1. Feverish illness in children Implementing NICE guidance May 2007 NICE clinical guideline 47

2. Changing clinical practice NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations to work towards implementing NICE guidelines Compliance with developmental standards will be monitored by the Healthcare Commission

3. What this presentation covers Background to the guideline Key recommendations Suggested actions Resources from NICE

4. 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.

5. Key recommendations Traffic light system Detection of fever Clinical assessment Management by remote assessment Management by a non-paediatric practitioner Management by a paediatric specialist Antipyretics

6. 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

7. Traffic light system: green ColourNormal colour of skin, lips and tongue ActivityResponds normally to social cues Content/smiles Stays awake or awakens quickly Strong/normal cry/not crying HydrationNormal skin and eyes Moist mucous membranes OtherNone of the amber or red symptoms or signs

8. Traffic light system: amber ColourPallor reported by parent/carer ActivityNot responding normally to social cues Wakes only with prolonged stimulation Decreased activity No smile RespiratoryNasal flaring Tachypnoea: RR>50/min age 6-12 months, RR>40/min age >12 months Oxygen saturation ≤ 95% in air Crackles HydrationDry mucous membranes Poor feeding in infants CRT ≥3 seconds Reduced urine output OtherFever for ≥5 days Swelling of a limb or joint Non-weight bearing/not using an extremity A new lump >2cm

9. Traffic light system: red ColourPale/mottled/ashen/blue ActivityNo response to social cues Appears ill to a healthcare professional Unable to rouse or if roused does not stay awake Weak/high pitched/continuous cry RespiratoryGrunting Tachypnoea: RR>60 /min Moderate or severe chest indrawing HydrationReduced skin turgor OtherAge 0-3 months, temperature ≥38°C Age 3-6 months, temperature ≥39°C Non blanching rash Bulging fontanelle Neck stiffness Status epilepticus Focal neurological signs Focal seizures Bile-stained vomiting

10. 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.

11. 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.

12. 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 MeningitisNeck stiffness Bulging fontanelle Decreased level of consciousness Convulsive status epilepticus Herpes simplex encephalitis Focal neurological signs Focal seizures Decreased level of consciousness PneumoniaTachypnoea Chest indrawing Crackles Cyanosis Nasal flaring Oxygen saturation ≤95%

13. Symptoms and signs of specific diseases (2) Urinary tract infection (in children aged older than 3 months) Vomiting Poor feeding Lethargy Irritability Abdominal pain or tenderness Urinary frequency or dysuria Offensive urine or haematuria Septic arthritis/ osteomyelitis Swelling of a limb or joint Not using an extremity Non-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

14. Management by remote assessment

15. Management by a non-paediatric practitioner Do symptoms and/or signs suggest an immediately life- threatening illness? No 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 Provide parents/carers with a safety net or refer to a paediatric specialist for further assessment If any red features Refer child urgently to the care of a paediatric specialist Yes Refer immediately to emergency medical care

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

17. 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.

18. 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

19. 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.

20. 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

21. 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

22. 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’.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. advice sheet Develop protocols for staff on when children are safe to be cared for at home.

23. 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.

24. Suggested actions: training 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.

25. Access tools online Costing tools costing report costing template Implementation advice Audit criteria Available from: www.nice.org.uk/CG47

26. 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