Feverish illness is still a significant cause of death in the under 5s

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Dr John Crimmins shows how NICE quality statements can promote best practice in the assessment and monitoring of children aged under 5 years with unexplained fever

Arrange a face-to-face consultation wherever possible
Listen to parents—they know the child best
Trust clinical acumen—if a child appears ill to a healthcare professional, then that is a high-risk sign (see the red column of the traffic light table4)
Take and record the child’s temperature with an electronic aural or axillary thermometer
Measure and record the heart rate
Measure and record the respiratory rate and assess respiratory effort
Assess the child’s circulation and hydration, including measuring and recording capillary refill time
Look for signs and evidence of:

specific infections (e.g. non-blanching rash)
pneumonia
urine infection (by testing)

Use the traffic light system as an assessment tool and indicator of the need to refer to a specialist team
Provide the parents/carers with appropriate safety net information and advice

Assessing a child aged under 5 years with a fever is an everyday part of primary care. It is estimated that in any year, up to 40% of children in this age group are seen by healthcare professionals because of a febrile illness.1 The vast majority of these children will have a mild self-limiting viral illness. A few children, however, will be in the early stages of a more serious bacterial infection, for example a urinary tract infection, bacterial pneumonia, or meningitis.

The need for a quality standard

Febrile illness remains a significant cause of death in infants and children under the age of 5 years, as shown in Figure 1 (see below).2

International comparative studies show that the UK still has higher death rates for infants and children aged under 5 years than other comparable Western nations (worse than Nordic countries in in particular)3 so although the assessment of febrile children is generally good, we do need to improve.

Figure 1: Contributions of the four major causative categories to childhood mortality, England and Wales, 2004*²

Diagnosis and assessment

Early symptoms and signs of serious bacterial infection (SBI) are generally very similar to those of self-limiting viral infections. The severity of the disease process and ultimate outcome are inextricably linked to early diagnosis and appropriate management. A further factor relevant to assessing a child with a fever is the changing pattern of healthcare; the initial contact currently may not be to the child’s GP but to a telephone helpline, out-of-hours (OOH) service provider, or an accident and emergency (A&E) service (paediatric or general).

The aim of 2013 NICE Clinical Guideline (CG) 160, Feverish illness in children: assessment and initial management in children younger than 5 years (updating and replacing NICE CG47 [2007], see www.nice.org.uk/cg160)4 and now NICE Quality Standard (QS) 64 for Feverish illness in children under 5 years (published in July 2014, see www.nice.org.uk/guidance/qs64)1 is to provide a framework for assessment and help in identifying those children who are most at risk of being in the early stages of an SBI and of managing them promptly and effectively. This framework applies to any setting, the expectation being that the assessment will be equally effective in each of the assessment situations outlined in the previous paragraph. See Table 1, below, for a list of the quality statements in NICE QS64.1 The statements have been developed from the updated guideline (NICE CG160) and represent aspirational but achievable goals in the assessment and management of febrile children. The basis for and principles behind each of the quality statements are given below.

Table 1: NICE quality standard for feverish illness in children under 5 years (QS64)¹
No	Quality Statement
1	Infants and children under 5 years with unexplained fever have their risk of serious illness assessed and recorded using the traffic light system.⁴
2	Infants and children under 5 years who are seen in person by a healthcare professional have their temperature, heart rate, respiratory rate and capillary refill time measured and recorded if fever is suspected.
3	Infants and children presenting with unexplained fever of 38°C or higher have a urine sample tested within 24 hours. See statement 1 of NICE quality standard 36 on Urinary tract infection in infants, children and young people for the quality measures, what the quality statement means, source guidance and definitions.⁵
4	Parents and carers who are advised that they can care for an infant or child under 5 years with unexplained fever at home are given safety net advice, including information on when to seek further help.
NICE (2014). Feverish illness in children under 5 years. Quality Standard 64. Available at: www.nice.org.uk/guidance/QS64. Reproduced with permission.

NICE Quality Standard 64 on feverish illness in children and young people

Risk of serious illness—statement 1

Using the traffic light system

There is no single or simple means of differentiating between children in the early stages of a viral illness and children with an SBI. The traffic light system was developed and modified during guideline development from available evidence of possible early indicators of SBI and other assessment scoring systems published previously, such as the Yale Observation Scale. It is intended as an easy-to-use assessment framework for healthcare professionals, whatever their level of experience and training. It focuses on the significant parts of the history, observation, and examination of a sick child that may be indicators of early SBI. Further information about the traffic light system can be found in NICE CG160 (and see bit.ly/1toP8tX);4 see also this author’s 2013 article on NICE CG160 in Guidelines in Practice at bit.ly/1rzZrHw6

It is reassuring to know that a child who fits entirely into the green category is at very low risk of SBI as this matches subjective impressions. Similarly, it is no surprise that a child with symptoms or signs falling into the red category needs urgent specialist intervention, as this again will be the immediate subjective impression. The presence of features in the amber column should raise awareness of an increasing risk, and if two or more amber features are present, then referral to a specialist unit should be considered.

