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Rapid Responses: Rapid Responses published:
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Feverish illness in children
- Theo HM Fenton, CR7 7YE (31 August 2007)
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Possibility of repeat consultations is vital
- Paolo Tomasi (4 September 2007)
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Spotting the sick child. One video-clip . . “is worth a thousand words”.
- William A.M. Cutting (4 September 2007)
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Face to face essential
- Ffion C Davies (5 September 2007)
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Integrated telephone assessment needed
- Tony Kelpie (5 September 2007)
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Guideline seeks to strengthen clinical intuition
- James A Cave, On behalf of the guideline development group and the National (13 September 2007)
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From the coal face
- chris harnden (21 September 2007)
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Theo HM Fenton, Consultant Paediatrician Mayday Hospital, Croydon, Surrey, CR7 7YE
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In his BMJ editorial (1), Dr Harnden states that "a careful global assessment, examination, and medical record are rightly considered good practice". However, he rather contradicts this by saying "it is premature to recommend that every febrile child visiting a general practitioner should routinely have a measurement of temperature, heart rate, respiratory rate and capillary refill time". What does he mean by "careful... examination" if it does not include at least some assessment of these variables? Although it may be indeed difficult to measure the heart rate precisely, it is easy to establish (and record) whether or not a child is tachycardic. There may be a lack of hard evidence for the sensitivity and specificity of some of these variables, but that is true for most aspects of the clinical examination -- yet nobody would suggest that it is premature to recommend performing it. In his Lancet article (2), Dr Harnden and his colleagues wrote that cold hands and feet and abnormal skin colour are typical early features of meningococcal disease, and that these features represent changes in the peripheral circulation. Surely therefore Dr Harnden does not dispute that assessment of capillary refill time is probably an important part of clinical examination of the febrile child? And NICE and Dr Harnden agree about the importance of explicit follow-up arrangements. The guidelines (3) include much about "safety-netting". The NICE guidelines certainly do not advocate abandoning clinical intuition, but they -- like the article in Pediatrics (4) -- perhaps help to reveal a bit about how experienced clinicians perform what may sometimes seem to be diagnostic magic. The guideline authors acknowledge that further research is needed on several aspects. Indeed, they mention that Thompson M and others are currently doing a prospective study about the predictive value of heart rate and other vital signs in children with fever. In the meantime, they have based their recommendations on much collective wisdom from scores of sources -- including (2), and a thorough and critical analysis of the existing hard data. I take my hat off to them. (1) Harnden A. Recognising serious illness in feverish young children in primary care. BMJ 2007;335:409-410. (2) Thompson M et al. Clinical recognition of meningococcal disease in children and adolescents. Lancet 2006;367:397-403. (3) National Institute for Health and Clinical Excellence. Feverish illness in children—assessment and initial management in children younger than 5 years. 2007. (NICE clinical guideline No 47). (4) McCarthy et al. Further definition of history and observation variables in assessing febrile children. Pediatrics 1981;67:687-93. Competing interests: None declared |
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Paolo Tomasi, Scientific Administrator European Medicines Agency, London E14 4HB
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I thoroughly endorse the editorial by Anthony Harnden. In my opinion, the core of the matter is to make very clear to the parents/carers that there remains a certain degree of uncertainty with every febrile illness, and if they feel that the situation is deteriorating or are otherwise worried, they should bring the child for examination again, even after only a few hours. Or at least, the should be able to call the same doctor who saw the child initially (not a new one). This is crucial, because parents may be embarrassed to request a repeat consult, fearing they will be making a nuisance of themselves, and may even think it unnecessary, since the child had been "cleared" only a few hours before. I recall a case I saw in the Emergency department(an elderly patient though, not a child), of a febrile illness which left me suspicious. I told the relatives to bring the patient back the next day for a recheck; they did not come. Three days ago, I discovered that the patient had been admitted to the resuscitation ward, where she died thereafter (no specific diagnosis was ever made). When I met the relatives in the hospital corridor, I asked them why they had not brought the patient back when I had advised, and their answer was: "We do apologize, doctor, but on that day she was not feeling very well, and besides, we did not want to disturb you." They really were apologetic, to me... Paolo Tomasi Competing interests: None declared |
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William A.M. Cutting, Retired paediatrician, advisor to TALC Previously University of Edinburgh, EH9 1UW
