Assessment and initial management of feverish illness in children younger than 5 years: summary of updated NICE guidance

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1 GUIDELINES Assessment and initial management of feverish illness in children younger than 5 years: summary of updated NICE guidance Ella Fields, 1 Jiri Chard, 1 M Stephen Murphy, 1 Martin Richardson, 2 on behalf of the Guideline Development Group and technical team 1 National Collaborating Centre for Women s and Children s Health, London W1T 2QA, UK 2 Peterborough and Stamford Hospitals Foundation Trust, Peterborough PE3 9GZ, UK Correspondence to: J Chard jchard@ncc-wch.org.uk Cite this as: BMJ 2013;346:f2866 doi: /bmj.f2866 This is one of a series of BMJ summaries of new and updated guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists. Further information about the guidance, a list of members of the guideline development group, and the supporting evidence statements are in the full version on bmj.com. Among children presenting with fever, especially in a primary care setting, serious illness is uncommon. The prevalence of serious illness has been reported at 0.8% in primary care 1 and 7.2% in secondary care. 2 For this reason it is important that guidance is available to help healthcare professionals distinguish the many who have minor transient conditions from the occasional child with a serious or even life threatening infection. This article summarises the key recommendations from the 2013 update of the National Institute for Health and Care Excellence (NICE) guidelines on feverish illness in children. 3 Recommendations NICE recommendations are based on systematic reviews of the best available evidence and explicit considera- Colour (of skin, lips, or tongue) Normal colour tion of cost-effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group s (GDG) experience and opinion of what constitutes good practice. Evidence levels for the recommendations are in the full version of this article on bmj.com. Clinical assessment of feverish children This should consist of three stages: Identify life threatening features (airway, breathing, circulation, disability). If any are present, refer immediately for emergency medical care. Use the traffic light table (fig 1) to assess the risk of serious illness as being low (green), intermediate (amber), or high (red). (Updated recommendation Pallor reported by parent or carer Pale, mottled, ashen, or blue Activity Responds normally to social cues Content or smiles Stays awake or awakens quickly Strong normal cry or not crying Not responding normally to social cues No smile Wakes only with prolonged stimulation Decreased activity No response to social cues Appears ill to a healthcare professional (see box of definitions of terms) Does not wake, or if roused does not stay awake Weak, high-pitched, or continuous cry Fig 1 Traffic light table for assessing risk of serious illness in feverish children aged <5 years old. Children with fever and any features from the red column should be considered as being at high risk. Children with fever and any features from the amber column and none in the red column should be considered at intermediate risk. Children with features in the green column and none in the amber or red columns are at low risk. (This table should be used only in conjunction with this guideline on investigations and initial management) Respiratory Circulation and hydration Other Normal skin and eyes Moist mucous membranes None of the amber or red symptoms or signs Nasal flaring Tachypnoea: Respiratory rate (RR) >50 breaths/min at ages 6 12 months RR >40 breaths/min at ages >12 months Oxygen saturation 95% in air Crackles in the chest Tachycardia: >160 beats/min at age <12 months >150 beats/min at age months >140 beats/min at age 2-5 years Capillary refill time 3 seconds Dry mucous membranes Poor feeding in infants Reduced urine output Temperature 39 C at ages 3 6 months Fever for 5 days Rigors (see definitions box) Swelling of a limb or joint Non-weight bearing limb or not using an extremity Grunting Tachypnoea: RR > 60 breaths/min Moderate or severe chest indrawing Reduced skin turgor Temperature 38 C at ages <3 months Non-blanching rash Bulging fontanelle Neck stiffness Status epilepticus Focal neurological signs Focal seizures This traffic light table should be used in conjunction with the recommendations in this guideline on investigations and initial management in children with fever BMJ 25 MAY 2013 VOLUME