Measuring and recording vital signs—statement 2

Several of the parameters used in the traffic light system depend on the history of the presenting illness and subjective assessments of the child. Objective measurements are also essential and these should be taken and recorded in every assessment:

Fever. Height or duration of fever alone is not directly related to the severity of the disease, although it is important in young infants. Temperature should be taken with an electronic aural or axillary thermometer and recorded during any face-to-face consultation
Heart rate. Heart rate varies with age and with temperature. Recent studies were available during the development of the updated (2013) guideline so that upper limits of expected heart rate for age groups have been included in the traffic light table; a heart rate that exceeds these expected rates is an amber feature and therefore heart rate should be taken and recorded
Respiratory rate. Respiratory rate also varies with age, temperature, and respiratory tract involvement in the disease. As with heart rate, exceeding the upper limits of normal respiratory rate has been defined and identified as a factor for increased risk of SBI and should therefore be taken and recorded. Respiratory effort should be noted and recorded. Moderately increased effort may be indicated by nasal flaring and use of accessory muscles of respiration (intermediate risk) while grunting respiration and moderate to severe chest indrawing indicates very significantly increased work of breathing (high risk)
Capillary refill time is increased where the circulation is compromised, for example in dehydration or other hypovolaemic states. If it is measured peripherally (e.g. in hands or feet), the findings can be affected by extraneous factors such as ambient temperature, so capillary refill time should be measured centrally and recorded as an objective indicator of circulatory status.

Urine testing—statement 3

Typical symptoms and signs of urinary tract infection (UTI) may be absent or impossible to elicit in children, particularly at a pre-verbal stage. It is important to determine whether a UTI is present if fever is unexplained so that appropriate treatment can be given and to prevent permanent renal damage from untreated infections.

As detailed in NICE CG54 on UTI in children,7 urine should be collected by a clean catch technique and tested for presence of nitrites and leucocytes; if either or both are present, the specimen should be sent for microscopy and culture.

Safety net advice—statement 4

The initial assessment of a child with fever may take place at any stage during the natural progression of the disease. It is vital to explain to parents and carers that if there are no features that raise concern at the time of consultation, this does not mean that the illness could not progress to become more serious. Verbal and written safety net advice should therefore be given, in a format the parents and carers can understand, and should include:1

expected course of the disease based on provisional diagnosis
specific symptoms or signs that might indicate significant deterioration or give cause for concern
how and when to seek further medical advice should there be deterioration or further concern.

Implementing the quality standard in primary care

Traffic light table

The traffic light table4 (see bit.ly/1toP8tX) has already been widely used in primary care and copies are readily available; the table should also be readily available in OOH centres, A&E departments, or anywhere else where acute assessments might be made. Currently, this is the standard that determines (both clinically and medico-legally) whether an appropriate assessment has been performed, so its use should become universal.

Measuring and recording vital signs

Temperature, heart rate, respiratory rate, and capillary refill time should each be recorded in the medical records whenever a febrile child is examined. Together they provide an unbiased, objective indicator of the status of the child at the time of examination and a vital baseline for comparison if further assessment is required; changes may be the best indicator as to whether the child’s condition is improving or deteriorating.

The regularity of recording each of these parameters in medical records could be the basis for clinical audits and evidence of improvements in clinical practice (see Audit points, below).

Urine testing

Obtaining appropriate urine specimens from children is difficult and time-consuming. It is clear, however, that some UTIs go undiagnosed and also that inappropriate antibiotic treatment is given for suspected UTIs. Developing systems for routinely collecting and testing urine samples from children with unexplained fever may represent an improvement in clinical practice.

Clinical audits relating to how often urine testing is performed and whether it is performed appropriately would be a means of monitoring such changes in practice (see Audit points below).

