Red Flags
- Child appears unwell
- Red/amber on vital signs
- Rapidly spreading rash
- Safeguarding concerns
Differential Diagnosis
Urgent Action Needed
- Invasive Meningococcal Disease
- Sepsis/Alternative Bacterial Infection
- Acute Leukaemia
Management of Urgent Differential Diagnosis
- Arrange emergency transfer to hospital for any child with red flags for meningococcal disease or sepsis.
- Inform the Children’s Hospital ED on the advice line 0117 342 8666.
- Refer to NICE guidelines for pre-hospital management of meningococcal disease, including administration of IM/IV antibiotics.
- Acute leukaemia should also be referred for same day ED assessment.
Other Differential Diagnosis
- Viral Infection
- Idiopathic Thrombocytopenia
- Henoch-Schonlein Purpura
- Haemolytic Uraemic Syndrome
- Mechanical
- Non-Accidental Injury
Information about Alternative Diagnoses
Viral Infection
Petechial rashes can present with URTI/flu-like illness or gastroenteritis, commonly caused by adenovirus and enterovirus.
Idiopathic Thrombocytopenia (ITP)
Most common haematological cause of NBR in a well child, usually with a preceding viral illness. Refer to the Bristol Children’s Hospital guidelines for assessment, investigation, and management - ITP guidelines.
Henoch-Schonlein Purpura (HSP)
IgA mediated vasculitis often occurring after a group A streptococci infection. A typical rash presents on the back of the legs, buttocks, and arms. Refer to the Bristol Children’s Hospital guidelines for assessment, investigation, and management - HSP guidelines.
Haemolytic Uraemic Syndrome (HUS)
Mostly a result of infection by E. coli 0157, presenting with the triad of thrombocytopenia, acute kidney injury, and haemolytic anaemia. Contact with farm animals or contaminated food/environments should be considered in children presenting with acute bloody diarrhoea. There can be a period of up to 7 days between the diarrhoea and the onset of HUS.
Mechanical
Forceful coughing or vomiting can result in a petechial rash, specifically in the SVC distribution. Alternative causes of petechial rash need to be excluded.
Non-Accidental Injury (NAI)
Consider non-accidental injury, especially if there are other concerning examination findings such as linear marking, bruising, or other injuries. BNSSG have pathways for NAI in non-mobile children and mobile children: