Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Feverish illness in children
- Anthony Harnden (5 June 2007)
-
Re: Testing the urine of feverish children
- Theo Fenton (6 June 2007)
-
Feverish Illness in Children
- Monica Lakhanpaul, Martin Richardson, James Cave, John Crimmins, Phil Alderson (13 June 2007)
-
Guidelines a boon to junior doctors
- Mary Ann Kwok, Danny Lim (19 June 2007)
-
NICE feverish child guideline relevant equally in primary care
- roderick macfaul (21 June 2007)
-
NICE Guideline on management of children under five with a fever
- Susan M Hall (21 June 2007)
|
|
|||
|
Anthony Harnden, University Lecturer and Principal in General Practice Department of Primary Health Care
Send response to journal:
|
In the UK the overwhelming majority of febrile children presenting to the health service are managed in primary care. The management expertise is in primary care. Yet this NICE guideline (reference) is dismissive of that primary care expertise and like other guidelines demonstrates a lack of understanding of the primary care context. At the start of the full guideline the glossary of terms defines a non-paediatric practitioner as ‘a health care professional who does not have recognised expertise in the management of children (paediatric specialist) – a term mainly used to refer to those health professionals working in primary care’. With the use of such terminology it hardly surprising that – despite nominal representation – most GPs feel disenfranchised with the NICE juggernaut The diagnosis and management of febrile children is a difficult topic to appraise because of the paucity of primary care data. But algorithms principally based on data from secondary care just aren't helpful for British GPs. Within this guideline - inter alia - I have concerns about: the failure to define the time point in the illness as a critical part of the history, the lack of evidence for physical sign measurements (including capillary refill) in primary care, the necessity for all febrile under 5's to have a urine examination, the definition of clinical features within the intermediate group (most of whom experienced GPs would assess as ill in primary care and refer to hospital) and the very broad statement about not prescribing antibiotics to children without apparent source of fever. I hope that before the BMJ choose to publish further synopses of NICE guidelines you will welcome constructive criticism of the guideline and invite a GP with expertise who has not been involved in the process to write an accompanying commentary Competing interests: None declared |
|||
|
|
|||
|
Theo Fenton, Consultant Paediatrician Mayday Univesrity hospital, Croydon CR7 7YE
Send response to journal:
|
Regarding urine tests in febrile children (without clear focus) <5yrs presenting to primary care, NICE's fever guidelines recommend following their forthcoming UTI guidelines -- a draft version of which is available on the NICE website; these do not advocate urine examination for all such children.
See page 5 of this document:
http://www.nice.org.uk/page.aspx?o=374385
Competing interests: None declared |
|||
|
|
|||
|
Monica Lakhanpaul, Co-director, National Collaborating Centre for Women and Children’s Health NCC-WCH,27 Sussex Place, Regent's Park, London, NW1 4RG, Martin Richardson, James Cave, John Crimmins, Phil Alderson
Send response to journal:
|
Response to Harnden Anthony Harnden suggests (1) that the NICE guideline on fever in children is dismissive of the expertise in primary care and fails to understand the context in primary care. We disagree. The guideline development group included two GPs, one of whom led on the development of the guideline on management in primary care, as well as others who contribute to frontline management of children with fevers. During the consultation on the guideline, we received many positive responses from GPs, organisations representing GPs, and other primary care professionals. Harnden objects to the term ‘non-paediatric practitioner’ used in the guideline. This term is not ideal, but is intended to cover the increasing diversity of people who might be first contact in this situation; pharmacist, nurse, A&E consultant, GP, NHS direct, out-of-hours call handler, paramedic etc. The guideline would have been unworkable if each of these groups had a different algorithm or plan. The range of expertise between these groups and between individual members of a certain profession will be wide. This is acknowledged within the guideline and reflected in the range of options given for management of children with ‘amber’ features. We agree with Harnden that the lack of good quality evidence from primary care makes this topic a difficult one for developing guidelines, but it does not mean that guidelines should not be developed. In these circumstances the use of secondary care data supplemented by expert opinion, formal consensus techniques, and widespread consultation is a robust strategy. Authors Monica Lakhanpaul, Co-director, National Collaborating Centre for Women and Children’s Health/Senior Lecturer in Child Health Martin Richardson, Consultant Paediatrician, Chair of Guideline Development Group James Cave, GP, Member of Guideline Development Group John Crimmins, GP, Member of Guideline Development Group Phil Alderson, Associate Director, Centre for Clinical Practice, NICE Reference Rapid responses 5th June 2007 Competing interests: None declared |
