BMJ 2007;334:1163-1164

Assessment and Initial Management of Feverish Illness in Children Younger Than 5 Years

Assessment and Initial Management of Feverish Illness in Children Younger Than 5 Years

Summary of NICE Guidance

Background to the guideline

Key recommendations

Suggested actions

Resources from NICE

What this presentation covers

Background: why this guideline matters

Feverish illness in children:

is the most common reason for children to be taken to the doctor

is a cause of concern for parents and carers

can be a result of a simple self-limiting infection or a life-threatening infection

can have no apparent source.

•Traffic light system

1

•Detection of fever

2•C

linical assessment

3

•Management by remote assessment

4

•Management by a non-paediatric practitioner

5

•Management by a paediatric specialist

6

•Antipyretics

7

Key recommendations

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

Traffic light system:

Colour Normal colour of skin, lips and tongue

Activity

Responds normally to social cues

Content/smiles

Stays awake or awakens quickly

Strong/normal cry/not crying

HydrationNormal skin and eyes

Moist mucous membranes

Other None of the amber or red symptoms or signs

Traffic light system:Colour Pallor reported by parent/carer

Activity

Not responding normally to social cuesWakes only with prolonged stimulationDecreased activityNo smile

Respiratory

Nasal flaringTachypnoea: RR> 50/min age 6-12 months, RR> 40/min age >12 monthsOxygen saturation ≤ 95% in airCrackles

Hydration

Dry mucous membranesPoor feeding in infantsCRT ≥3 secondsReduced urine output

Other

Fever for ≥5 daysSwelling of a limb or jointNon-weight bearing/not using an extremity A new lump >2cm

Traffic light system:Colour Pale/mottled/ashen/blue

Activity

No response to social cuesAppears ill to a healthcare professionalUnable to rouse or if roused does not stay awakeWeak/high pitched/continuous cry

RespiratoryGruntingTachypnoea: RR>60 /min Moderate or severe chest indrawing

Hydration Reduced skin turgor

Other

Age 0-3 months, temperature ≥38°CAge 3-6 months, temperature ≥39°C Non blanching rash Bulging fontanelle Neck stiffness Status epilepticusFocal neurological signs Focal seizures Bile-stained vomiting

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.

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.

Symptoms and signs of specific diseases

Meningococcal disease

Non-blanching rash, particularly with one or more of the following:

•an ill-looking child •lesions >2 mm in diameter (purpura) •a CRT of ≥3 seconds•neck stiffness

Meningitis

Neck stiffness Bulging fontanelleDecreased level of consciousnessConvulsive status epilepticus

Herpes simplex encephalitis

Focal neurological signs Focal seizuresDecreased level of consciousness

PneumoniaTachypnoea Chest indrawingCrackles CyanosisNasal flaring Oxygen saturation ≤95%

Symptoms and signs of specific diseases (2)

Urinary tract infection (in children aged older than 3 months)

VomitingPoor feeding LethargyIrritabilityAbdominal pain or tenderness Urinary frequency or dysuriaOffensive urine or haematuria

Septic arthritis/ osteomyelitis

Swelling of a limb or jointNot using an extremityNon-weight bearing

Kawasaki disease

Fever >5 days and at least four of the following: •bilateral conjunctival injection •change in upper respiratory tract mucous membranes •change in the peripheral extremities•polymorphous rash •cervical lymphadenopathy

Management by remote assessment

Do symptoms and/or signs suggest an immediately life-threatening illness?

No Yes

Look for traffic light symptoms and signs

If all green features and no amber or red

Child can be managed at home with appropriate care advice

If any amber features and no red If any red features

Send child for assessment in a face-to-face setting.

Send child for urgent assessment in a face-to-face setting within 2

hours

Refer immediately to emergency medical care

Management by a non-paediatric practitioner

Do symptoms and/or signs suggest an immediately life-threatening illness?

No Yes

Look for traffic light features and symptoms and signs of specific diseases

If all green features and no amber or red

Child can be managed at home with appropriate care advice

If any amber features and no diagnosis reached

If any red features

Provide parents/carers with a safety net or refer to a

paediatric specialist for further assessment

Refer child urgently to the care of a paediatric specialist

Refer immediately to emergency medical care

Management of children 3 months to 5 years by a paediatric specialist

· Perform test for urinary tract infection.

· Assess for pneumonia.

· Do not perform routine blood tests or chest X-ray.

Perform (unless deemed unnecessary)· urine test for urinary tract infection· full blood count· blood culture· C-reactive protein.

Perform chest x-ray if fever higher than 39°C and white blood cell count greater than 20 x 109/litre.

Consider lumbar puncture if child is younger than 1-year old.

Perform:· blood culture· full blood count· urine test for urinary tract infection· C-reactive protein.

Consider the following, as guided by clinical assessment:· lumbar puncture in children

of all ages· chest X-ray· serum electrolytes· blood gas.

Consider admission. If admission is not necessary but no diagnosis has been reached, provide a safety net for the

parents/carers.

· If no diagnosis is reached, manage the

child at home with appropriate care advice.

Assess: look for life-threatening, traffic light and specific diseases symptoms and signs

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.

Management of children under 3 months by a paediatric specialist

· Assess: look for life-threatening, traffic light and specific diseases symptoms and signs

· Observe and monitor:· temperature· heart rate· respiratory rate.

· Perform:· full blood count· C-reactive protein· blood culture· urine test for urinary tract infection· chest X-ray if respiratory signs are present· stool culture if diarrhoea is present.

· Admit, perform lumbar puncture and start parenteral antibiotics if the child is:· younger than 1-month old· 1–3 months old appearing unwell · 1–3 months old and with a white blood cell count of less than 5 or greater than 15 x 109/litre

· Whenever possible, perform lumbar puncture before the administration of antibiotics

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.

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

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

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.

Suggested actions: training

Use the traffic light system when developing training.

Review training needs to identify whether training in body temperature measurement is required.

Training should be available for healthcare professionals working with children in the potential diagnoses of fever and other symptoms in children.

Ensure that either electronic, chemical dot or infra-red tympanic thermometers are available for staff to use.

Ensure that staff are confident in measuring body temperature using these thermometers.

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/guidance/pdf/English

‘Understanding NICE guidance’ – a plain English version http://guidance.nice.org.uk/CG47/publicinfo/pdf/English

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