Article Text

Download PDFPDF

NICE guideline: feverish illness in children—assessment and initial management in children younger than 5 years
  1. Tessa Davis1,2
  1. 1Department of Paediatric Emergency, Sydney Children's Hospital, Sydney, New South Wales, Australia
  2. 2Department of Paediatrics, North Western Deanery, Manchester, UK
  1. Correspondence to Dr Tessa Davis, Department of Paediatric Emergency, Sydney Children's Hospital, Sydney, New South Wales, Australia; tessardavis{at}me.com

Statistics from Altmetric.com

Information about the current guideline

The National Institute for Health and Care Excellence (NICE) guideline for feverish illness in children (assessment and initial management in children younger than 5 years) was partially updated in May 2013.1 Not all sections were reviewed, but the following were: the signs and symptoms of serious illness; the predictive value of tachycardia; the use of inflammatory markers; and the role of paracetamol and ibuprofen. The aim of the guideline is to optimise the management of young children with fever, and in particular to guide health professionals to recognise the signs of serious infection.

The update made new recommendations based on current evidence. This guideline was developed by the National Collaborating Centre for Women's and Children's Health. They worked with the Guideline Development Group to review the evidence and write the recommendations.

It is linked to other NICE guidance on Bacterial meningitis and meningococcal septicaemia and Urinary tract infection in children.2–4

Previous guideline

The previous NICE guideline on feverish illness in children was published in May 2007.

Key issues that the guideline addresses

  • The traffic light system (see ‘Clinical bottom line’ section; figure 1):

    • This uses symptoms and signs to assess the risk of serious illness. Children at highest risk will be red and those at lowest risk will be green (see box 1).

  • Definition of temperature:

    • A baby less than 3 months old with a temperature of 38°C or more will be categorised red; a 3–6-month-old baby with a temperature of 39°C or more will be amber; but once a child is over 6 months old, the height of the temperature does not correlate with the severity of the illness.

  • Cause of the temperature:

    • Assess for features of meningitis, urinary tract infection, pneumonia, meningococcal disease and herpes simplex encephalitis. But also remember to consider septic arthritis or osteomyelitis, which can be easily overlooked. If a fever is ongoing for more than 5 days, Kawasaki disease should be in the differential.

  • The importance of tachycardia:

    • The traffic light system now takes into account tachycardia. The definition of tachycardia is taken from Advanced Paediatric Life Support (APLS) guidance (see figure 2).5 A child with a tachycardia is automatically amber.

  • Management and treatment of pyrexia in infants under 3 months:

    • Investigate this age group with blood (full blood count (FBC), C-reactive protein (CRP) and blood culture) and urine microscopy and culture. Chest X-ray or stool culture should be requested when clinically indicated. If aged less than 1 month; 1–3 months and unwell; or 1–3 months with a white cell count <5×109/L or >15×109/L, then perform a lumbar puncture. Give intravenous antibiotics in all patients who fulfil the criteria for a lumbar puncture. Choice of antibiotics should be a third generation cephalosporin (eg, cefotaxime or ceftriaxone) plus listeria cover (eg, ampicillin or amoxicillin).

  • Management and treatment of pyrexia in infants 3 months or older:

    • Investigate a fever with no focus in a child of this age if there are any red features—with bloods (FBC, CRP, blood culture) and urine microscopy and culture. Perform a chest X-ray, lumbar puncture, urea and electrolytes, and a capillary or venous gas if indicated. Investigate a child of this age with amber features unless deemed unnecessary by an experienced paediatrician.

  • When to check a urine sample:

    • All children with a fever and no source should have a urine sample checked (even if they are green).

  • Antipyretics:

    • Use either paracetamol or ibuprofen, according to individual preference but do not use them simultaneously. Only use antipyretics for a child who appears distressed and not simply to reduce the fever. Switch agents if the child remains distressed.

