Assessment and initial management of feverish illness in children younger than 5 years: summary of updated NICE guidance
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2866 (Published 22 May 2013) Cite this as: BMJ 2013;346:f2866
- Ella Fields, research fellow1,
- Jiri Chard, senior research fellow1,
- M Stephen Murphy, clinical co-director1,
- Martin Richardson, consultant paediatrician2
- on behalf of the Guideline Development Group and technical team
- 1National Collaborating Centre for Women’s and Children’s Health, London W1T 2QA, UK
- 2Peterborough and Stamford Hospitals Foundation Trust, Peterborough PE3 9GZ, UK
- Correspondence to: J Chard jchard{at}ncc-wch.org.uk
Among children presenting with fever, especially in a primary care setting, serious illness is uncommon. The prevalence of serious illness has been reported at 0.8% in primary care1 and 7.2% in secondary care.2 For this reason it is important that guidance is available to help healthcare professionals distinguish the many who have minor transient conditions from the occasional child with a serious or even life threatening infection. This article summarises the key recommendations from the 2013 update of the National Institute for Health and Care Excellence (NICE) guidelines on feverish illness in children.3
Recommendations
NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost-effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s (GDG) experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italics in square brackets.
Clinical assessment of feverish children
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This should consist of three stages:
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- Identify life threatening features (airway, breathing, circulation, disability). If any are present, refer immediately for emergency medical care. [Based on high to very low quality evidence from observational studies, and the experience and opinion of the GDG]
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- Use the “traffic light” table (fig 1⇓) to assess the risk of serious illness as being low (green), intermediate (amber), or high (red). (Updated recommendation with substantive changes, including addition of tachycardia as a risk factor for serious illness.) [Based on high to very low quality evidence from observational studies, and the experience and opinion of the GDG]
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- Attempt to identify a focus of infection or features of specific serious conditions (see table⇓). [Based on high to very low quality evidence from observational studies, and the experience and opinion of the GDG]
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Fig 1 “Traffic light” table for assessing risk of serious illness in feverish children aged <5 years old. Children with fever and any features from the red column should be considered as being at high risk. Children with fever and any features from the amber column and none in the red column should be considered at intermediate risk. Children with features in the green column and none in the amber or red columns are at low risk. (This table should be used only in conjunction with this guideline on investigations and initial management)
Clinical features of specific serious diseases in conjunction with fever
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Measure and record temperature, heart rate, respiratory rate and capillary refill time as part of the routine assessment of a child with fever. [Based on high to very low quality evidence from randomised controlled trials, observational studies, the experience and opinion of the GDG, and a wider consensus survey]
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In children aged 4 weeks to 5 years, measure body temperature by one of the following methods:
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- Electronic thermometer in the axilla
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- Chemical dot thermometer in the axilla
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- Infra red tympanic thermometer. [Based on high to very low quality evidence from randomised controlled trials and observational studies, the experience and opinion of the GDG, and a wider consensus survey]
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Reported parental perception of a fever should be considered valid and taken seriously by healthcare professionals. [Based on low and very low quality evidence from observational studies and the experience and opinion of the GDG]
Management
Management in primary care (fig 2⇓) and specialist care (fig 3⇓) is determined by the assessment of risk of serious illness. [Based on high to very low quality evidence from observational studies, and the experience and opinion of the GDG]
The following substantive changes have been made for the 2013 update:
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Tachycardia was added to the amber (intermediate risk) column (age related values from Advanced Paediatric Life Support 6 are appropriate)
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“Rigors” was added to the amber column
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“Age 3-6 months, temperature ≥39°C” was moved from the red (high risk) column to the amber column
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“A new lump >2 cm” was removed
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“Bile-stained vomiting” was removed.
Fig 2 Management of feverish illness in children aged <5 years old by the non-specialist. [Based on moderate to very low quality evidence from observational studies, the experience and opinion of the GDG, and a wider consensus survey]
Fig 3 Management of feverish illness in children aged <5 years old by the paediatric specialist. [Based on moderate to very low quality evidence from observational studies, the experience and opinion of the GDG, and a wider consensus survey]
Antipyretic agents
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Consider using either paracetamol or ibuprofen in children with fever who seem distressed. (Updated recommendation.) [Based on high to very low quality evidence from randomised controlled trials and the experience and opinion of the GDG]
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Do not use antipyretic agents with the sole aim of reducing body temperature in children with fever. (Updated recommendation.) [Based on high to very low quality evidence from randomised controlled trials and the experience and opinion of the GDG]
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Antipyretic agents do not prevent febrile convulsions and should not be used just for this purpose. [Based on high quality evidence from randomised controlled trials and the experience and opinion of the GDG]
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When using paracetamol or ibuprofen in children with fever:
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- Continue only as long as the child appears distressed
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- Consider changing to the other agent if the child’s distress is not alleviated
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- Do not give both agents simultaneously
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- Consider alternating these agents only if the distress persists or recurs before the next dose is due. (Updated recommendation.) [Based on high to very low quality evidence from randomised controlled trials studies and the experience and opinion of the GDG]
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Overcoming barriers
Parents and carers are naturally worried by feverish illness in their children, and often the initial thought is to reduce the temperature using products containing ibuprofen or paracetamol. This guideline makes it clear that ibuprofen and paracetamol should be used only to reduce distress in a child, rather than to reduce temperature alone. It is important for health professionals to get this message across to parent and carers, and a leaflet has been produced to support this (http://publications.nice.org.uk/ifp160).
