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Fever in Children Younger Than 5 Years

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Assessment and Initial Management of Feverish Illness in Children Younger Than 5 Years
Summary of NICE Guidance
BMJ 2007;334:1163-1164

Published in: Health & Medicine
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Fever in Children Younger Than 5 Years

  1. 1. Assessment and Initial Management of Feverish Illness in Children Younger Than 5 Years<br />Summary of NICE Guidance<br />BMJ 2007;334:1163-1164<br />
  2. 2. What this presentation covers<br />Background to the guideline<br />Key recommendations <br />Suggested actions <br />Resources from NICE <br />
  3. 3. Background: why this guideline matters<br />Feverish illness in children:<br />is the most common reason for children to be taken to the doctor<br />is a cause of concern for parents and carers<br />can be a result of a simple self-limiting infection or a life-threatening infection<br />can have no apparent source.<br />
  4. 4. Key recommendations<br />
  5. 5. The Traffic Light System<br />Tool for identifying the likelihood of serious illness<br />Children with only symptoms and signs in the ‘green’ column are at low risk<br />Children with one or more symptom or sign in the ‘amber’ column are at intermediate risk<br />Children with one or more symptom or sign in the ‘red’ column are at high risk<br />
  6. 6. Traffic light system:<br />
  7. 7. Traffic light system:<br />
  8. 8. Traffic light system:<br />
  9. 9. Detection of fever<br />In children aged 4 weeks to 5 years measure body temperature by:<br />electronic thermometer in the axilla or<br />chemical dot thermometer in the axilla or<br />infra-red tympanic thermometer. <br />Use an electronic thermometer in the axilla for children younger than 4 weeks.<br />
  10. 10. Clinical assessment<br />Check for any immediately life-threatening features.<br />Use traffic light system to check for symptoms and signs that predict the risk of serious illness.<br />Look for a source of fever and check symptoms and signs associated with specific diseases.<br />Measure and record temperature, heart rate, respiratory rate, capillary refill time and assess for dehydration.<br />
  11. 11. Symptoms and signs of specific diseases<br />
  12. 12. Symptoms and signs of specific diseases (2)<br />
  13. 13. Do symptoms and/or signs suggest an immediately life-threatening illness? <br />Yes<br />No<br />Refer immediately to emergency medical care<br />Look for traffic light symptoms and signs<br />If all green features and no amber or red<br />If any amber features and no red<br />If any red features<br />Send child for urgent assessment in a face-to-face setting within 2 hours<br />Child can be managed at home with appropriate care advice<br />Send child for assessment in a <br />face-to-face setting. <br />Management by remote assessment<br />
  14. 14. Management by a non-paediatric practitioner<br />Do symptoms and/or signs suggest an immediately life-threatening illness?<br />No<br />Yes<br />Look for traffic light features and symptoms and signs of specific diseases<br />Refer immediately to emergency medical care<br />If all green features and no amber or red<br />If any amber features and no diagnosis reached<br />If any red features<br />Child can be managed at home with appropriate care advice<br />Provide parents/carers with a safety net or refer to a paediatric specialist for further assessment<br />Refer child urgently to the care of a paediatric specialist<br />
  15. 15. Management of children 3 months to 5 years by a paediatric specialist<br /><ul><li> Perform test for urinary tract infection.
  16. 16. Assess for pneumonia.
  17. 17. Do not perform routine blood tests or chest X-ray.</li></ul>Perform (unless deemed unnecessary)<br /><ul><li> urine test for urinary tract infection
  18. 18. full blood count
  19. 19. blood culture
  20. 20. C-reactive protein.</li></ul>Perform chest x-ray if fever higher than 39°C and white blood cell count greater than 20 x 109/litre.<br />Consider lumbar puncture if child is younger than 1-year old.<br />Perform:<br /><ul><li> blood culture
  21. 21. full blood count
  22. 22. urine test for urinary tract infection
  23. 23. C-reactive protein.</li></ul>Consider the following, as guided by clinical assessment:<br /><ul><li> lumbar puncture in children of all ages