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Identification of a seriously ill pyrexial child, as opposed to one who is miserable and irritable because he is uncomfortable with a simple condition, requires care and experience. Harnden reminds us that there is no simplistic formula, it needs a full assessment in which a careful examination is more important than the history, which why “telephone triage” can be dangerous. A further review is important as the condition of children evolve and change rapidly.1 He also points out that the NICE (National Institute for Clinical Excellence) guidelines for children with fever and its traffic light system is of limited value.2 These matters are of importance because fewer GPs see patients “out of hours” so increasing numbers of first consultations in U.K. are now delegated to telephone screening and staff in walk-in centres with limited experience. Also it is difficult for staff to gain experience and see many seriously ill children during training because of shorter hours and relatively fewer critically ill children. To give the health workers the experience to identify these seriously ill children, modern technology, in the form of video-clips, CDs and DVDs, must play a larger part in training. This year I have seen two examples. “Spotting the sick child” is a very good DVD produced for the Department of Health by Dr Ffion Davies and colleagues in the A&E Departments of Leicester Royal Infirmary and the Royal London Hospital.3 After a practical introduction and demonstration of a simple but rapid examination routine, there are clips of many children with difficult breathing, fever, dehydration, abdominal pain etc. Some even show the progression of the condition. The second is a CD produced for the WHO by Dr Trevor Duke and others of Melbourne University, Australia. It supports and illustrates the recent WHO Pocket Book of “Hospital care for children”. It contains three video-clips of ill children and many still images, all in a context to reinforce the method set out in the Pocket Book. There must be other good teaching videos, CDs and DVDs out there, but there is scope and need to produce and share such practical teaching material. William A.M. Cutting
1. Harnden A. Recognising serious illness in feverish young children in primary care. BMJ 2007;335:409-410. (1 September) 2. National Institute for Health and Clinical Excellence. Feverish illness in children – assessment and initial management in children younger than 5 years. 2007 (NICE Clinical guideline No 45.)http://guidance, nice.org.uk/CG47. 3. Davies F. et al. Spotting the sick child.2005. ffion.davies@uhl- tr.nhs.uk .Copies available from www.achmedia.com/products.ssc.shtml. 4. Duke T et al. Hospital care for children. A CD ROM training resource for the management of common illnesses with limited resources. 2007. To be used in conjunction with the WHO pocket book of hospital care for children. cah@who.int Competing interests: None declared |
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Ffion C Davies, Consultant in Emergency Medicine Leicester Royal Infirmary LE1 5WW
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The editorial by Dr Harnden is timely in the current political climate of the UK urgent care. Diagnosing serious bacterial illness (SBI) in febrile children, as distinct from the normal febrile response to viral (and bacterial) challenges in all children as their immune systems mature, is like finding the proverbial “needle in the haystack” as SBI becomes more rare. An awareness of meningitis, pneumonia, septic arthritis, urinary tract infection and Kawasaki disease is essential. None of us gets it right all the time. Getting it wrong has serious consequences. Dr Harnden is right to advocate face to face assessment by experienced clinicians. Performing snapshot assessments in emergency settings, where time is precious, is notoriously risky. Serial assessment of the child is best but not always possible. A scientific approach of measuring heart rate, capillary refill, respiratory rate and behaviour takes less than 3 minutes1 and is achievable in these settings. Dr Harnden is wrong in stating that this is not achievable in primary care. To state that there is no evidence that measurement of these parameters helps identify SBI may be true for primary care but is not true in hospital (Emergency Department or paediatric wards). Lack of evidence of association is not evidence of lack of association, so logic would dictate that a similar assessment should take place in primary care. The Intercollegiate Advisory Group for Services for Children in Emergency Departments has concerns about the abilities of telephone triage systems and inadequately trained frontline staff to differentiate the seriously ill child from those with self-limiting febrile illness. These staff include Emergency Care Practitioners, Emergency Nurse Practitioners, F2 doctors and perhaps recently appointed General Practitioners. In the wake of the new GMS contract, increasing numbers of parents access telephone advice, Emergency Departments or Primary Care Centres for assessment of their febrile infant (particularly out of hours). These points of contact must ensure staff have basic paediatric assessment skills2. To substitute experienced primary care, emergency medicine and paediatric staff with cheaper alternatives is not necessarily a safe strategy. The low incidence of SBI means that the majority of the time, the majority of children will come to no harm. This is no consolation for the parent of a seriously ill child. Dr Ffion Davies
1. The 3-minute toolkit. Spotting the Sick Child (DVD) available from http://www.ocbmedia.com 2. Services for Children in Emergency Departments (Intercollegiate Report) 2007. Available from the Royal College of Paediatrics and Child Health or from http://www.rcpch.ac.uk/Health-Services/Emergency-Care Competing interests: None declared |
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Tony Kelpie, GP 1 Cheviot Road, Southampton
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Dr Harnden incorrectly sets telephone ADVICE as an alternative to rapid clinical assessment; in an efficiently run service the two should be complementary, and telephone ASSESSMENT used to decide whether urgent face -to-face consultation is or is not needed at any point in time. Many symptoms and behavioural features may be reliably assessed on the telephone, and a large number of inappropriate face-to-face consultations thus avoided. This is particularly important in the out-of-hours situation, where experienced clinicians will always be in short supply. Efficient access to skilled telephone assessment enables deterioration (or improvement) in the patient's condition to be responded to appropriately. Currently most out-of-hours services have room for improvement, but we should at least be clear about what we are aiming to achieve. Best wishes Tony Kelpie Competing interests: None declared |
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James A Cave, GP Partner RG20 8UY, On behalf of the guideline development group and the National
