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At the heart of general practice since 1960

June 2007: Traffic light system helps GPs assess fever in children

Is pyrexia significant?

Should children be given antipyretics?

What are 'red' symptoms?

Is pyrexia significant?

Should children be given antipyretics?

What are 'red' symptoms?

there have been concerns that fever in children is not always managed as it might be in both primary and secondary care.

Infant mortality in the UK has dropped by a factor of 40 over the past 100 years and now stands at around 0.5%; one child in 200 will die in their first year of life.1 Much of this improvement has resulted from better public health measures and immunisations. However, in recent years the infant mortality rate in the UK has failed to continue to fall as it has in many other European countries.1

Infection is the second highest cause of death in the first year of life, after congenital defects, and causes 100 deaths in England and Wales each year.1 This, and continuing concerns over high-profile cases of meningitis, led to the perception of a need to improve the recognition, evaluation and treatment of feverish illnesses in children.

Guidance on feverish illness in children has recently been published by NICE (see table 1, attached).1 The guidance is a useful tool for GPs to use, and is broadly divided into six areas:

• Detection of fever

• Clinical assessment of a child with fever

• Management by remote assessment

• Management by the non-paediatric practitioner

• Management by the paediatric specialist

• Antipyretic interventions.

Clinical Assessment

Temperature

NICE advises measuring temperature in the axilla with an electronic thermometer for all age groups.

Tympanic thermometers can be used in older children (see table 2, below).

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Duration and height of fever is not predictive of serious illness, except in two specific cases:

• A fever of ? 38°C in a child under three months signifies a one in 10 risk of a serious bacterial infection

• A fever for at least five days is part of the diagnostic criteria for Kawasaki disease.

GPs should not rely on a decrease or lack of decrease in temperature with antipyretics after one to two hours to differentiate the severity of illness.

Symptoms and signs as predictors of illness

A number of scoring systems have been devised to assess symptoms and signs that are predictive of serious illness in children, including the Yale Observation Scale (YOS).2 These scoring systems and other findings from prospective studies on symptoms and signs, have been used to develop the single traffic light system for identifying likelihood of serious illness (see table 1, attached). Other symptoms and signs were also added to the table if there was evidence that they were predictive of serious illness to make the table as comprehensive as possible.

The traffic light system has not been assessed for effectiveness. However, from the YOS studies a child with only green symptoms has a 97.4% chance of being well, while a child with two or more red symptoms has a 92% risk of being seriously ill.2

Specific signs

Heart rate

While an abnormal heart rate is assumed to be a marker of serious illness, and is widely seen as a marker of shock, there are no studies that link serious illness to heart rate in feverish children. Indeed, there is little research on what the normal heart rate in patients aged less than five years should be. However, studies investigating this are underway.

Although there is no evidence to support heart rate as a marker of serious illness, there was a consensus that it should be measured and recorded. This will allow assessment of change when a child is under observation.

Capillary refill time

The guideline development group found that capillary refill time (CRT) is the most specific sign for dehydration (0.85, 95% CI 0.72-0.98). However, it is not particularly sensitive (0.6, 95% CI 0.29-0.91). The test is more accurate when a CRT of more than three seconds is taken to be abnormal.3

CRT should be taken thus:

• The child's hand should be held at the height of their heart.

• The physician should firmly compress the skin on the back of the child's hand for three seconds.

• The compression should be removed and the GP should measure the time taken for the colour to return.

Testing CRT is quick, reproducible and useful. It should be included in the assessment of a child with fever.

Respiratory rate

A respiratory rate of >60 breaths/minute is a high-risk marker for illness in children (a red risk factor). It is also a specific marker for dehydration and for pneumonia (see table 3, attached).

Dehydration

Parents and carers should be advised to look for the most sensitive signs of dehydration. These are:

• Sunken fontanelle

• Dry mouth

• Sunken eyes

• Absent tears

• Poor overall appearance.

Clinicians are advised to look for the most specific signs of dehydration. These are:

• Prolonged CRT

• Abnormal skin turgor

• Abnormal respiratory pattern

• Weak pulse

• Cool extremities.

Management

Symptoms and signs of specific diseases

The NICE guideline details the symptoms and signs that are predictive of serious illness (see table 3, attached). The evidence for these was taken from prospective cohort studies.1

Safety netting

GPs deal with uncertainty every day. The NICE guidance recommends safety netting for at-risk children who do not require referral yet exhibit amber or red signs. It involves developing a management plan with the carers or parents.

The plan should not only specify what follow up is required and when, but also inform parents and carers of what to look for and how to act if a more serious symptom or sign develops.

In the future practices may increasingly use a fever card, similar to a head injury card, to provide parents with simple advice.

Antipyretic interventions

There is little evidence to support the use of antipyretics in children, and no evidence to support alternating ibuprofen and paracetamol.

The guidance recommends that GPs should offer antipyretic agents to children who are miserable to help them feel better. However, this was determined by consensus and not by evidence.

Conclusion

It is important that the underlying evidence behind the guidance is understood. The following recommendations by NICE are evidence-based, and where evidence is sparse have been determined by consensus:

• GPs should be prepared to see a feverish child that has been assessed by another health professional (such as NHS Direct) and found to have a red symptom within two hours of referral

• In children with fever, GPs should undertake a full assessment (history and examination). This should include checking the child has not recently travelled abroad and measuring and recording the child's temperature, heart rate, respiratory rate and CRT

• Risk should be assessed using the traffic light system. Urine should be checked if appropriate, and GPs should consider referral to secondary care where appropriate

• At-risk children who do not require referral and do not have a specific diagnosis (amber symptoms) should be given an appropriate safety net

• GPs should not prescribe antibiotics indiscriminately to feverish children, and should be ready to give parenteral antibiotics (benzylpenicillin or a third-generation cephalosporin) to children with suspected meningococcal disease

• The common practice of alternating ibuprofen and paracetamol has no evidence base and no antipyretic agent prevents febrile convulsions.

It is rare for clinicians to see the original guidance. The NICE quick reference guide is a set of short notes from the NICE guidance,4 which itself is an abridged version of the complete guidance. This means that sometimes the nuances are lost, creating confusion as to how the authors came to the conclusions they did. Therefore, it is strongly recommended that interested GPs and training practices consult the full guidance available from the National Collaborating Centre for Women's and Children's Health.

useful information Useful information

The full guidance is available from the NICE website.
www.nice.org.uk/CG047

The guidance is also available for purchase with a CD database of all studies in childhood illness from the National Collaborating Centre for Women's and Children's Health.
www.rcog.org.uk

Author

Dr James Cave
BSc MB BS DRCOG FRCGP
GP, Newbury, Berkshire, on behalf of the NICE Guideline Development Group for Feverish Illness in Children and the technical team

kps Key points Traffic light system Table 1: Traffic light system for identifying likelihood of serious illness in children with fever

Traffic light system

symptoms and signs Table 3: Symptoms and signs of specific diseases

Symptoms and signs

Table 2: Use of thermometers Kawasaki disease. The patient must have had a fever

for more than five days before the diagnosis is made Figure 1 A non-blanching rash should be considered a

high-risk symptom of severe illness in children Figure 2

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