  24. 24. chest X-ray
  25. 25. serum electrolytes
  26. 26. blood gas.
  27. 27. If no diagnosis is reached, manage the child at home with appropriate care advice. </li></ul>Consider admission. If admission is not necessary but no diagnosis has been reached, provide a safety net for the parents/carers. <br />Assess: look for life-threatening, traffic light and specific diseases symptoms and signs<br />
  28. 28. The safety net<br />The safety net should be one or more of the following:<br />verbal and/or written information on warning symptoms and how further healthcare can be accessed<br />arranging further follow-up <br />liaising with other healthcare professionals, including out-of-hours providers, to ensure direct access for the child if required.<br />
  29. 29. Management of children under 3 months by a paediatric specialist<br /><ul><li>Assess: look for life-threatening, traffic light and specific diseases symptoms and signs
  30. 30. Observe and monitor:
  31. 31. temperature
  32. 32. heart rate
  33. 33. respiratory rate.
  34. 34. Perform:
  35. 35. full blood count
  36. 36. C-reactive protein
  37. 37. blood culture
  38. 38. urine test for urinary tract infection
  39. 39. chest X-ray if respiratory signs are present
  40. 40. stool culture if diarrhoea is present.
  41. 41. Admit, perform lumbar puncture and start parenteral antibiotics if the child is:
  42. 42. younger than 1-month old
  43. 43. 1–3 months old appearing unwell
  44. 44. 1–3 months old and with a white blood cell count of less than 5 or greater than 15 x 109/litre
  45. 45. Whenever possible, perform lumbar puncture before the administration of antibiotics</li></li></ul><li>Antipyretics<br />Antipyretics do not prevent febrile convulsions and should not be used specifically for this purpose. <br />Do not routinely give antipyretic drugs to a child with fever with the sole aim of reducing body temperature<br />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.<br />
  46. 46. Implementation Advice<br />Feedback to NICE suggests that there are likely to be three key areas for successful implementation:<br /><ul><li> Traffic light system
  47. 47. Providing the safety net
  48. 48. Training for non-specialist and non-clinical staff</li></li></ul><li>Suggested actions: traffic light system<br />Review clinical assessment tools to ensure that they include the features of the traffic light system.<br />Review care pathways and protocols to ensure that they reflect the traffic light system.<br />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<br />
  49. 49. Suggested actions: providing the safety net<br />Review protocols to ensure that information is provided about the treatment and care of children with fever.<br />Patient information is available from a variety of sources, including a booklet about this guideline for parents/carers, ‘Understanding NICE guidance’.<br />When a child is discharged give the parents/carers an advice sheet about how to care for their child and potential warning signs.<br />Develop protocols for staff on when children are safe <br />to be cared for at home.<br />
  50. 50. Suggested actions: training<br />Use the traffic light system when developing training.<br />Review training needs to identify whether training in body temperature measurement is required.<br />Training should be available for healthcare professionals working with children in the potential diagnoses of fever and other symptoms in children.<br />Ensure that either electronic, chemical dot or infra-red tympanic thermometers are available for staff to use.<br />Ensure that staff are confident in measuring body temperature using these thermometers.<br />
  51. 51. Access the guideline online<br />Quick reference guide – a summary http://guidance.nice.org.uk/CG47/quickrefguide/pdf/English <br />NICE guideline – all of the recommendations http://guidance.nice.org.uk/CG47/niceguidance/pdf/English <br />Full guideline – all of the evidence and rationale http://guidance.nice.org.uk/CG47/guidance/pdf/English <br />‘Understanding NICE guidance’ – a plain English version http://guidance.nice.org.uk/CG47/publicinfo/pdf/English <br />
  52. 52. thank you for your attention<br />••••••••••••••••••••••••••••••••<br />

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