- 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
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

*neonatal deaths and deaths due to perinatal events have been excluded; data from the Department of Health, courtesy of R MacFaul
Reproduced from: NICE/NCC-WCH. Feverish illness in children: assessment and initial management in children younger than 5 years. Clinical Guideline No 47. London: RCOG; 2007, with the permission of the Royal College of Obstetricians and Gynaecologists.
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).
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
Measuring and recording vital signs—statement 2
- 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
Safety net advice—statement 4
- 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
Measuring and recording vital signs
Urine testing
Safety net advice
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.
Conclusion
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
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