little quieter than usual this afternoon."
●Colour and warmth: "Pink, not pale or blotchy. His hands and feet feel warm. His chest and tummy are hot."
●Breathing: "It sounds normal. He's not breathing fast, there's no grunting, and his tummy isn't pulling in. I counted earlier because I was worried and it was about forty a minute."
●Skin and soft spot: "No rash. I looked him over at his last change. The soft spot on his head feels flat, the same as always."
●Floppiness or fits: "No. He moves his arms and legs as normal. No jerking or staring."

Ideas, Concerns, Expectations

Gating note: Gwyneth does not raise any of the following unprompted. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

●Ideas: She thinks Arlo has caught Seren's cold, because Seren has had a runny nose and cough for a week and has been kissing the baby. She knows babies run hot sometimes and half expects to be told to give Calpol and watch him. "Seren's been coughing all over him for a week, so I assumed he'd caught it. Babies get temperatures, don't they?"
●Concerns: She does not want to be the mother who rushes in over nothing. Last year she took Seren to A&E with a barking cough, waited six hours, and was told it was a virus and sent home at midnight. She also dreads Arlo being kept in, with Dafydd away and Seren to think about. She has heard that very young babies get "a needle in the back". "Last time we sat there six hours and they said it was a virus. I don't want to go through that again, not with Dafydd away."
●Expectations: She expects reassurance that it is probably Seren's cold, advice on Calpol, and a plan to watch him overnight and come in the morning if he is no better. She does not expect to be sent anywhere tonight. "I was hoping you'd say give him a dose, keep an eye on him, and bring him in if he's no better in the morning."

If Asked: Medical History and Medications

Gating note: Gwyneth answers each of these when the doctor asks.

●Pregnancy and birth: "A normal pregnancy. He was born at thirty nine weeks, vaginal delivery, 3.4 kilos. My waters broke and labour started within a few hours. I had no temperature in labour and no antibiotics. As far as I know I'm not a carrier of anything. I'd have been told."
●After birth: "Home the next day. A bit yellow for a couple of days, then it went. Never in the special care unit."
●Medicines and allergies: "Vitamin D drops every day and nothing else, and nothing today. No allergies that we know of."
●Immunisations: "He hasn't had any yet. His first ones are booked for next week."
●Family: "Nothing that I know of."

Social History and Lifestyle Impact

●Household: Gwyneth is alone with Arlo and Seren tonight. Dafydd is offshore for another three days.
●Seren: She has had a runny nose and cough for about a week but no temperature. She is in the lounge watching a film and cannot be left alone.
●Help: Nerys lives ten minutes away and would come round if rung. If the doctor suggests it, Gwyneth says she could ring her straight away, and Nerys could sit with Seren or come along.
●Transport: She has a car with a baby seat and is happy to drive. She would not feel able to drive and watch the baby on her own if he became unwell.
●Work and mood: On maternity leave. Breastfeeding is going well. She is short on sleep but not low in mood.

If Asked: Associated Symptoms

Gating note: Gwyneth answers these only when asked. Every one is negative unless stated.

●If asked about sick contacts or visitors: "Seren, as I said. Mum held him yesterday and was fine. No one with a cold sore has kissed him. Nobody has had diarrhoea or been sick."
●If asked about urine: "Nothing unusual. The nappies don't smell strange and he doesn't seem in pain passing water. He just has fewer."
●If asked about the cord, skin, eyes or ears: "The cord came off at ten days and healed. No redness or pus, no sticky eyes, no swelling anywhere."
●If asked about a swollen limb or moving a limb less: "No. He's kicking both legs equally."
●If asked whether she can bring him in or be examined today: "Yes, if you think he needs seeing. I can get in the car."
●If asked to examine him herself or do tests by phone: she describes what she can see, but declines anything clinical. "I'm not going to poke him about. Can't someone just look at him properly?"

