Paediatric Clinical Guideline
Resus/A&E 13.1
February 2002
MANAGEMENT OF THE CHILD WITH A NON-BLANCHING RASH.
Children commonly present with a non-blanching rash, with or without other features
of illness. They are a diagnostic dilemma. The minority with invasive meningococcal
disease and other invasive bacterial infections (about 10%) need to be distinguished
from the majority with benign self-limiting illnesses. Recent studies 1-5 have allowed
us to derive an evidenced-linked guideline for the management of these children.
Differential Diagnosis.
The differential diagnosis of a non-blanching rash includes:
 Meningococcal disease (MCD)
 Sepsis with other bacteria (uncommon)
 Viral illnesses
 Trauma/Mechanical/NAI
The following groups are distinct and usually not difficult to diagnose:
 Idiopathic thrombocytopenia (ITP)
 Henoch Schonlein purpura (HSP)
 Acute leukaemias
 Haemolytic uraemic syndrome (HUS)
They have other specific signs or symptoms:
ITP: Usually well children with multiple bruises and petechiae noted over several
days
HSP: Usually a classical distribution of purpura, bruising and urticaria on the
buttocks and extensor surfaces of the limbs, sometimes associated with joint or
abdominal pain
Acute leukaemias: Symptoms of slower onset associated with anaemia,
lymphadenopathy or hepatosplenomegaly
HUS: Oliguria/anuria associated with anaemia, usually following a diarrhoeal illness
This leaves a further group of children in whom we need to distinguish MCD and
other bacterial sepsis, from self- limiting viral illness or trauma.
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Paediatric Clinical Guideline
Resus/A&E 13.1
February 2002
The following algorithm is based on observation and investigation of these children
and provides a simple guide to their assessment and management. Prior
administration of penicillin does not alter the algorithm but these children
should have a senior review prior to discharge in order to reassure parents.
Non blanching rash
Purpura
(lesions >2mm in diameter)
Yes
Admit and treat as MCD at once
(See MCD Protocol)
No
Ill
(irritable, lethargic, toxic)
and/or
Capillary refill > 2secs
and/or
Hypotensive
Yes
No
Rash confined to the SVC distribution
(above the nipple line)
No
Admit and observe
FBC, blood culture, CRP and
meningococcal PCR
If well, no spread of rash and
CRP<6mg/l, discharge otherwise admit and treat as MCD
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Yes
Discharge if no other
clinical concerns
Paediatric Clinical Guideline
Resus/A&E 13.1
February 2002
References
1. Mandl KD, Stack AM, Fleisher GR. Incidence of bacteraemia in infants and
children with fever and petechiae Journal of Pediatrics 1997;131:398-404
2. Brogan P, Raffles A. The management of fever and petechiae: making sense of rash
decisions. Arch Dis Child 2000;83:506-507.
3. Marzouk O, Bestwick K, Thomson AP, Sills JA, Hart CA. Variation in serum Creactive protein across the clinical spectrum of meningococcal disease. Acta Paediatr
1993 82:729-33.
4. Nielson HE et al. Diagnostic assessment of haemorrhagic rash and fever. Arch Dis
Child 2001 85:160-165.
5. Wells LC, Smith JC, Weston V, Collier J, Rutter N. The child with a non-blanching
rash: How likely is meningococcal disease? Arch Dis Child 2001 85:218-222.
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Paediatric Clinical Guideline
Resus/A&E 13.1
February 2002
PAEDIATRIC CLINICAL GUIDELINES
ISSUE:
VERSION: FINAL
Title: Management of the Child with a Non-blanching Rash
Author:
Job Title:
Dr Louise Wells
Paediatric Specialist Registrar
First Issued: February 2002
Date Revised:
Review Date: February 2005
Document Derivation:
i.e. References:
Included in document
Consultation Process:
Ratified By:
Paediatric Clinical Guidelines Committee
Chaired By:
Dr Kate Armon
Consultant with Responsibility: Dr Stephanie Smith
Distribution:
Training issues:
All wards QMC and CHN
Included in Induction Programme
Audit:
This guideline has been registered with Nottingham City Hospital NHS Trust
and QMC Clinical Guidelines Committee. However, clinical guidelines are
’guidelines’ only. The interpretation and application of clinical guidelines will
remain the responsibility of the individual clinician. If in doubt contact a senior
colleague or expert. Caution is advised when using guidelines after the
review date.
MANUAL AMENDMENTS RECORD
(please complete when making any hand-written changes/ amendments to guideline and not processed
through guideline committee)
Date
Page 4 of 4
Author
Description