The care of sick children is a core part of general practice and the new guideline from NICE on Feverish illness in children1 aims to improve the assessment and management of these children. In particular it intends to aid in the detection of serious illness. It is considered core guidance,1,2 with many guidelines branching off it (such as the recent NICE guideline on Urinary tract infection in children;3 and its guideline on Management of meningococcal disease and meningitis in children and young people, which is expected at the end of 20094).
Need for a guideline
During the first 18 months of a child’s life, he or she will experience an average of eight infective episodes.2 The majority of these will be simple, self-limiting, feverish episodes with no sequelae. These infections are best managed by care and symptomatic treatment at home with the support of the primary care team. Only a tiny number of these children will have a serious, life-threatening illness that requires timely specialist paediatric intervention. Nevertheless, 100 infants (0–12 months of age) die each year from infection.2 One child in every one hundred in the age group 1–4 years of age can be expected to contract a serious infection, with 30 deaths per year in that age group in England and Wales.2
Better public health measures, in particular immunisations, have brought about a reduction in infant mortality rates over the past 100 years.2 However, the rate of decline in mortality in the UK is not as great as that seen elsewhere in Europe, which means that the infant mortality rate in some countries is 30–40% lower than in the UK.2
The challenge for the NHS, and particularly for healthcare professionals in primary care, has been to identify the cases of serious illness among the ‘fever noise’ in busy emergency clinics. The NICE guideline on Feverish illness in children1 was written with two main aims: the first of these, the focus of this article, is to help primary care in all its variety to assess children with fever; and the second, to ensure that children referred to secondary care receive correct and evidence-based treatment.
Quality of the evidence
While good general practice-based research is lacking, there is no shortage of high quality research into the care of children first presenting for healthcare, and this formed the foundation of the NICE guideline. Where good evidence was missing, the NICE guideline development group sought a consensus opinion from professionals who work in the field. However this consensus survey only made up a small part of the guideline; for example, the traffic light table (see Table 1) is only based on high quality prospective studies.
Table 1: Traffic light system for identifying risk of serious illness
GREEN — LOW RISK
AMBER — INTERMEDIATE RISK
RED — HIGH RISK
|Colour||• Normal colour of skin, lips and tongue||• Pallor reported by parent/carer||• Pale/mottled/ashen/blue|
• Responds normally to social cues
• Not responding normally to social cues
• No response to social cues
• Nasal flaring
• Normal skin and eyes
• Dry mucous membrane
|• Reduced skin turgor|
|Other||• None of the amber or red symptoms or signs||
• Fever for ?5 days
• Age 0–3 months, temperature ?38°C
RR=respiratory rate; CRT=capillary refill time
Assessment of feverish illness in a child
Much of the approach of the healthcare professional when assessing a child is standard practice, but key points to cover are:
- identification of any immediate life-threatening features (collapse, respiratory arrest, etc.)2
- assessment of the child’s likelihood of having a serious or self-limiting illness, without necessarily diagnosing any one particular condition2—use clinical acumen and refer to the traffic light table (see Table 1)
- determination of the source of the illness2—use clinical acumen following examination and undertake necessary investigations, such as urinalysis
- implementation of appropriate management plans and treatment options on the basis of the above, with particular thought to safety netting
- maintenance of an accurate, contemporaneous record of findings, which should include temperature, heart rate, respiratory rate, and capillary refill time.
Why thermometer use is important
Many GPs currently do not use a thermometer at all because they do not feel it alters their management. The evidence, however, clearly demonstrated the high risk of serious bacterial infection in infants below the age of 6 months.
A child 0–3 months of age with a fever ?38°C or a child 3–6 months old with a fever ?39°C has a greatly increased risk of having a serious bacterial infection,2 and these children should therefore be assessed by the paediatric specialist team.
The evidence for how a temperature should be taken is weak. Although rectal temperature has been considered the gold standard measurement in the past it was not acceptable to 80% of healthcare professionals when asked by the Delphi technique. Pragmatism thus suggests axillary measurements taken using an electronic thermometer or a chemical dot thermometer should be acceptable in all age groups, with ear thermometers being acceptable in older age groups.1,2 Liquid crystal forehead strip-type thermometers are unacceptable as the accuracy is poor.1,2
The NICE ‘traffic light’ table
The NICE guideline summarises its system for identifying the risk of serious illness in children into a ‘traffic light’ table (see Table 1).1,2 This is a concise summary of the considerable evidence NICE found on symptoms and signs, and their sensitivity and specificity at detecting serious illness in children with fever.
Symptoms or signs that are particularly likely to indicate serious illness are found in the red column and children exhibiting these would normally be expected to be referred urgently to hospital in the appropriate manner.
Symptoms that indicate illness but are not sensitive or specific for serious illness are given an amber rating. Detecting these in a child may suggest referral (particularly if the GP detects a number of them), or may just suggest review later is appropriate.
Symptoms and signs in the green column indicate health and these, together with an absence of amber or red symptoms, mean it is safe to manage this child at home.
Full assessment of a child with fever
The NICE guideline on Feverish illness in children covers every child presenting (remotely or face to face) to primary care with a fever, or whose parents report that this episode of illness has included a fever.1,2
If this is a remote assessment (telephone triage for example), a thorough history should be taken to ascertain the presence or absence of amber and red symptoms. If red symptoms are highlighted, then at the very minimum an urgent face-to-face consultation with a healthcare professional within 2 hours should be arranged.1,2 Clearly, evidence of collapse might indicate a life-threatening illness and the need for emergency ambulance or GP emergency visit.