2 bmj.com Previous articles in this series ЖЖLong term follow-up of survivors of childhood cancer: summary of updated SIGN guidance (BMJ 2013;346:f1190) ЖЖRecognition, intervention, and management of antisocial behaviour and conduct disorders in children and young people: summary of NICE-SCIE guidance (BMJ 2012;346:f1298) ЖЖFertility (update): summary of NICE guidance (BMJ 2013;346:f650) ЖЖRecognition and management of psychosis and schizophrenia in children and young people: summary of NICE guidance (BMJ 2013;346:f150) ЖЖEctopic pregnancy and miscarriage: summary of NICE guidance (BMJ 2012;345:e8136) Clinical features of specific serious diseases in conjunction with fever Diagnosis to be considered Meningococcal disease* Bacterial meningitis* Herpes simplex encephalitis Pneumonia Urinary tract infection Septic arthritis Kawasaki disease Symptoms and signs in conjunction with fever Non-blanching rash, particularly with 1 of the following: Ill looking child Lesions >2 mm in diameter (purpura) Capillary refill time 3 seconds Neck stiffness Neck stiffness Bulging fontanelle Decreased level of consciousness Convulsive status epilepticus Focal neurological signs Focal seizures Decreased level of consciousness Tachypnoea (respiratory rate >60 breaths/min at ages 0 5 months, >50 breaths/min at 6 12 months, or >40 breaths/min at >12 months) Cyanosis Nasal flaring Chest indrawing Crackles in the chest Oxygen saturation 95% Lethargy Irritability Vomiting Poor feeding Abdominal pain or tenderness Urinary frequency or dysuria Not using an extremity Non-weight bearing Swelling of a limb or joint Fever for >5 days and 4 of the following: Bilateral conjunctival injection Change in mucous membranes (such as injected pharynx, dry cracked lips, or strawberry tongue) Change in extremities (such as oedema, erythema, or desquamation) Polymorphous rash Cervical lymphadenopathy *See NICE guideline on bacterial meningitis and meningococcal septicaemia for more detail. 4 See NICE guideline on urinary tract infection in children for more detail. 5 with substantive changes, including addition of tachycardia as a risk factor for serious illness.) Attempt to identify a focus of infection or features of specific serious conditions (see table). Measure and record temperature, heart rate, respiratory rate and capillary refill time as part of the routine assessment of a child with fever. In children aged 4 weeks to 5 years, measure body temperature by one of the following methods: Electronic thermometer in the axilla Chemical dot thermometer in the axilla Infra red tympanic thermometer Reported parental perception of a fever should be considered valid and taken seriously by healthcare professionals. Management Management in primary care (fig 2) and specialist care (fig 3) is determined by the assessment of risk of serious illness. The following substantive changes have been made for the 2013 update: Tachycardia was added to the amber (intermediate risk) column (age related values from Advanced Paediatric Life Support 6 are appropriate) Rigors was added to the amber column Age 3-6 months, temperature 39 C was moved from the red (high risk) column to the amber column A new lump >2 cm was removed Bile-stained vomiting was removed. Antipyretic agents Consider using either paracetamol or ibuprofen in children with fever who seem distressed. (Updated recommendation.) Do not use antipyretic agents with the sole aim of reducing body temperature in children with fever. (Updated recommendation.) Antipyretic agents do not prevent febrile convulsions and should not be used just for this purpose. When using paracetamol or ibuprofen in children with fever: Continue only as long as the child appears distressed Consider changing to the other agent if the child s distress is not alleviated Do not give both agents simultaneously Consider alternating these agents only if the distress persists or recurs before the next dose is due. (Updated recommendation.) Fig 2 Management of feverish illness in children aged <5 years old by the nonspecialist Children with only green features can be cared for at home with appropriate advice for parents and carers, including advice on when to seek further attention from healthcare services If any amber features are present and no diagnosis has been reached, provide parents or carers with a safety net (see box of definitions of terms) or refer to specialist paediatric care for further assessment. The safety net should be 1 of the following: Providing verbal and/or written information on warning symptoms and how further healthcare can be accessed Arranging further follow-up at a specified time and place Liaising with other healthcare professionals, including out of hours care providers, to ensure direct access for the child if further assessment is required For children whose clinical features suggest an immediately life threatening illness, refer immediately for emergency medical care by the most appropriate means of transport From remote assessment Children with any red features but not considered to have an immediately life threatening illness should be urgently assessed face to face by a healthcare professional within 2 hours From non-specialist care For children with any red features but not considered to have an immediately life threatening illness, refer urgently to the care of a paediatric specialist 36 BMJ 25 MAY 2013 VOLUME 346