  • When to discharge:

    • If a fever reduces with antipyretics this does not indicate absence of a serious infection. If the child has amber or red features they should be reassessed after 1–2 h.

  • Criteria for admission:

    • In addition to the usual clinical markers for admission, use other social factors as an indicator: social circumstances; parental concern; serious infectious contacts; travel abroad; or repeated presentations.

Box 1

Steps for assessing fever in children

  1. Identify any life-threatening features (particularly those which could compromise the airway, breathing or circulation).

  2. Use the traffic light system to assess for the risk of serious illness.

  3. Look for signs and symptoms to indicate a focus for the illness and manage appropriately if a focus is found.

Figure 2

Table of tachycardia ranges from NICE Guideline. http://www.nice.org.uk/nicemedia/live/14171/63908/63908.pdf (page 7).

What do I need to know?

What should I stop doing?

  • Stop using ibuprofen and paracetamol together (see box 2).

  • Stop giving antipyretics simply to lower temperature.

  • Stop being reassured against a serious illness by fever that resolves with antipyretics.

  • Stop treating every pyrexial child aged 1–3 months old with antibiotics. This is only needed if they are unwell or have a white cell count <5×109/L or >15×109/L.

Box 2

Use and rationale of paracetamol and ibuprofen

  • Only use if the child is distressed and not simply to lower the temperature.

  • Lowering the temperature does not prevent febrile convulsions.

  • Choose one drug and use it on its own.

  • If the child remains distressed then switch to using the other drug instead.

  • A fever that resolves with paracetamol or ibuprofen does not reflect the severity of the illness.

What should I start doing?

  • Checking a urine sample on: every pyrexial child under 3 months; and every pyrexial child over 3 months with no focus of infection.

  • Taking note of tachycardia in a pyrexial child.

  • Reassessing any child with amber or red features after 1–2 h.

What can I continue to do as before?

  • Use the traffic light system to grade the level of clinical concern.

  • Consider less common causes of pyrexia (like septic arthritis, osteomyelitis and Kawasaki disease).

  • Investigate any child under 3 months with a temperature

  • Understand that lowering the temperature will not prevent a febrile convulsion.

  • Admitting to hospital if there are significant social reasons to do so (even if the clinical markers do not seem strong).

Life or limb saving points

  • Avoid sending home children with a tachycardia where there is fever with no focus (see box 3).

  • Review all children with amber or red features 1–2 h after initial assessment.

Unresolved controversies

Pyrexial children aged 1–3 months may not all require lumbar puncture and intravenous antibiotics. If the child is well and the white cell count (WCC) >5×109/L and <15×109/L then blood tests (FBC, CRP and blood culture (B/C)) can be sufficient.

Box 3

What do I need to inform families?

  • Explain that once over 6 months of age, the height of the temperature does not mean the child is more sick.

  • Advise parents only to give paracetamol or ibuprofen if the child seems distressed and not just because of the temperature.

  • Advise parents only to give one of the antipyretics at a time and not both together.

  • Advise parents not to overwrap or underdress a pyrexial child; and tepid sponging is not recommended.

  • Explain that lowering the temperature does not prevent a febrile convulsion.

  • Give information on discharge of how to recognise amber or red signs.

Whether or not to investigate an older pyrexial child (over 6 months) that is amber remains unclear, and is at the discretion of the clinician.6 The decision here should depend on the level of clinician experience and judgement (see box 4).

Box 4

Website links

Clinical bottom line

  • Be clear about how to use antipyretics in a pyrexial illness.

  • Recognise the significance of temperatures in the different age groups.

  • Tachycardia should not be ignored.

  • The traffic light system is a helpful guide to direct investigations and management, but clinical judgement is still needed for those cases where the features are not clear-cut.

Acknowledgments

The author would like to thank Life in the Fast Lane (http://www.lifeinthefastlane.com) and FOAM (Free Open Access Medical Education) for encouraging the online education and innovation that led to the writing of this article.

References

View Abstract

Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.