New guidance uses a traffic light system to aid diagnosis of serious illness in feverish under fives, says Dr Natasha Gilani

Fever in children under 5 years of age is one of the most common reasons for a parent/carer to take a child to see their GP. In children with fever without apparent source the cause is usually a self-limiting viral illness.1 However, the possibility of missing a serious diagnosis, such as meningitis, is a cause of great concern for doctors and parents/carers. In addition, the clinical picture in young children can change very rapidly, either deteriorating within hours or suddenly improving.

Need for the guideline

Infectious disease is a major cause of childhood mortality and morbidity in the UK. Even though the infant mortality rate has fallen from 20% to 0.5% over the past century, mainly as a result of improved public health and childhood immunisations, mortality rates in the UK are 30–40% higher than in some other European countries1 Furthermore, it has been shown that children from the most deprived areas are twice as likely to die from meningococcal disease than those from affluent areas2 This often results from the infection being identified too late, suboptimal treatment, and deficiencies in healthcare.

What the guideline aims to do

The main aim of the guideline is to aid assessment of disease severity, and includes information on remote access assessment and how to measure temperature. It also covers clinical management in primary care and when to refer to secondary care, and guidance on secondary care assessment, including investigations and treatment. The guideline is intended to be followed by the GP until a clinical diagnosis has been made, at which point the child should be treated accordingly.

Key points

The key points for primary care are:

  • detection of fever should be measured using either an electronic thermometer or a chemical dot thermometer in the axilla for all children, or, alternatively, using an infra-red tympanic thermometer in children over 4 weeks of age
  • a traffic light system can be used, enabling GPs to check for the presence or absence of symptoms or signs that can predict the risk of serious illness in children
  • all children should have routine measurement of temperature, heart rate, respiratory rate, and capillary refill time, which should be documented
  • a child being assessed by remote access, who has any ‘red’ features according to the traffic light system, but which are not immediately life-threatening, should be seen in a face-to-face setting within 2 hours
  • appropriate care advice should always be provided when sending a feverish child home, including when to seek help, or information on arrangements for further follow-up (a safety net)
  • oral antibiotics should not be prescribed without apparent source for the fever
  • antipyretics do not need to be given routinely, but can be prescribed if a raised temperature is causing a child distress—they do not prevent febrile convulsions.

Main recommendations and advice

The guideline provides some good advice on the management of fever in children, particularly for GPs, who may be lacking in paediatric experience, and it will give them confidence and reassurance in their patient management decisions. The tables in the guideline detailing the ‘traffic light system’ and the ‘symptoms and signs of serious illness’ such as meningitis and pneumonia, are easy to read. They provide a useful reference tool, which will help focus the clinician’s history-taking and examination, and which can be used as a teaching aid. The cost of the potential change in referral patterns to secondary care remains to be seen.

Many children will present more than once to a doctor during the course of the same illness, possibly accessing both their own GP’s surgery and the out-of-hours practitioner. The recommendation to document temperature, heart rate, respiratory rate, and capillary refill time in all children with a fever will highlight any trend in disease progression, especially if the child’s condition is deteriorating. It is hoped that this will assist early detection of serious illness, and, consequently, reduce mortality. Emphasis is placed on recording the type of thermometer and route used to measure temperature, which allows more accurate comparison of readings taken by different clinicians at different times.

Remote access and care at home

I was pleased that the guideline included some advice on remote access assessment of a patient, which will aid with triaging of these patients, and should reduce unnecessary assessment of children who are at low risk of serious illness. However, parental anxiety or the wish for their child to be seen by a doctor will override the guidance recommendations. The advice for care at home reiterates the need to always provide a ‘safety net’, and to check whether parents/carers understand what signs to look for, how to manage temperature, and when to seek further advice. In my practice this information is usually provided verbally as a result of time constraints, but an advice sheet for parents to take home could be easily written based on the guidelines.

Summary

The guidance briefly mentions the need for a patient-centred approach, allowing for the parents/carers wishes and needs to be taken into account. Overall, I think the guidance is a useful tool to aid in the initial assessment of fever in a child, and it provides clear tables and algorithms to follow3 These allow a quick overview of key points not to be missed in the history and examination, aid important safety netting, and should improve communication with the parent/carer.

Given the need to improve mortality rates from meningococcal disease, and infant mortality from infection overall, I welcome publication of the new NICE guideline on feverish illness in children.1 It will consolidate the management of affected children across the country and should improve the difference in disease outcome between poor and affluent areas.

written by Dr David Jenner, NHS Alliance PBC Lead
  • These illnesses are a common cause of A&E attendance and acute admission
  • They often present out of hours — contracts placed with out of hours providers should include reference to the use of these guidelines
  • It is uncertain whether this guideline will increase referral demand on specialist paediatric services or reduce it
  • PBC commissioners should ensure responsiveness in hours and out of hours services to reduce unnecessary attendance at A&E
  • Tariff cost for A&E attendance = £55–£73; admission for febrile convulsion = £696; other viral illness = £10231
  1. National Collaborating Centre for Women’s and Children’s Health. Feverish illness in children — assessment and initial management in children younger than 5 years. Clinical guideline. London: RCOG, 2007.
  2. Heyderman R, Ben-Shlomo Y, Brennan C, Somerset M. The incidence and mortality for meningococcal disease associated with area deprivation: an ecological study of hospital episode statistics. Arch Dis Child 2004; 89 (11): 1064–1068.
  3. National Institute for Health and Care Excellence. Feverish illness in children—assessment and initial management in children younger than 5 years . Quick reference guide. Clinical Guideline 47. London: NICE, 2007.G