Assessment and initial management of feverish illness in children younger than 5 years: summary of NICE guidance
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39218.495255.AE (Published 31 May 2007) Cite this as: BMJ 2007;334:1163
All rapid responses
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Regarding urine tests in febrile children (without clear focus) <_5yrs xmlns:document="urn:x-prefix:document" xmlns:http="urn:x-prefix:http" presenting="presenting" to="to" primary="primary" care="care" nices="nices" fever="fever" guidelines="guidelines" recommend="recommend" following="following" their="their" forthcoming="forthcoming" uti="uti" _--="_--" a="a" draft="draft" version="version" of="of" which="which" is="is" available="available" on="on" the="the" nice="nice" website="website" these="these" do="do" not="not" advocate="advocate" urine="urine" examination="examination" for="for" all="all" such="such" children.="children." see="see" page="page" _5="_5" this="this" document:_="document:_" http:_="http:_" www.nice.org.uk="www.nice.org.uk" page.aspxo="374385" p="p"/>Competing interests:
None declared
Competing interests: No competing interests
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
Competing interests: No competing interests
Re: Assessment and initial management of feverish illness in children younger than 5 years: summary of NICE guidance
I read the updated Nice guidance on assessment and management of feverish illness in children with interest and noted that one of the recommended signs to document was respiratory rate 1. During a recent student GP attachment I carried out a small retrospective audit on the numerical recording of this parameter in a small, suburban teaching practice in Lincoln and found the results to be disappointingly low. Only 26% (17 out of 66) children under 5 years old, presenting with an acute infective illness in November 2012, had their respiratory rate documented. My results support existing research that GPs infrequently document vital signs in clinical practice2. Although other factors such as child behaviour, parental concern and clinical intuition are all important in the identification of serious illness in young children fundamental, basic vital signs are simple and quick to carry out and provide essential diagnostic clues when correctly interpreted. Educational interventions to increase awareness of the importance of recording this data are urgently needed and it is to be hoped that the NICE guidelines will aid this process.
References:
1 Fields E, Chard J, Stephen Murphy M, Richardson M. Assessment and initial management of feverish illness in children younger than five years: summary of updated NICE guidance. British medical journal 2013;346:f2866
2 Blacklock C, Haj-Hassan T, Thompson M. When and how do GPs record vital signs in children with acute infections? British Journal of General Practice 2012;62(603): e679-e686
Competing interests: No competing interests