3 Fig 3 Management of feverish illness in children aged <5 years old by the paediatric specialist Test urine for urinary tract infection Check for specific symptoms and signs of pneumonia Do not routinely perform blood tests or chest x rays in children with fever who have no amber or red features of serious illness The following tests may be performed: Urine testing for urinary tract infection Full blood count, C reactive protein, and blood cultures Consider lumbar puncture for children <1 year old Chest x ray in a child with a fever >39 C and leucocyte count > /L Undertake the following tests: Full blood count Blood culture C reactive protein Urine testing for urinary tract infection Consider the following investigations: Lumbar puncture in children of all ages (if not contraindicated) Chest x ray irrespective of body temperature and leucocyte count Serum electrolytes Blood gases Overcoming barriers Parents and carers are naturally worried by feverish illness in their children, and often the initial thought is to reduce the temperature using products containing ibuprofen or paracetamol. This guideline makes it clear that ibuprofen and paracetamol should be used only to reduce distress in a child, rather than to reduce temperature alone. It is important for health professionals to get this message across to parent and carers, and a leaflet has been produced to support this ( nice.org.uk/ifp160). The original traffic light system for assessing risk of serious illness was generally well accepted in the National Health Service, 7 but, there has been some concern that it was not validated. 8 However, a recent article goes some way towards validating it, 9 and its data were incorporated in this 2013 update. 2 A recent Health Technology Assessment report has highlighted potential problems of using tools such as DEFINITIONS USED IN GUIDELINE Fever Defined as an elevation of body temperature above the normal daily variation for the purposes of this guideline. Appears ill to a healthcare professional An overall impression the assessing healthcare professional makes when a child presents. This impression is formed not only from objective measurements but also from subjective feelings about how the child looks or reacts. If a healthcare professional s subjective impression is that the child is ill looking, then the child is probably at high risk of serious illness. 10 Healthcare professionals should be confident to follow their impressions of a child s wellbeing. Rigors An episode of shaking or shivering, which can occur when the child has high temperature. Rigors can be confused with febrile convulsions. However, unlike in a seizure, the child is conscious and alert during the episode. Safety netting Providing support for a patient when the clinician is uncertain as to the presence of a self limiting illness and is concerned that the patient s condition may deteriorate. Safety netting may take different forms, such as dialogue with the parent or carer about symptoms and signs to watch for, advice about when to seek further medical attention, review after a set period, and liaising with other healthcare services. the traffic light table in isolation. 10 For example, the Yale Observation Scale is moderately useful at identifying serious illness but could not be used as a rule out criterion. It is important that the traffic light table in this guideline is used in combination with other recommendations, both in this guideline (such as the need for urine analysis) and in other relevant guidelines (such as the NICE Clinical Guidelines on urinary tract infection in children 5 and bacterial meningitis and meningococcal septicaemia 4 ) for complete management. Contributors: All authors contributed to the initial drafting of this article and revising it critically. They have all approved this version. MSM is the guarantor. Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: EF, JC, and MSM have support from the National Institute for Health and Care Excellence for the submitted work. Provenance and peer review: Commissioned; not externally peer reviewed. 1 Van den Bruel A, Aertgeerts B, Bruyninckx R, Aerts M, Buntinx F. Signs and symptoms for diagnosis of serious infections in children: a prospective study in primary care. Br J Gen Pract 2007;57: Craig JC, Williams GJ, Jones M, Codarini M, Macaskill P, Hayen A, et al. The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of febrile illnesses. BMJ 2010;340:c National Institute for Health and Care Excellence. Feverish illness in children: assessment and initial management in children younger than five years. (Clinical guideline CG160.) nice.org.uk/cg160). 4 National Institute for Health and Clinical Excellence. Bacterial meningitis and meningococcal septicaemia: management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care. (Clinical guideline 102.) National Institute for Health and Clinical Excellence. Urinary tract infection: diagnosis, treatment and long-term management of urinary tract infection in children. (Clinical guideline 54.) guidance.nice.org.uk/cg54. 6 Advanced Life Support Group. Advanced paediatric life support: the practical approach. 4th ed. BMJ Books/Blackwells, National Institute for Health and Clinical Excellence. Feverish illness in children: assessment and initial management in children younger than five years. (Clinical guideline 47.) org.uk/cg47. 8 Harnden A. Recognising serious illness in feverish young children in primary care. BMJ 2007;335: De S, Williams GJ, Hayen A, Macaskill P, McCaskill M, Isaacs D, et al. Accuracy of the traffic light clinical decision rule for serious bacterial infections in young children with fever: a retrospective cohort study. BMJ 2013;346:f Thompson M, Van den Bruel A, Verbakel J, Lakhanpaul M, Haj-Hassan T, Stevens R, et al. Systematic review and validation of prediction rules for identifying children with serious infections in emergency departments and urgent-access primary care. Health Technol Assess 2012;16(15): BMJ 25 MAY 2013 VOLUME

