The NICE guidance on fever in children

Dr James Cave answers key questions concerning the NICE guidance on feverish children.

If I was following NICE guidance perfectly, how would I manage a feverish child?

You should see the child within two hours if they have already been triaged and thought to have a 'red' symptom (see table, page 41).

You should assess the child fully, taking a history and examining the child with particular focus on the traffic light table.

Your examination would include measuring their temperature with an electronic thermometer in the axilla, taking their pulse, respiratory rate, blood pressure and capillary refill time. You would record all your findings in the notes.

Children who have life-threatening features would need immediate resuscitation and admission. Children with 'red' features should be considered high risk and admitted urgently to a paediatric unit (not A&E).

Children with no 'red' features but amber features are at moderate risk of serious illness. The GP must manage this risk appropriately. Some will require admission, others should be further assessed later and some can go home with good instructions to the carer.

Children with symptoms in the 'green' category only are low risk and can be safely managed at home.

I never measure a child's temperature. Why should I start now?

The review of research carried out by the NICE team showed that parents' reports of fever can be trusted, and there is only a weak correlation between height of fever and severity of illness.

However, it is easy to miss fever and, in children under six months old, fever is predictive of serious illness.

Placing a thermometer under the axilla at the beginning of your assessment will not increase the time it takes to see a child.

I can spot a sick child, why do we need this guidance?

I expect you can. Collapsed children are not difficult to spot, and therefore most GPs are probably spotting high-risk 'red' children already.

The problem is that the evidence shows we are not managing unwell children as well in the UK as in the rest of Europe. Partly, this may be down to failures in secondary care (hence NICE's drive to ensure feverish children are cared for by paediatric specialists) but also there is concern that primary care is missing some children.

We all have stories of children who were seen in the afternoon and collapsed later that evening. Could some of these children have been picked up earlier? There is no direct evidence but collapse is considered the end stage of a temporal process and the premise of admitting children for observation is based on this.

In addition, proper assessment and recording of information is vital to allow review by another person later.

Where do the symptoms and signs that make up the traffic light table come from?

The Yale Observation Studies considered a large number of studies that looked at the predictive value of symptoms. Many were discounted because they included the use of investigations not available in primary care.

These studies are entirely observation based and are the basis for most of the symptoms and signs. The group added others where studies existed to confirm that they were useful. Each of the symptoms and signs in the table has evidence for being there. This is not an idle list.

Vomiting alone has not found its way on to the list because it is poorly predictive of severity of illness.

Why does the guidance not support using paracetamol and ibuprofen together?

Because there is no evidence that this combination does any good, but increases the cost of antipyretics to the NHS and parents. The issue of 'treating fever' is now more steeped in fashion and tradition than in evidence. Treating fever with antipyretics can undoubtedly make a child who is feeling unwell feel better.

Parents phone us because they are concerned about fever and we do them a disservice by concentrating on getting rid of the fever at the expense of properly assessing the child and reassuring them.

The guidance in our practice is short on detail, where can I get the complete guidance?

The complete guidance is available on the NICE website (http://guidance.nice.org.uk/CG47). However, if you want a document with the full reasoning behind the guidance, including the Delphi consultation and a full database of the 300 papers the clinical group reviewed, contact the National Collaborating Centre for Women's & Children's Health (ncc-wch@rcog.org.uk). There will be a charge for this.

Dr Cave is a GP in Newbury, Berkshire and a member of the guideline development group for fever in childhood

For a downloadable version of the traffic light table visit www.healthcarerepublic.com and search on 'Downloads'

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