Face-to-face consultation should include a thorough history and examination. The guidance does not presume to provide a textbook on the assessment and examination of the child, and this guidance assumes professionals are working within their competence when undertaking this work. While most GPs are good at spotting the seriously sick child, anecdotal and more recent research shows that a proportion of children will be admitted to hospital a few hours after seeing their GP. Combined with the fragmentation of out-of-hours services and the use of other primary care providers, good contemporaneous notes are necessary, which can be used by team members later to check whether the child’s condition has deteriorated.
For this reason the guideline development group considered it good practice, in addition to one’s standards notes, to record the following in the notes of a child seen with a fever, or history of fever:1,2
- temperature—in the very young a raised temperature is a considerable risk factor for serious illness
- heart rate
- respiratory rate—an indicator of serious illness, with rates above 60 breaths/min signifying a high risk (red sign) of serious illness, and lower rates amber signs
- capillary refill time—the most specific test we have for dehydration and a simple quick indicator (with ?3 seconds considered an amber sign).
Management of the feverish child
The guideline contains an algorithm for the management of a feverish child (see Figure 1). Following assessment by the GP, children with red signs should be referred urgently to a paediatric specialist. (This does not mean sending a letter with the child to be seen in casualty.) Clearly children with suspected meningococcal disease should be given parenteral benzylpenicillin or a third-generation cephalosporin. This need not be given intravenously; intramuscularly is as effective and intravenous access is difficult in infants. Children with green symptoms and signs and no amber or red symptoms can be safely managed at home.1,2
Figure 1: An algorithm for management of the feverish child
National Institute for Health and Care Excellence (NICE) (2007) CG 47 Feverish illness in children: assessment and initial management in children younger than 5 years. London: NICE. Reproduced with permission. Available from www.nice.org.uk
Children with amber symptoms or signs require special consideration. Some may require paediatric assessment (for example, in a child with fever for more than 5 days who also has some of the features of Kawasaki disease), others may require further assessment at a later stage or simply clear verbal and/or written information to the parents or carers.1,2
Safety netting is a term first used by Roger Neighbour,5 and is an essential part of general practice. It enables GPs to handle risk and uncertainty with the minimum of hazard.
A number of myths have developed over the past few years: there is no evidence whatsoever that treating pyrexia prevents febrile convulsions; nor that treating pyrexia improves outcomes. The only rationale to treat a fever is to make a child more comfortable. Tepid sponging is not recommended.1,2 The NICE guideline development group looked carefully at the evidence surrounding the use of paracetamol and ibuprofen together and could find no evidence that this combination therapy is anything other than more expensive.2 It seems reasonable though, if the child is still distressed or unwell following the administration of one agent, to try the other. It should be stressed again, however, that the aim should not be to lower the fever simply because the child has one.1,2
The management of feverish illness in children is a typical aspect of primary care: managing a common problem carefully in a way that does not undermine parents’ confidence in the care of their children. The NICE guidance offers the best possible way to do this and will make good GPs better.
NICE implementation tools
NICE has developed the following tools to support implementation of its guideline on Feverish illness in children: assessment and initial management in children younger than 5 years:
The implementation advice document contains suggested actions for implementing the guideline. It aims to help implementers identify recommendations in the guideline that are not part of current practice, and should be used alongside the costing report and template.
The slides are aimed at supporting organisations to raise awareness of the guideline at a local level and can be edited to cater for local audiences. They do not cover all the recommendations from the guideline but contain key messages, and should be used in conjunction with the quick reference guide.
A costing statement has been produced to provide an implementation tool to estimate the financial impact to the NHS of implementing this clinical guideline. This statement focuses on the financial impact of the recommendations that require most change in resources to implement in England.
The audit criteria and audit reporting template have been developed to assist NHS trusts to determine whether the service is implementing, and is in compliance with, the clinical guideline. Users can cut and paste the criteria into their own programmes or they can use the template provided.
Discharge advice sheet
The discharge advice sheet considers implementation issues that are specific to the guideline—practical advice is provided to help those responsible for planning and implementing the guideline. It will help implementers identify recommendations in the guideline that are not part of current practice, and suggests actions to be taken. The advice should be used alongside the costing analysis and slide set.
These tools are available to download from www.nice.org.uk
- 20–40% of children under 5 are taken to a doctor each year with fevera
- Coprescribing of ibuprofen and paracetamol is not cost effective
- NICE estimates that following its guidance on Feverish illness in children will not result in any significant change in costs to commissionersa
- PBC groups should ensure out-of-hours providers follow the NICE guideline as they see many children with feverish illness
- this could be built as a quality marker into contracts with providers and audited by record analysis
- Cost of paediatric admissions:b
- febrile convulsions = £619
- major infections = £2409
- minor infections = £762
- National Institute for Health and Care Excellence. Feverish illness in children—assessment and initial management in children younger than 5 years. Clinical Guideline 47. London: NICE, 2007.
- 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.
- National Institute for Health and Care Excellence. Urinary tract infection in children: diagnosis, treatment and long-term management. Clinical Guideline 54. London: NICE, 2007
- Neighbour R. The Inner Consultation. 2nd edition. Oxford: Radcliffe Publishing, 2005.G