4 10-MINUTE CONSULTATION Adult acute rhinosinusitis J Bird, 1 TC Biggs, 1 M Thomas, 2 RJ Salib Department of Otolaryngology/ Head & Neck Surgery, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK 2 University of Southampton, Aldermoor Health Centre, Southampton 3 Clinical Experimental Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton Correspondence to: J Bird jonathan.bird83@googl .com Cite this as: BMJ 2013;346:f2687 doi: /bmj.f2687 This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs. bmj.com Previous articles in this series ЖЖHearing loss in adults (BMJ 2013;346:f2496) ЖЖAssessment and management of renal colic (BMJ 2012;346:f985) ЖЖVasectomy (BMJ 2013;346:f1674) ЖЖDry eye (BMJ 2012;345:e7533) ЖЖMinor incised traumatic laceration (BMJ 2012;345:e6824) A 35 year old woman presents to her general practitioner with a 10 day history of worsening nasal congestion, purulent nasal discharge, and frontal headaches. What you should cover Ask about Rhinosinusitis (including nasal polyps) is an inflammatory condition of the nose and paranasal sinuses. Diagnosis requires at least two symptoms, one of which must be nasal discharge or obstruction, with the others comprising facial pain or smell disturbance. Acute rhinosinusitis is defined as symptoms lasting less than 12 weeks with complete resolution and can be subdivided into Acute viral rhinosinusitis (common cold) Defined by duration of symptoms of less than 10 days. Acute non-viral rhinosinusitis Defined by an increase in symptoms after 5 days or persistent symptoms after 10 days. Acute bacterial rhinosinusitis Suggested by the presence of at least three symptoms or signs of Discoloured discharge (with unilateral predominance) and purulent secretions Severe local pain (with unilateral predominance) Fever (>38 C) Elevated erythrocyte sedimentation rate or C reactive protein Double sickening (that is, a deterioration after an initial milder illness). Chronic rhinosinusitis (with or without polyps) is defined as more than 12 weeks of symptoms without complete resolution. The following points are important within the history in acute rhinosinusitis: Nasal blockage, obstruction, or congestion Is the blockage unilateral or bilateral? Acute rhinosinusitis is usually associated with bilateral symptoms. With unilateral symptoms, bear in mind the possibility (albeit rare) of an underlying malignancy. Nasal discharge (anterior or posterior nasal drip) Attempts should be made to assess and record the character, amount, and pattern of nasal discharge over time. Facial pain or pressure Facial pain without nasal obstruction or discharge is highly unlikely to be due to sinusitis. Purely unilateral facial pain is unlikely to be sinogenic, most commonly it is dental in origin. Change, reduction, or loss of sense of smell. Resolution of symptoms Frequent short lasting episodes with complete resolution are likely to be associated with acute viral rhinosinusitis, whereas infrequent long lasting episodes with no resolution are suggestive of chronic rhinosinusitis. Respiratory symptoms These may include DIFFERENTIAL DIAGNOSIS OF ACUTE RHINOSINUSITIS Differential diagnosis of acute rhinosinusitis to exclude on history and examination: Dental pain (particularly in cases of unilateral facial pain) Neuralgic (atypical) facial pain Temporomandibular joint pain Migraine Trigeminal neuralgia Temporal arteritis Neoplastic conditions pharyngeal, laryngeal, or tracheal irritation causing sore throat, change in voice, and cough. Systemic symptoms Malaise, headache, and fever may also occur. Examination If the patient seems to be systemically unwell then heart rate, blood pressure, and temperature should be assessed. A fever of >38 C is more likely to be associated with bacterial infection. Percussion over the maxillary, ethmoid, and frontal sinuses or leaning forward may exacerbate facial pain or pressure. However, the sensitivity and specificity of these signs in the identification of acute bacterial rhinosinusitis have not been established, and they are not diagnostic in isolation. Perform anterior rhinoscopy (with an otoscope or Thudichum s nasal speculum with headlight, depending on availability) and look for Mucopurulent discharge or nasal polyps (polyps can sometimes be confused with an engorged inferior turbinate, but they are insensate, in contrast to the inferior turbinate) Other nasal pathology (such as a neoplasm, particularly in the presence of unilateral polyp or mass and associated bloody nasal discharge) In case of diagnostic doubt (that is, symptoms suggestive of neoplasm as mentioned above), patients should be referred for nasal endoscopy (rigid or fibreoptic), which is currently the optimum method for nasal examination. Imaging: A plain radiograph of the sinuses is not recommended for the diagnosis and management of acute rhinosinusitis Computed tomography is the primary investigation carried out by otolaryngologists if complications are suspected or when planning endoscopic sinus surgery. What you should do Management (see figure) Acute rhinosinusitis is common, with an annual p revalence 38 BMJ 25 MAY 2013 VOLUME 346

