May 2010 No. 17

NICE Bites

Produced for healthcare professionals by North West Medicines Information Service,

The Pharmacy Practice Unit, 70 Pembroke Place, Liverpool, L69 3GF. Editor: Lindsay Banks. Telephone 0151 794 8117. E-mail: nwmedinfo@nhs.net

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This guidance applies to the assessment and initial management of children younger than 5 years with feverish illness. See full guideline for treatment algorithms.

Care pathway – see full guideline. Detection of fever ♦ Take all reports of fever seriously. ♦ Fever is defined as a temperature of 38ºC or above. ♦ Measure body temperature:

in children < 4 weeks old, use an electronic thermometer in the axilla (armpit),

in children > 4 weeks old, use an electronic or chemical dot thermometer in the axilla OR, an infra-red tympanic thermometer.

Assessment of a child with fever ♦ Check for life-threatening features (compromise of Airways,

Breathing or Circulation, or Decreased level of consciousness). If any present: refer immediately.

♦ Check for a source of fever and signs and symptoms that indicate a specific disease – see full guideline.

♦ Use the ‘traffic light’ system to identify signs and symptoms of serious illness – see pages 16-17 of the quick reference guide.

♦ latory

♦ Measure and record temperature, heart rate, respiratory rate and capillary refill time.

♦ Check for signs of dehydration including: prolonged capillary refill time, abnormal skin turgor, abnormal respiratory pattern, weak pulse, cool extremities.

Measure blood pressure if there is evidence of circu

compromise. Do NOT use du♦ ration or height of fever alone to predict

♦ ted infection if the child has

M fever e, according to traffic light

A mended.

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pears distressed or is unwell; *

♦ ing antipyretics.

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as possible. Give benzylpenicillin or a third-e ).

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likelihood of serious illness. Consider the risk of an imporrecently travelled abroad.

anagement of a child with♦ Recommend referral or care at hom

level of risk - see Table 1.

ntipyretic interventions♦ Tepid sponging is NOT recom♦ Do NOT over or under dress a child with fev

Prescribing ♦ If the child ap

Give EITHER paracetamol* OR ibuprofen

Ask the views of parents/carers when consider♦ Do NOT alternate or combine paracetamol with ibuprofen.

y give the alternative agent if the child does not respond to Onlthe first drug.

Do NOT routinely give antipyretic drugs with the sole aim of: reducing body temperature of a child who is otherwise well,

preventing febrile convulsions. OT prescribe oral antibiotics to childr

parent source. ♦ If meningococcal disease is suspected, give parenteral

antibiotics as soon *generation cephalosporin (e.g. cefotaxime* or ceftriaxon *

ee Summary of Product Characteristics for full prescribing information.

Feverish illness in children NICE CG47: 2007

Table 1. Traffic light system for assessment and referral Use this table in conjunction with the tables and treatment algorithms in the full guideline.

Risk Remote assessment Face-to-face assessment RED High risk

♦ Refer for urgent face-to-face assessment within 2 hours.

♦ Refer urgently for management by a paediatric specialist.

AMBER Intermediate risk

♦ Refer for face-to-face assessment. Use clinical judgement to determine the urgency of this assessment.

♦ If no diagnosis reached: send the child home with a ‘safety net’ (see box) OR refer to a paediatric specialist for further assessment.

GREEN Low risk

Manage at home with appropriate care advice – see Table 2 .

Table 2. Care at home ‘Safety net’

Advise parents and carers: ♦ of the antipyretic interventions available, ♦ to give the child regular fluids (breastfeeding should continue), ♦ to look for signs of dehydration, ♦ how to identify a non-blanching rash, ♦ to check the child during the night ♦ to seek further advice if:

the child has a fit, the child develops a non-blanching rash, the child’s health gets worse, the fever lasts longer than 5 days

♦ Give the parent or carer verbal and/or written information on warning symptoms and how to access further healthcare if symptoms develop.

♦ Arrange a follow-up appointment at a scheduled time and place. ♦ Liaise with other healthcare professionals, including out-of-hours

providers, to ensure the parent/carer has direct access to a further assessment for their child.

NICE Bites May 2010 No. 17 Feverish illness in children – continued.

NICE CG47: 2007

Management by a paediatric specialist Children < 3 months of age with fever – see full guideline.

