Feverish illness in children

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Feverish illness in children
Dr Michèle Hamilton-Ayres Consultant
Paediatrician Cheltenham General Hospital

NICE clinical guideline 47
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Changing clinical practice

• NICE guidelines are based on the best available
  evidence
• Guidelines help healthcare professionals in their
  work, but they do not replace their knowledge and
  skills
• The Department of Health asks NHS organisations
  to work towards implementing NICE guidelines
• Compliance with developmental standards will be
  monitored by the Healthcare Commission

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What this presentation covers

• Background to the guideline
• Describes the care pathway as presented in the
  guideline
• Key recommendations
• Suggested actions
• Resources from NICE

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Background why this guideline matters

• Feverish illness in children
• is the most common reason for children to be
  taken to the doctor 20-40 of parents reporting
  a feverish illness over the course of a year
• is a cause of concern for parents and carers
• can be a result of a simple self-limiting
  infection or a life-threatening infection
  leading cause of death in children under 5
• can have no apparent source.

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Key recommendations

• Traffic light system
• Detection of fever
• Clinical assessment
• Management by remote assessment
• Management by a non-paediatric practitioner
• Management by a paediatric specialist
• Antipyretics

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The Traffic Light System

• Tool for identifying the likelihood of serious
  illness
• Children with only symptoms and signs in the
  green column are at low risk
• Children with one or more symptom or sign in the
  amber column are at intermediate risk
• Children with one or more symptom or sign in the
  red column are at high risk

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Traffic light system green
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Traffic light system amber
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Traffic light system red
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Detection of fever

• In children aged 4 weeks to 5 years measure body
  temperature by
• electronic thermometer in the axilla or
• chemical dot thermometer in the axilla or
• infra-red tympanic thermometer.
• Use an electronic thermometer in the axilla for
  children younger than 4 weeks.

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Clinical assessment

• Check for any immediately life-threatening
  features.
• Use traffic light system to check for symptoms
  and signs that predict the risk of serious
  illness.
• Look for a source of fever and check symptoms
  and signs associated with specific diseases.
• Measure and record temperature, heart rate,
  respiratory rate, capillary refill time and
  assess for dehydration.

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Symptoms and signs of specific diseases
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Sequelae of Bacterial Meningitis
Percentage of children
Bedford H et al BMJ 2001 323 533-536
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Symptoms and signs of specific diseases (2)
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• Test urine when an infant or child presents with
• unexplained fever of 38C or higher
• or
• symptoms and signs suggestive of UTI
• Consider testing urine when an infant or child
  presents with
• an alternative site of infection, but remains
  unwell
• Do not test urine when an infant or child
  presents with
• an obvious alternative source of fever

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Management by remote assessment
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Management by a non-paediatric practitioner
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Management of children 3 months to 5 years by a
paediatric specialist
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The safety net

• The safety net should be one or more of the
  following
• verbal and/or written information on warning
  symptoms and how further healthcare can be
  accessed
• arranging further follow-up
• liaising with other healthcare professionals,
  including out-of-hours providers, to ensure
  direct access for the child if required.

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Management of children under 3 months by a
paediatric specialist
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Antipyretics

• Antipyretics do not prevent febrile convulsions
  and should not be used specifically for this
  purpose.
• Do not routinely give antipyretic drugs to a
  child with fever with the sole aim of reducing
  body temperature
• Do not administer paracetamol and ibuprofen at
  the same time but consider using the alternative
  agent if the child does not respond to the first
  drug.

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Implementation Advice

• Feedback to NICE suggests that there are likely
  to be three key areas for successful
  implementation
• Traffic light system
• Providing the safety net
• Training for non-specialist and non-clinical
  staff

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Suggested actions traffic light system

• Review clinical assessment tools to ensure that
  they include the features of the traffic light
  system.
• Review care pathways and protocols to ensure
  that they reflect the traffic light system.
• The green section of the Traffic Light System
  could be used to help staff feel confident when
  making the decision to advise that a child is
  managed at home

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Suggested actions providing the safety net

• Review protocols to ensure that information is
  provided about the treatment and care of children
  with fever.
• Patient information is available from a variety
  of sources, including a booklet about this
  guideline for parents/carers, Understanding NICE
  guidance.
• When a child is discharged give the
  parents/carers an advice sheet about how to care
  for their child and potential warning signs.
• Develop protocols for staff on when children are
  safe
• to be cared for at home.

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Access the guideline online

• Quick reference guide a summary
  http//guidance.nice.org.uk/CG47/quickrefguide/pdf
  /English
• NICE guideline all of the recommendations
  http//guidance.nice.org.uk/CG47/niceguidance/pdf/
  English
• Full guideline all of the evidence and
  rationale http//guidance.nice.org.uk/CG47/guidanc
  e/pdf/English
• Understanding NICE guidance a plain English
  version http//guidance.nice.org.uk/CG47/publicinf
  o/pdf/English

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Do you have any questions?
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Thank you for your referrals

• Do not hesitate to discuss any issues with team
  on call including consultant paediatrician for
  advice