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Dear Editor Dr Harnden’s Editorial on recognising serious illness in feverish young children(1) raises some important points in the management of this vulnerable group. He is right to stress the importance of primary care and right to ask what can be done to improve the UK’s poor track record in the treatment of febrile children. He is right to express frustration at the lack of good research in this important field and he is right to support the importance of an experienced GP’s clinical intuition. Dr Harnden however is dismissive of the National Institute of Clinical Excellence(2) (NICE) guidance, suggesting that it relies too much on consensus techniques and widespread consultation rather than rigorous interpretation of the evidence. This unsubstantiated attack in an editorial in the BMJ is to be regretted if it reduces the use of this important tool particularly as I and my colleagues feel sure that Dr Harnden and his co- workers in Oxford are working as hard as all of us to reduce deaths and morbidity from feverish illness in children. To achieve this it was vital NICE produced a tool that will be helpful to all health care professionals (HCPs) working in all parts of the health service to detect those febrile children who are well, those that need specialist paediatric assessment and those that require further follow up, care or review (safety netting). This required the guidance to span all kinds of assessment from that by a pharmacist, through telephone triage in all the varying arenas, casualty and including the experienced GP. Dr Harnden is right to raise the importance of clinical intuition and quotes from several studies where the subjective “global assessment” or “something- is-wrong sign3” have been demonstrated to be highly specific and sensitive in the hands of very experienced senior doctors, yet even in these papers they alone are still poor at detecting serious illness without the use of other symptoms and signs. Intuition is a vital part of all medicine particularly primary care but medical intuition must be set in the bedrock of scientific objectivity. Dr Harnden will not see his goal of every febrile child being assessed by an experienced GP and must accept that children will be assessed by other HCPs including inexperienced GPs and these people need good quality, accessible guidance. Whilst the “traffic light “ system may not add much value to him I have found it enormously helpful in my clinical practice. Despite his assertion, the traffic light table is based on the highest quality evidence, using only large prospective studies of children with undifferentiated fever presenting to healthcare for the first time. Furthermore, despite Dr Harnden’s dismissal the table actually follows the same systematic approach that he describes to his global assessment. He is incorrect in suggesting children with “red” features are obviously very sick as they include some features such as fever in the under six month olds that I would have previous considered only as an intermediate risk. Whilst the traffic light table has been the most obvious feature of the guidance (and one we are please to see being adopted internationally), it only forms part of the complete guidance. Other areas of NICE guidance include safety netting that gives patients further access to healthcare and the need for HCPs to take parental concern seriously-surely something Dr Harnden can support? We do not understand why Dr Harnden feels measuring temperature, heart rate respiratory rate and capillary refill time (CRT) is practical in triage settings but not general practice. It takes only a few minutes of the ten minute consultation most GPs now provide and I find this quiet time of observation with the thermometer under the arm often settles the child and provides me with valuable objective evidence to use with my clinical judgement then and later should the child require further assessment by myself or another clinician in the practice. Respiratory rate is a useful sign of serious illness, abnormal CRT is the best measure we have for dehydration and fever is important in certain age groups. Dr Harnden himself has discussed the importance of looking for a pulse rate that may be higher than expected for a certain height of fever4. Moreover, Dr Harnden discusses the importance of analysing the velocity of illness in clinical practice. We would agree but surely the most objective way of studying changes in a child’s clinical condition is to take serial measurements of vital signs. The NICE guidance could never have been a textbook of paediatric illness and, like all clinical guidelines; it is not supposed to be a substitute for clinical judgement or intuition. It does however provide a useful tool based on the best available evidence. The gauntlet to improve the care of this vulnerable group has been thrown down. We would urge all HCPs, and particularly GPs to not be complacent in their management of febrile children. Dr James Cave FRCGP GP partner Downland Practice, Newbury On behalf of the guideline development group and the National Collaborating Centre Women and Children's Health Technical team Competing Interests: Dr Cave was a member of the guideline development group 1. Harnden A. Editorial: Recognising serious illness in feverish young children in primary care. BMJ 2007;335:409-10 2.National Institute for Health and Clinical Excellence. Feverish illness in children-assessment and initial management in children younger than 5 years. 2007. (NICE clinical guideline No 42.)http://guidance.nice.org.uk/ CG47 3. Van den Bruel A, Aertgeerts B, Bruyninckx R, Aert M, Buntinx F. Signs and symptoms for diagnosis of serious infections in children: a prospective study in primary care. Br J Gen Pract 2007;57:538-46 4. Radio 4 Casenotes 2006 14th February. (http://www.bbc.co.uk/radio4/ science/casenotes_tr_20060214.shtml) Competing interests: Dr cave was a member of the guideline development group. |
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chris harnden, gp New Zealand
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I read my namesake's article with interest. I'm A GP at the coalface in New Zealand facing the usual rush of sick feverish kids on a friday. I agree that basic measurements should be documented. However the vast majority of times I am educating and reassuring parents that their children are not critically unwell. I find in order to reassure kids I have to tell parents the signs of serious illness so they can be reassured that their children are not critically ill. This probably can only be done face to face rather than over the phone. Competing interests: None declared |
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