5 of 6-15%, although it is often self managed without medical care being sought. The primary cause of acute rhinosinusitis is viral, with only 0.5-2% developing secondary acute bacterial rhinosinusitis. Acute rhinosinusitis is usually self limiting, as evidenced in most randomised trials. Therefore, antibiotics should not be routinely prescribed as they are unlikely to affect the duration or severity of illness. Antibiotic therapy should be reserved for patients with progressive or worsening symptoms or for those who are systemically unwell (for example, fever >38 C or worsening facial pain), with a 5-7 day course being most appropriate. Amoxicillin-clavulanate (rather than amoxicillin alone because of emergence of antimicrobial resistance among respiratory pathogens) is recommended as empirical therapy for non-penicillin allergic adults at a dose of 500 mg/125 mg orally three times daily. In penicillinallergic patients, doxycycline (100 mg orally twice daily) or c larithromycin (500 mg orally twice daily) would be reasonable choices. Additional treatment with a systemic decongestant (such as pseudoephedrine) or topical nasal decongestant (such as xylometazoline) or nasal saline douche (such as Sterimar or Sinus Rinse) may have modest benefits, and patients can be advised to purchase these over the counter if necessary. Intranasal corticosteroids in short courses (such as mometasone furoate 50 μg nasal spray twice daily for 7-14 days) are effective as monotherapy for moderate disease and in combination with antibiotics for severe disease. Nasal decongestants should not be used for more than 10 days as they can induce rebound Diagnose acute rhinosinusitis Acute onset of at least two symptoms, one of which must be Nasal blockage or purulent nasal discharge Other symptoms are Facial pain Smell disturbance Perform anterior rhinoscopy for signs Imaging not required unless complications Symptoms <10 days Common cold (acute viral rhinosinusitis) Symptomatic relief Worsening or severe symptoms Consider 5 day trial of antibiotics, nasal decongestant, and nasal douche No improvement after 48 hours or progression in symptoms Refer to ENT Topical nasal steroids Improvement after 48 hours Continue treatment for 7-14 days Systemically well Management algorithm for adults with acute rhinosinusitis Increased symptoms after 5 days or persistent symptoms after 10 days No complications 5 day trial of antibiotics, nasal decongestant, and nasal saline douche, and possibly topical nasal steroids No improvement after 48 hours Refer to ENT Systemically unwell Complications (such as periorbital cellulitis, frontal swelling, double vision, etc) Urgent referral to ENT USEFUL READING Thomas M, Yawn BP, Price D, Lund V, Mullol J, Fokkens W, et al. EPOS primary care guidelines: European position paper on the primary care diagnosis and management of rhinosinusitis and nasal polyps 2007 a summary. Prim Care Respir J 2008;17: Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European position paper on rhinosinusitis and nasal polyps Rhinol Suppl 2012;(23):3 p preceding table of contents, Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. EPOS 2012 European position paper on rhinosinusitis and nasal polyps A summary for otorhinolaryngologists. Rhinology 2012;50(1):1-12 rhinitis (rhinitis medicamentosa). Antihistamines do not have a role in the treatment of acute rhinosinusitis. Steam inhalations have not shown consistent benefit in the treatment of acute rhinosinusitis, but some clinical trials have shown symptomatic relief. Signs of impending complications (orbital, intracranial, etc) should prompt immediate specialist referral. In summary, most cases of uncomplicated acute rhinosinusitis will settle with conservative measures. General practitioners should advise patients to keep well hydrated and to use analgesia and nasal or systemic decongestants. Topical nasal steroids and nasal saline douches can be trialled if a patient wishes. In systemically unwell patients whose symptoms have increased after five days or persisted after 10 days, a five day trial of antibiotics in conjunction with nasal decongestants or douches and topical steroids should be considered. If there is no improvement after having taken antibiotics for 48 hours or if signs of impending complications (orbital or intracranial) have developed, a referral to ear, nose, and throat (ENT) services (urgent in the latter scenario) should be made. For a more detailed management approach, refer to the algorithm (figure). When to refer immediately The sinuses are in close anatomical proximity to the orbits and brain. As such, acute rhinosinusitis can lead to complications associated with substantial morbidity or even mortality. Such complications are thankfully rare but are more commonly encountered in the paediatric population. Immediate referral (same day) for urgent investigation and intervention should therefore be considered in the following circumstances: Periorbital oedema or cellulitis Displaced globe Double vision Ophthalmoplegia Reduced visual acuity Frontal swelling Signs of meningitis or focal neurological signs. Competing interests: We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Not commissioned; externally peer reviewed. Accepted: 28 December 2012 BMJ 25 MAY 2013 VOLUME