Responses to Management (The Negotiation Phase)

●
If the doctor says Arlo needs to be assessed in hospital today:
- ●Reaction: Pauses, then pushes back. "Right now? He's smiling at me. Is that really necessary?" If told that a baby under three months with a temperature of 38 or more needs urgent checking because serious infection can look mild at first: "I didn't know it was that clear cut." If the doctor makes it optional ("you might want to go"), she says: "So it's up to me? I'll see how he is, then." She accepts a single clear instruction with a reason.
●
If the doctor discusses A&E, waiting and what will be done:
- ●Reaction: Worried about the wait and about needles. "Last time it was six hours. And what will they do to him?" If told he will be seen promptly, will probably have blood and urine tests, may start antibiotics through a drip, may have a lumbar puncture and may stay in: "Stay in? What about Seren?" Then, quieter: "It's not something really serious, is it?" She settles if told that most babies have a virus but it needs ruling out, and that coming now is right.
●
If the doctor gives advice about Calpol:
- ●Reaction: If told not to give it: "Oh. But he's hot." If told it is not licensed under two months and would not make him safe and could hide a fever that needs checking: "Fair enough. I only asked because the box says two months." If told to go ahead: "Okay, I'll give him a dose and see," and does not question it.
●
If the doctor asks how she will get there, or about Seren and Nerys:
- ●Reaction: Practical. "I can drive. Mum could be here in ten minutes and either have Seren or come with me." If told to ring Nerys and leave straight away: "Right, I'll ring her now." If told to dial 999 as she is alone with two children: "An ambulance, for a baby who is smiling?" then, with reasons, "Okay, if that's what's best."
●
If the doctor suggests 111, a call back, or being seen tomorrow instead:
- ●Reaction: Hopeful. "So the morning would be fine? I can bring him as soon as you open." She gives way only when told plainly that waiting is unsafe.
●
If the doctor gives safety netting or what to look for on the way:
- ●Reaction: Wants specifics. "What should I be looking for in the car?" If vague ("keep an eye on him"): "Keep an eye on what, exactly?" She repeats back clearly when given signs such as pale, blue or blotchy skin, fast breathing or grunting, floppiness, being hard to wake, a fit, or a rash that does not fade, and what to do, and says she will keep feeding him and keep him lightly dressed.

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Arlo is 7 weeks old with a temperature of 38.3°C, feeding a little less and still smiling. His mother is composed, knows the box says from two months, and hopes for reassurance, a dose and a quiet night. The station tests whether the candidate applies an age specific rule over a reassuring picture and persuades a capable, reluctant mother to act tonight.
●The model plan: confirm the temperature was measured properly, screen quickly for features that make this an emergency, recognise that 38°C or more under 3 months is high risk, and arrange face to face assessment by a paediatric team today. Advise against paracetamol, pre alert the receiving unit, sort out Seren and transport with her, give specific safety netting for the journey, and make sure the practice checks that Arlo arrives.
●Acceptable alternatives: 999 ambulance if she is alone and no second adult is available, or the car with Nerys beside Arlo if she can come within minutes. Referral directly to a paediatric assessment unit or to a children's emergency department are both fine. Asking Nerys to come first is acceptable only if departure follows immediately. Seeing him in the practice first is acceptable only if it happens at once and he is sent on without delay.

Why Age Under 3 Months Changes Everything

●Young infants have immature immune systems and they show serious infection poorly. A baby with bacteraemia, urinary tract infection or meningitis may feed adequately and smile in the early hours. Parents and clinicians over rely on how a baby looks.
●NICE NG143 (fever in under 5s, last updated November 2021) lists a temperature of 38°C or more in a child under 3 months as a red feature in its traffic light table, and poor feeding in infants as an amber feature. NICE NG254 (suspected sepsis in under 16s, published November 2025, partially replacing NG51) also lists 38°C or more under 3 months as a high risk criterion, with emergency medical care for any high risk child.
●A smile, normal colour and reasonable cry are reassuring features that cannot overrule the age threshold. Under 3 months, height of temperature is a trigger in itself, whereas for children over 6 months NG143 says not to use the height of temperature alone.
●The reported parental perception of fever should be taken seriously (NG143). Here the mother's reading is accurate: a digital axillary thermometer is acceptable, and forehead strips are not.

A Focused Telephone History

●Establish how the temperature was measured, the timing and whether anything has been given. A response to paracetamol does not distinguish serious from non serious illness (NG143).
●Ask about feeding in specifics: duration against usual, number of wet nappies and vomiting. Here the feeds are down to a third of usual length and wet nappies are about half the usual, which are amber features and support, not weaken, the case for urgent review.
●Check alertness and tone, colour and perfusion, breathing, fontanelle, rash, fits and floppiness. A non blanching rash, grunting, a bulging fontanelle or an infant who does not stay awake would make this a 999 call.
●Ask about a source: cough, urine, stool, cord, skin, joints. In young infants, urinary tract infection and bacteraemia are the common serious causes.
●Birth history matters: gestation, maternal fever in labour, group B streptococcus, neonatal unit stay and jaundice. Here all are reassuring, so the case is driven by age and feeding.
●His first immunisations are not yet due, so vaccination cannot explain the fever (NG143 notes vaccines can cause fever in under 3 months).
●Ask what she thinks is happening and what she hopes for. Her answers explain her reluctance and shape how the advice is given.

