Assessment and initial management of feverish illness in children younger than 5 years: summary of NICE guidanceBMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39218.495255.AE (Published 31 May 2007) Cite this as: BMJ 2007;334:1163
- Martin Richardson, consultant paediatrician1,
- Monica Lakhanpaul, clinical co-director and senior lecturer in child health2
- on behalf of the Guideline Development Group and the technical team
- 1Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough PE3 6DA
- 2National Collaborating Centre for Women and Children's Health, Royal College of Obstetricians and Gynaecologists, London NW1 4RG, and University of Leicester
- Correspondence to: M Richardson
Why read this summary?
Infectious diseases remain a major cause of childhood mortality and morbidity in the United Kingdom (personal communication, R MacFaul, Department of Health) with some evidence that this is associated with deficiencies in health care.1 Fever in young children usually indicates an underlying infection, but identifying the cause can pose a diagnostic challenge. In the absence of national guidance, feverish illness is variably managed across the UK. There is thus a perceived need to improve its assessment and management. This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) on how to assess and initially manage feverish illness in children aged under 5 years.2
NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, a range of consensus techniques is used to develop recommendations. In this summary, recommendations derived primarily from consensus techniques are indicated with an asterisk (*).
The recommendations are largely based around an evidence based traffic light system that is used to assess the risk of serious illness as low (green), intermediate (amber), or high (red), and to direct management accordingly (figs 1-3⇓⇓⇓).
This guideline applies until the underlying condition is diagnosed, at which point the child should be treated according to guidance for that condition.
Assessment and management according to the risk of serious illness
Clinical assessment should consist of three stages:
Identify life threatening features (airway, breathing, circulation, disability). If any are present, refer immediately for emergency medical care
Assess the risk of serious illness using the traffic light system (fig 1⇑; based on prospective cohort studies and validated scoring systems)
Attempt to identify a focus of infection or features of specific serious conditions (box).
Clinical features of specific serious diseases in conjunction with fever
Non-blanching rash, particularly with one or more of:
An ill looking child
Lesions larger than 2 mm in diameter (purpura)
A capillary refill time of ≥3 seconds
Decreased level of consciousness
Convulsive status epilepticus
Herpes simplex encephalitis
Focal neurological signs
Decreased level of consciousness
Tachypnoea: respiratory rate >60 breaths/min if age 0-5 months; >50 breaths/min if age 6-12 months; >40/min if age >12 months
Crackles on auscultation
Oxygen saturation ≤95%
Urinary tract infection
Abdominal pain or tenderness
Urinary frequency or dysuria
Offensive urine or haematuria
Septic arthritis or osteomyelitis
Swelling of a limb or joint
Not using an extremity
Fever for more than five days and at least four of:
Bilateral conjunctival injection
Change in mucous membranes
Change in the extremities
Measure and record temperature, heart rate, respiratory rate, and capillary refill time in all children with feverish illness.*
Management in primary and specialist care is determined by the assessment of risk of serious illness (figs 2⇑ and 3⇑). Children who progress to the later stages of the guideline are likely to have fever without apparent source, a relatively common problem that is recognised as being particularly challenging to manage.3
Other key recommendations
Parental perception of fever should be taken seriously
Measuring body temperature:
1. Do not routinely use the oral and rectal routes in children aged 0-5 years*
2. In infants under the age of 4 weeks, use an electronic thermometer in the axilla
3. In children aged 4 weeks to 5 years, use an electronic thermometer in the axilla, a chemical dot thermometer in the axilla, or an infrared tympanic thermometer
Do not routinely use antipyretic agents with the sole aim of reducing fever in children who are otherwise well*
Do not routinely administer paracetamol and ibuprofen either in combination or alternately; but consider using the alternative drug if the child does not respond to the first agent
Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose
Do not prescribe oral antibiotics to children with fever without apparent source.
Unlike previous disease-focused guidelines, this problem-focused guidance is not accompanied by definite targets to be achieved. Instead, it requires health professionals to be aware of key clinical features for assessing the risk of serious illness in a child with fever and to record these features so that the child's progress can be monitored.
Some recommendations may not be readily accepted as they are derived from formal consensus (through the Delphi technique) rather than published evidence. Such recommendations arose only where no relevant published evidence was available, and the Delphi panel reflected a wide range of opinion, from parents and carers as well as workers in primary and secondary health care. Other children's guidelines based on a combination of formal evidence and the Delphi process have reduced attendance times in emergency departments and the number of unnecessary investigations.4
To support implementation, the Guideline Development Group has developed a leaflet (available from August 2007 at www.nice.org.uk/CG047) that can be given to parents and carers of children with feverish illness.
Although childhood mortality has decreased enormously in the past 100 years, largely due to the prevention and treatment of infectious diseases, infection remains a major cause of mortality in children aged up to 5 years. Some European countries now have childhood mortality rates 30% to 40% lower than that of the United Kingdom (personal communication, R Macaul, Department of Health), suggesting that more can be done to reduce childhood mortality in the UK.
