Feverish illness in children (update) CG160 Support for education and learning 2013 NICE Clinical guideline CG160 Feverish illness in children – May 2013 Dr Julia Surridge Dr Julie Mott Paediatric EM Consultants

What we will cover…. hopefully Background “New” recommendations Cases

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

Feverish illness Fever is A temperature above the normal range for that child A parent report of “fever” in any child Under 3 months >38C needs investigating Between 3 months and 6 months >39C is a high risk marker Measure body temperature by: electronic thermometer in the axilla Or if over 4 weeks infra-red tympanic thermometer

New recommendations The following areas have new recommendations: Clinical assessment of children with fever Assessment of risk of serious illness Symptoms and signs of specific illnesses Management by the paediatric specialist Observations in hospital Antipyretic interventionsDrug interventions to reduce body temperature

The Traffic Light Table 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 table: main changes Added to all risk groups Colour – relates to skin, lips or tongue Circulation and hydration Circulation – in amber Tachycardia: > 160 beats/minute, age < 1 year > 150 beats/minute, age 1 year - 24 months > 140 beats/minute, age 2-5 years Moved from red to amber age 3-6 months, temperature ≥39°C The text shown in bold highlights the new copy which has been added to the traffic light table as a result of the update

Traffic light table: minor changes Changes to the ‘amber’ intermediate risk category: RespiratoryCrackles in the chest OtherAge 3–6 months temperature ≥39°C Rigors Non-weight bearing limb/not using an extremity Removeda ‘new’ lump >2 cm Removed from ‘red’ high risk category Otherbile stained vomiting The text shown in bold highlights the new copy which has been added to the traffic light table as a result of the update

Symptoms and signs of specific illness Consider urinary tract infection in a child aged 3 months or older with fever and 1 or more of the following: vomiting poor feeding lethargy irritability abdominal pain or tenderness urinary frequency or dysuria

Observations in hospital When a child has been given antipyretics, do not rely on a decrease or lack of decrease in temperature at 1–2 hours to differentiate between serious and non-serious illness

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 Assess: look for life-threatening, traffic light and specific diseases symptoms and signs  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 10 9 /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. Consider a period of observation in hospital (with or without investigations) as part of the assessment to help differentiate non-serious from serious illness.

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 10 9 /litre Whenever possible, perform lumbar puncture before the administration of antibiotics

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.

Drug interventions in fever of unknown cause Paracetamol or ibuprofen should not be used with the sole aim of reducing body temperature but can be used to treat the distress caused by fever and being unwell If paracetamol or ibuprofen are used, give one or the other and only alternate them if the distress persists or recurs before the next dose There is no evidence that simultaneous use of paracetamol and ibuprofen is an effective approach to reducing body temperature

NICE Pathway The NICE feverish illness in children pathway shows all the recommendations from the guideline Click here to go to NICE Pathways website

Evidence Services Visit Evidence Services for the best available evidence on all aspects of feverish illness in children Click here to go to the Evidence Services website

Feverish illness

What is the most likely diagnosis? 1.Meningitis 2.Mumps 3.Measles 4.Erythema infectiosum

Enter question text... 1.Meningitis 2.Pneumococcal pneumonia 3.Meningococcal septicaemia 4.Takayasu’s arteritis 5.Herpes simplex encephalitis 6.Kawasaki syndrome 7.Measles 8.Scarlet fever

n text... 1.Meningitis 2.Pneumococcal pneumonis 3.Meningococcal septicaemia 4.Takayasu’s arteritis 5.Herpes simplex encephalitis 6.Kawasaki syndrome 7.Measles 8.Scarlet fever

Enter question text... 1.Meningitis 2.Pneumococcal pneumonia 3.Meningococcal septicaemia 4.Takayasu’s arteritis 5.Herpes simplex encephalitis 6.Kawasaki syndrome 7.Measles 8.Scarlet fever

Enter question text... 1.Oral amoxicillin 2.Paracetamol and ibuprofen 3.No treatment 4.Non-urgent referral to hospital 5.Immediate parenteral benzylpenicillin 6.Paracetamol and ibuprofen alternately 7.Urgent referral to hospital 8.Paracetamol alone

... 1.Oral amoxicillin 2.Paracetamol and ibuprofen 3.No treatment 4.Non-urgent referral to hospital 5.Immediate parenteral benzylpenicillin 6.Paracetamol and ibuprofen alternately 7.Urgent referral to hospital 8.Paracetamol alone

Enter question text... 1.Oral amoxicillin 2.Paracetamol and ibuprofen 3.No treatment 4.Non-urgent referral to hospital 5.Immediate parenteral benzylpenicillin 6.Paracetamol and ibuprofen alternately 7.Urgent referral to hospital 8.Paracetamol alone

Summary of key messages Assess children with learning disabilities using the traffic light table, taking into account their disability Children who are assessed as low risk‘green’ can be cared for at home with appropriate advice If any ‘amber’ features are present and no diagnosis has been reached, provide parents or carers with a ‘safety net’ or refer to specialist paediatric care for further assessment Children assessed remotely with ‘red’ features should be sent for urgent referral Antipyretics should not be used with the sole aim of reducing fever

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