Where and How Quickly Arlo Should Be Seen

●NG143 recommends that a child with a red feature but no immediately life threatening illness is referred urgently to a paediatric specialist, and for remote assessment says face to face assessment within 2 hours. NG254 advises emergency medical care for high risk criteria, transferring immediately by the most appropriate means (usually 999), with pre alert of secondary care.
●In practice this means a children's emergency department or paediatric assessment unit, with a phone call ahead. A routine GP appointment, a call back or NHS 111 would add delay and is not the right route.
●Transport is a judgement. If a calm second adult can come quickly and sit with the baby, a private car is reasonable. If Gwyneth would be alone with two children, a 999 ambulance is justified, and pre alerting happens through the ambulance control as well. Waiting for Nerys for 10 minutes then leaving at once is acceptable; waiting for Dafydd is not.
●Document the advice, her understanding and the plan. Ask the practice to confirm that Arlo has arrived, for example by phoning the unit or Gwyneth within an hour or two. If she cannot go, she must say so, so that an ambulance can be sent.

What Happens at the Hospital

●NG143 sets out the paediatric assessment of infants under 3 months with fever: observations (temperature, heart rate, respiratory rate), full blood count, blood culture, C reactive protein and urine testing, with a chest X-ray only if respiratory signs are present and stool culture if there is diarrhoea.
●Lumbar puncture is performed in infants under 1 month and in those aged 1 to 3 months who appear unwell or whose white cell count is below 5 or above 15 x 10^9 per litre. Parenteral antibiotics are given to infants under 1 month with fever, to those aged 1 to 3 months who appear unwell, and to those with an abnormal white cell count. The regimen is a third generation cephalosporin plus an antibiotic active against listeria.
●Tell her honestly that Arlo may be admitted, that most infants turn out to have a viral illness, and that the tests are to rule out serious infection. Local infant fever pathways may adjust these steps.
●Oral antibiotics from primary care are not advised for fever without a known source (NG143).

The Paracetamol Question

●NG143 says to consider paracetamol or ibuprofen only for children with fever who appear distressed, and not with the sole aim of reducing temperature. Arlo is not distressed.
●The BNF for Children notes that oral paracetamol is not licensed under 2 months, though it lists doses from 1 month. The label is correct, but Gwyneth's real question is whether to wait at home.
●Giving a dose would not make him safe, could mask the fever and might delay assessment. The hospital team can decide if he becomes distressed.
●Do not use tepid sponging, and do not underdress or overwrap him. Keep him feeding with breast milk.

Safety Netting for the Journey and the Wait

●A specific list is more useful than "keep an eye on him". Look for pale, blue, mottled or ashen skin or lips, fast breathing, grunting or the tummy sucking in, floppiness or a weak or high pitched cry, being hard to wake or not staying awake, a fit, a bulging soft spot, and a rash that does not fade under a glass or fingertip pressure.
●If any appears on the way: pull over, call 999 and tell the call handler he is 7 weeks old with a fever.
●Keep feeding him, and take his red book.
●Make sure she knows to ring back if anything changes or if she cannot get there.

Handling a Competent, Reluctant Parent

●Gwyneth dislikes being told she is overreacting, knows the label and remembers a long, unhelpful A&E visit. Argue with the evidence, not her competence.
●Acknowledge that she did well, give the age rule in one sentence, and then give one clear instruction. Offering options lets her choose the one she hoped for.
●Honesty about needles and a possible stay builds more trust than false reassurance. Do not promise a short wait.
●Solve her barriers with her. Dafydd is away, Seren cannot be left and Nerys is ten minutes away. Once these are resolved, the objections fall away.

Common Mistakes in This Station

●Taking 38.3°C, a smile and normal colour as reassuring, or accepting a cold in the sister as the cause.
●Advising paracetamol and overnight observation, or offering a morning appointment, a call back or NHS 111.
●Offering hospital as an option rather than a clear instruction, so she chooses to wait.
●Not asking about wet nappies, feed duration, alertness and breathing, or missing the birth history.
●Prescribing or advising oral antibiotics.
●Giving vague safety netting such as "come back if he gets worse".
●Not solving who will look after Seren and how they will travel, or giving no handover and no check that she has arrived.
●Using terms such as sepsis or lumbar puncture without explanation.

Mapped to the RCGP curriculum topic: Patient < 19 years old.

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