Improved evaluation and treatment of febrile illnesses in children will hopefully reduce mortality. A recent national study of deaths from meningococcal disease (the leading cause of death from infectious diseases in children) showed that mortality from meningococcal disease is often associated with late identification, suboptimal treatment, and other deficiencies in health care.1 There is also concern that the provision of care for children with feverish illnesses varies considerably across the UK. Differences in childhood mortality due to health inequality are also well recognised: another study of meningococcal disease showed that child mortality from meningococcal disease in the most deprived areas of the UK is three times that in the most affluent areas.w1 One objective of a public service agreement issued by the Department of Health in 2001 is thus to reduce the gap in infant mortality between different social groups by 10% by 2010. Dealing with differences in the management of febrile illnesses in young children with this new NICE guideline may be one way to achieve this.
This guidance differs from previous NICE guidelines in that it deals with a presenting problem rather than a disease. Our aim was to develop a user friendly format that would also encourage implementation—its presentation as “traffic light” tables highlight levels of risk associated with various symptoms and signs.
This is the first NICE clinical guideline developed by the newly established children's guideline programme at the National Collaborating Centre of Women and Children's Health. The technical team, consisting of a clinic co-director, research fellow, information specialist, health economist, and project co-ordinator, supports the chair and Guideline Development Group (GDG) in the development of the guideline.
We followed standard NICE methodology with highly sensitive literature searches, literature appraisal, and evaluation and translation into recommendations by the GDG.w2 Although recommendations are based on data from the highest quality level of evidence available for the clinical question, NICE no longer grades recommendations, as the most important recommendations for clinical practice do not always come from the highest level of evidence. Most of our recommendations on assessment and identification of serious illness are based on prospective cohort studies. For a problem-based guideline rather than disease-specific guideline, search terms had to be more inclusive and less precise. Most of the highest level evidence came from prognostic studies, which are not easily identified by standard NICE filters and require the use of special filters. Health economics studies were also integrated into the review of evidence where appropriate.
Where no relevant evidence was found, we used a formal, two round, Delphi consensus method, which is considered more valid than a process of arriving at recommendations within the GDG.w3 The consensus method involved more than 50 clinicians, parents, and carers, and the GDG made final recommendations according to predetermined criteria.
Our presentation of recommendations with “traffic light” tables does not follow the standard NICE format. These tables are based on, firstly, prospective cohort studies of febrile children with non-specific symptoms and signs associated with serious illness. Most of the evidence is limited to data on infants less than six months old in a secondary care setting. No single symptom or sign is reliably associated with serious illness. The tables are also based on the validated Yale Observation Scale, which shows good correlation for children aged 3 months to 3 years who went on to develop serious illness. We felt, on the basis of clinical experience, that these data could be extrapolated to children up to the age of 5 years in the UK.
Future updates of the guideline will be produced as part of the NICE guideline development programme.w4
A study to confirm the normal range of heart rate for different body temperatures and to determine whether children with heart rates outside these ranges are at higher risk of serious illness.
A UK study to determine the validity of symptoms reported on remote assessment for children with fever (eg via telephone assessment).
Research on referral patterns between primary and secondary care for children with fever, so the health economic impact of this and future guidelines can be estimated.
A UK study of the performance characteristics and cost effectiveness of procalcitonin versus C-reactive protein in identifying serious bacterial infection in children with fever without apparent source.
Studies in primary care and secondary care to determine whether examination or re-examination after a dose of antipyretic medication is of benefit in differentiating children with serious illness from those with less serious conditions.
Guideline Development Group
Richard Bowker, James Cave, Jean Challiner, Sharon Conroy, John Crimmins, Annette Dearnum, Jennifer Elliott, Jane Houghton, Edward Purssell, Martin Richardson, Andrew Riordan, Peter Rudd, Ben Stanhope, Bridie Taylor.
National Collaborating Centre for Women and Children's Health staff: Adebayo Akande, Michael Corkett, Rosie Crossley, Hannah-Rose Douglas, Monica Lakhanpaul, Chia-Wen Lee, Peny Retsa.
w1 Heyderman RS, Ben-Shlomo Y, Brennan CA, Somerset M. The incidence and mortality for meningococcal disease associated with area deprivation: an ecological study of hospital episode statistics. Arch Dis Child 2004;89:1064-8.
w2 National Institute for Clinical Excellence. Guideline development methods: information for national collaborating centres and guideline developers. London: NICE, 2005.
w3 Murphy MK, Black NA, Lamping DL, McKee CM, Sanderson CFB, Askham J, et al. Consensus development methods and their use in clinical guideline development. Health Technology Assessment 1998;2(3):1-88.
w4 National Institute for Health and Clinical Excellence. Updating guidelines and correcting errors. In: The guidelines manual. (Ch 15.) www.nice.org.uk/page.aspx?o=423088
This is one of a series of BMJ summaries of new NICE guidelines, which are based on the best available evidence; they will highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
We thank members of the Guideline Development Group, National Collaborating Centre for Women and Children's Health staff, and also Françoise Cluzeau, Diane Crawford, Bobbie Lloyd, Roddy MacFaul, Wendy Riches, and Matthew Thompson.
Competing interests: None declared.
Funding: The National Collaborating Centre for Women and Children's Health was commissioned and funded by National Institute for Health and Clinical Excellence to write this summary.