Recognising serious illness in feverish young children in primary care
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39295.383843.AD (Published 30 August 2007) Cite this as: BMJ 2007;335:409All rapid responses
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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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Consultant in Emergency Medicine, Leicester Royal Infirmary, LE1 5WW.
Chair, Intercollegiate Advisory Group for Services for Children in
Emergency Departments.
Ffion.davies@uhl-tr.nhs.uk
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
Competing interests: No competing interests
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
TALC (Teaching Aids at Low Cost)
william.cutting@talktalk.net and
TALC@talcuk.org
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
From the coal face
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
Competing interests: No competing interests