Safety net advice

NICE QS64 and NICE CG160 set out recommended safety net advice for parents/carers and advice about when they should seek further help (see Boxes 1 and 2, below).1,4

Box 1: Safety net advice

>Advise parents or carers looking after a feverish child at home:

to offer the child regular fluids (where a baby or child is breastfed the most appropriate fluid is breast milk)
how to detect signs of dehydration by looking for the following features:

sunken fontanelle
dry mouth
sunken eyes
>absence of tears
poor overall appearance

to encourage their child to drink more fluids and consider seeking further advice if they detect signs of dehydration
how to identify a non-blanching rash
to check their child during the night
to keep their child away from nursery or school while the child’s fever persists but to notify the school or nursery of the illness.

NICE (2014). Feverish illness in children under 5 years. Quality Standard 64. Available at:

www.nice.org.uk/guidance/QS64; NICE. Feverish illness in children: assessment and initial management in children younger than 5 years. Clinical Guideline 160. NICE, 2013. Available at: www.nice.org.uk/cg160 Reproduced with permission.

Box 2: When to seek further help

Following contact with a healthcare professional, parents and carers who are looking after their feverish child at home should seek further advice if:

the child has a fit
the child develops a non-blanching rash
the parent or carer feels that the child is less well than when they previously sought advice
the parent or carer is more worried than when they previously sought advice
the fever lasts longer than 5 days
the parent or carer is distressed, or concerned that they are unable to look after their child.

NICE (2014). Feverish illness in children under 5 years. Quality Standard 64. Available at: www.nice.org.uk/guidance/QS64; NICE. Feverish illness in children: assessment and initial management in children younger than 5 years. Clinical Guideline 160. NICE, 2013. Available at: www.nice.org.uk/cg160 Reproduced with permission.

A safety net essentially involves providing adequate and appropriate information to parents and carers that will enable them to monitor their child and empower them to seek further help when this is indicated.

Some information is generally applicable (e.g. the appearance of a non-blanching rash and how they can access healthcare at any given point). Other important information needs to be individual (e.g. the likely progress of a viral illness if this is the provisional diagnosis).

Advice about when further assessment by a medical practitioner is required is difficult. I am concerned that if I say I should review a child in 48 hours, the parents/carers may not request medical help until that time, even if there is a significant deterioration in the child’s condition. Conversely, it is unnecessary to review children who have fully recovered. An increased level of parental concern is a better indicator of the need for, and timing of, further assessment.

Conclusion

While there is no simple means of differentiating between minor infections and SBIs in their early stages, the hope and expectation is that by using the NICE guideline and quality standard it will be possible to better identify early those children at risk of serious illness. This should result in prompt and appropriate referral to specialist care for higher risk children, leading to earlier intervention and better outcomes.

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead

This quality standard specifies use of the ‘traffic light’ system for the early identification of serious bacterial infection in feverish young children:

clinical commissioning groups should include requirements in contracts for this system to be used in their services, including NHS 111, A&E departments, GP out-of-hours services, and urgent care centres
encourage use of the system in local general practice and additionally in pharmacy, where minor illness services are commissioned

Clinical commissioning groups should agree with local microbiology laboratories criteria for urine culture in children with feverish illness and ensure that suitable sampling techniques are provided where clean catch samples are impractical
Clinical commissioning groups can use education events for local practices to:

reinforce the importance of using the traffic light system for assessing children and providing suitable safety net advice
facilitate the best use of antibiotics in this age group to help avoid overprescription and its associated risks of contributing to bacterial resistance.

NICE. Feverish illness in children under 5 years. Quality Standard 64. NICE, 2014. Available at: www.nice.org.uk/guidance/qs64
National Collaborating Centre for Women’s and Children’s Health. Feverish illness in children—assessment and initial management in children younger than 5 years. London: Royal College of Obstetricians and Gynaecologists, 2007. Available at: www.nice.org.uk/nicemedia/pdf/CG47Guidance.pdf
Wang H, Liddell C, Coates M et al. Global, regional and national levels of neonatal, infant and under 5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study. Lancet 2014; 384 (9947): 957–979.
NICE. Feverish illness in children: assessment and initial management in children younger than 5 years. Clinical Guideline 160. NICE, 2013. Available at: www.nice.org.uk/cg160
NICE. Urinary tract infection in infants, children and young people under 16. Quality Standard 36. NICE, 2014. Available at: www.nice.org.uk/guidance/qs36
Crimmins J. Raised heart rate is a new traffic light for risk in a feverish child. Guidelines in Practice, September, 2013. Available at: www.guidelinesinpractice.co.uk/sep_13_crimmins_fever_sep13#
NICE. Urinary tract infection in children: Diagnosis, treatment and long-term management. Clinical Guideline 54. NICE, 2007. Available at: www.nice.org.uk/guidance/cg054