|||
|
|
|||
|
Mary Ann Kwok, Paediatric FY2 Frimley Park Hospital, Danny Lim
Send response to journal:
|
As a Paediatric SHO, the newly-published NICE guidelines are a boon to us junior "Paediatricians" whilst "on-call". A febrile child is the single most common referral from A&E or the community. There is much angst among admitting doctors if they are missing a serious illness like meningococcal septicaemia or Kawasaki's. Having a systemic framework to asses and manage these children can only be a good thing for patients and doctors alike. Competing interests: None declared |
|||
|
|
|||
|
roderick macfaul, Hon (Retired ) Consultant Paediatrician Pinderfields Hospital, Wakefield WF1 4DG
Send response to journal:
|
The criticism made of the NICE feverish child guidance by Dr Harden in my view is not justified although he rightly acknowledges that the assessment of a febrile young child can be difficult. The assessment includes two major responsibilities and the challenges posed to address these are the same in every location of care and for whomever assesses the child. Thus the guidance is equally relevant to primary care specialists well as hospital based ones. These responsibilities are firstly to identify at an early stage progressive disease which is compromising organ function (e.g. respiratory , circulatory ) whether caused by viral or bacterial infection. Secondly, to determine whether antimicrobial therapy is indicated to either to prevent such progression, or prevent abscess formation or severe complications such as meningitis; and, to alleviate and shorten the illness. The NICE guidance recommends a brief structured approach including evaluating the time honoured clinical signs of pulse rate, respiratory rate and pattern and level of fever, combining these with an overall impression of alertness, seeking of rash and a measure of perfusion in the form of capillary refill. These all form the foundation of an assessment which points to observation for most but helps to select the minority who merit referral, urgent investigations or treatment. Recording of these clinical signs is especially important now that sequential observations are made in the same illness by different practitioners - however experienced with illness assessment one individual practitioner in this sequence may be. Their use offers a process in which earlier interventions when needed will occur with a view to improving care and reducing mortality and morbidity. The clinical process is short in any setting and so it is difficult to understand the basis of the arguments against the use of this guidance. Competing interests: As DH paediatric adviser R MacFaul proposed this topic to be placed in the NICE programme. He is also currently conducting research in the use of clinical signs in febrile children through RCPCH research unit. |
|||
|
|
|||
|
Susan M Hall, Honorary lecturer, Department of Child health, University of Sheffield Retired
Send response to journal:
|
Both the Guideline and the accompanying information for parents and carers of young children, have sections on the use of antipyretics, in which the advice is to use either paracetamol or ibuprofen. It is disappointing that the authors of the Guideline did not take the opportunity to state in addition, that aspirin should not be given to children under 16 except on medical advice, because of the risk of the child developing Reye’s syndrome. It is crucial that public health messages aimed at prevention of disease are sustained if they are to be continuingly effective -both public and professional memories for such messages are short, especially when the disease in question has almost disappeared as a result of the intervention. Aspirin is likely to be widely available in homes and it may be tempting to use it if the alternatives are not readily to hand especially if the carer either cannot, or does not think to, read the warning labelling on the package. The authors of the Guideline should note that in the Department of Health’s pandemic flu plan, their advice to the public on management of flu at home with antipyretics does remind parents that aspirin should not be given to children under 16(1). Richardson et al’s review of the NICE Guideline states that the Parent’s Leaflet is available from August 2007 -perhaps it is still possible to modify it to include this important public health message. 1. Pandemic flu -FAQ. www.dh.gov.uk/en/PandemicFlu/FAQonly/DH_065088 Competing interests: None declared |
|||