The original traffic light system for assessing risk of serious illness was generally well accepted in the National Health Service,7 but, there has been some concern that it was not validated.8 However, a recent article goes some way towards validating it,9 and its data were incorporated in this 2013 update.2
A recent Health Technology Assessment report has highlighted potential problems of using tools such as the traffic light table in isolation.10 For example, the Yale Observation Scale is moderately useful at identifying serious illness but could not be used as a “rule out” criterion. It is important that the traffic light table in this guideline is used in combination with other recommendations, both in this guideline (such as the need for urine analysis) and in other relevant guidelines (such as the NICE Clinical Guidelines on urinary tract infection in children5 and bacterial meningitis and meningococcal septicaemia4) for complete management.
Definitions used in guideline
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Fever—Defined as “an elevation of body temperature above the normal daily variation” for the purposes of this guideline.
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Appears ill to a healthcare professional—An overall impression the assessing healthcare professional makes when a child presents. This impression is formed not only from objective measurements but also from subjective feelings about how the child looks or reacts. If a healthcare professional’s subjective impression is that the child is ill looking, then the child is probably at high risk of serious illness.10 Healthcare professionals should be confident to follow their impressions of a child’s wellbeing.
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Rigors—An episode of shaking or shivering, which can occur when the child has high temperature. Rigors can be confused with febrile convulsions. However, unlike in a seizure, the child is conscious and alert during the episode.
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Safety netting—Providing support for a patient when the clinician is uncertain as to the presence of a self limiting illness and is concerned that the patient’s condition may deteriorate. Safety netting may take different forms, such as dialogue with the parent or carer about symptoms and signs to watch for, advice about when to seek further medical attention, review after a set period, and liaising with other healthcare services.
Further information on the guidance
What’s new in the 2013 guideline
New recommendations were formulated for the following topic areas:
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An updated traffic light table and associated recommendations on symptoms and signs to help identify children who are at risk of serious illness
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The recommendations on the use of antipyretics for children with feverish illness have been rewritten to encourage a rational, stepwise approach, with detail on when and how to use ibuprofen and paracetamol.
When formulating recommendations, the following groups were specifically considered to ensure equality:
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Infants or children with learning difficulties—for example, assessing social cues and activity may be different for this group, affecting the use of the traffic light table
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Infants or children presenting without a parent or carer—for example, a child’s recall of symptoms and signs may not be reliable, affecting the use of the traffic light table in this situation
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Infants or children from different ethnic groups—for example, assessing pallor or capillary refill time may be less useful in children with darker skin tones, affecting the use of the traffic light table in this group.
Methods
This guidance was developed by the National Collaborating Centre for Women’s and Children’s Health using NICE guideline development methods (www.nice.org.uk/guidelinesmanual). The GDG was established by the National Collaborating Centre for Women’s and Children’s Health, which incorporated healthcare professionals (including consultant paediatricians, a nurse practitioner, a nurse, and a general practitioner), parents with young children, and experts in guideline methodology. The GDG identified relevant clinical questions, collected and appraised clinical evidence, and evaluated the cost effectiveness of proposed interventions where possible. The draft guideline underwent a public consultation in which stakeholder organisations were invited to comment; the GDG then took all comments into consideration when producing the final version of the guideline.
Four different versions of this guideline have been produced: a full version containing all the evidence, the process undertaken to develop the recommendations, and all the recommendations; a care pathway; a version containing a list of all the recommendations, known as the “NICE guideline”; and a version for patients and the public. All of these versions are available from the NICE website. Further updates of the guidance will be produced as part of NICE’s guideline development programme.
Future research
The GDG identified the following priority areas for future research:
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A UK based epidemiological study on the symptoms and signs of serious illness in children with fever without apparent source
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How to measure temperature in young babies (tympanic v axilla electronic v axilla chemical dot v temporal artery)
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UK based study to determine the validity of symptoms reported on remote assessment for children with fever
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Referral patterns between primary and secondary care for children with fever
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UK based study of the performance characteristics and cost effectiveness of procalcitonin compared with C reactive protein in identifying serious bacterial infection in children with fever without apparent source
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Primary and secondary care based studies to determine whether examination or re-examination after a dose of antipyretic medicine is of benefit in differentiating children with serious illness from those with other conditions
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Studies on home based antipyretic use and parental perception of distress caused by fever (including help seeking behaviour, what triggers presentation to a healthcare professional, the decision to give an antipyretic, and the decision to change from one antipyretic to another).
Notes
Cite this as: BMJ 2013;346:f2866
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Previous articles in this series
Footnotes
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This is one of a series of BMJ summaries of new and updated guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
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The members of the Guideline Development Group were Leah Bowen, Richard Bowker, John Crimmins, Penny McDougall, Ed Purssell, Debra Quantrill, Martin Richardson (chair), Andrew Riordan, and Damian Roland (elected members); and Zosia Beckles, Jiri Chard, Hannah Rose Douglas, Ella Fields, M Stephen Murphy, Nitara Prasannan, and Cristina Visintin (NCC-WCH technical team).
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Contributors: All authors contributed to the initial drafting of this article and revising it critically. They have all approved this version. MSM is the guarantor.
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Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: EF, JC, and MSM have support from the National Institute for Health and Care Excellence for the submitted work.
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Provenance and peer review: Commissioned; not externally peer reviewed.