NICE child fever guidelines miss serious infections, BMJ study finds
The NICE ‘traffic light’ system for detecting serious bacterial infections in young febrile children misses too many infections, particularly UTIs, say the authors of a new study published in the BMJ.
In what is claimed to be the first major validation study of the 2007 NICE assessment pathway for assessing feverish illness in children, an Australian group found that the green-amber-red clinical decision support tool missed one in five UTIs. They concluded that it would be more useful as a triage tool if urinalysis was carried out in every child too.
When they used the NICE assessment tool in almost 16,000 children under five in a paediatric A&E department in Sydney, Australia, researchers found that 20% of UTIs, 14% of bacteraemia cases and 8% of pneumonia cases were in the ‘green’ zone and would be missed using the NICE system.
Writing in the BMJ, the researchers said ‘this is a substantial deficiency in a screening tool for serious bacterial infections in febrile young children’. They said that missing UTIs was especially worrying because occult bacteraemia is now quite rare in febrile children due to childhood pneumococcal vaccination, whereas UTIs are still found in more than 7% of children with fever without a clinically obvious source.
The NICE traffic light assessment system, released in 2007, is based on clinical signs such as a child’s colour, hydration, activity and respiratory status.
Combining the amber (intermediate) and (red) high risk categories, the NICE traffic light system was found to have a test sensitivity of 86% and specificity of 29% for detection of any serious bacterial infection. The addition of urinalysis significantly improved the assessment tools’ sensitivity to 92%.
The researchers said NICE guidelines recommend urinalysis in children with fever without apparent source, but they do not include this test in the traffic light system itself.
‘We recommend that urine analysis should be done routinely in children with fever and suspected bacterial infection and only children with a negative result should be classified as belonging to the green (low infection risk) zone,’ they concluded.
However, they added that the low test specificity of the traffic light system means that clinicans must still judge each case based on its individual features to avoid over-investigation and overtreatment.
Dr George Kassianos, the RCGP’s immunisation lead and a GP in Bracknell, Berkshire, said the findings highlighted the importance of urine analysis and this should be emphasised in the NICE traffic light system.
‘If you have a child with a high temperature of unknown origin one thing what we always do in our practice is to get a Multistix urine analysis there and then on the spot,’ he said. ‘This is good practice and if this is not in the guideline then NICE should be bring them up to date.’
But Dr Kathryn O’Brien, a GP in Cardiff and clinical lecturer at the Department of Primary Care and Public Health School of Medicine, Cardiff University, said that routine urine analysis in children was logistically difficult in general pratice, and that dipsticks are not recommended by NICE for use in children under three years old.
‘GPs infrequently sample urine from acutely ill children presenting in general practice - in less than 1% of consultations with ill children under five years old,’ she said.
A spokesperson for NICE said that the guideline on feverish illness in children was currently being updated, with a draft released for public consultation in November, but could not immediately say whether the BMJ study had been or would be considered as part of the updating process.
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