Children ≥ 3 months of age with fever ♦ Use the ‘traffic light’ system to identify signs and

symptoms of serious illness - see full guideline.

Immediate treatment of a child with fever ♦ Children with shock: give immediate intravenous fluid bolus

of 0.9% sodium chloride (20 ml/kg). Give further boluses as necessary.

♦ Give oxygen if signs of shock, oxygen saturation of less than 92%, or as clinically indicated.

♦ Give immediate parenteral antibiotics e.g. cefotaxime* or ceftriaxone* to a child with fever and any of the following:

has signs of shock, is unrousable, has signs of meningococcal disease, is less than 1 month old, is aged 1 to 3 months of age and appears unwell, is aged 1 to 3 months of age with a white blood cell count , < 5 or >15 x 109/litre.

Treatment of suspected infection ♦ If serious bacterial infection is suspected, until culture

results are available, give antibiotics against Neisseria meningitides, Streptococcus pneumoniae, Escherichia coil, Staphylococcus aureus and Haemophilus influenzae type b e.g. cefotaxime* or ceftriaxone*.

♦ If child is less than 3 months of age - add an antibiotic active against Listeria e.g. ampicillin* or amoxicillin*.

♦ If child has decreased level of consciousness, look for signs and symptoms of meningitis and herpes simplex encephalitis:

give parenteral antibiotics if appropriate, give intravenous aciclovir if herpes simplex encephalitis is suspected.

After administration of antipyretics ♦ Reassess a child with fever and any amber or red features

after 1 to 2 hours. ♦ Do NOT rely on a change in temperature after 1 to 2 hours

to differentiate between serious and non-serious illness.

Admission to hospital – see full guideline

*See Summary of Product Characteristics for full prescribing information.

UTI in children NICE CG54: 2007

This guideline covers the diagnosis, treatment and long-term management of urinary tract infection (UTI) in children.

Care pathway – see full guideline.

Assessment and diagnosis– see full guideline. ♦ Assess symptoms and signs;

unexplained fever is the most common presentation of UTI in infants,

presenting symptoms differ with age of child. ♦ Assess the child for risk of serious illness in line with NICE

CG47; Feverish illness in children. ♦ Do a urine test within 24 hours in infants and children with:

symptoms and signs of UTI, unexplained fever ≥ 38ºC, an alternative site of infection who remain unwell.

♦ Collect urine sample using method suitable for the age of the child – see full guideline.

Treatment and management ♦ Start antibiotic treatment based on assessment of symptoms

and urine microscopy and culture results – see full guideline for details.

Child < 3 months of age: ♦ Arrange urgent referral to a paediatric specialist. ♦ Give parenteral antibiotics – see NICE CG47; Feverish

illness in children. Child ≥ 3 months of age: ♦ If at high risk of serious illness: arrange urgent referral to a

paediatric specialist. Acute pyelonephritis/upper UTI: ♦ Consider referral to a paediatric specialist . ♦ Give oral antibiotics for 7 to 10 days.

e of antibiotic should be determined b♦ Choic y local policies; suitable options include:

a cephalosporin* or co-amoxiclav . oral antibiotics cannot be used:

*

tic for 2 to 4 days ♦ If

give an intravenous (IV) antibioe.g.cefotaxime* or ceftriaxone* followed by oral antibiotics for a total duration of 10 days.

Cystitis/lower UTI: ♦ Give oral antibiotics for 3 days. ♦ Choice of antibiotic should be determined by local policies;

suitable options include: trimethoprim*, nitrofurantoin*, cephalosporin* or amoxicillin*.

♦ If child is still unwell after 24 to 48 hours reassess. ♦ If an alternative diagnosis is not made:

send a urine sample for culture.

Prescribing ♦ Do NOT treat asymptomatic bacteriuria with antibiotics. ♦ If an aminoglycoside is the most appropriate choice of

antibiotic, use once daily dosing. ♦ Consider intramuscular administration if parenteral treatment

is required and IV administration is not possible. ♦ Laboratories should monitor resistance patterns of urinary

pathogens and advise prescribers accordingly.

have image investigation,

*See Summary of Product Characteristics for full prescribing

** line for definition of recurrent UTI.

Antibiotic prophylaxis ♦ If a child on prophylactic medication develops an infection,

treat with a different antibiotic, NOT a higher dose of the same antibiotic.

Do NOT give anti♦ biotic prophylaxis after first-time UTI; consider only after recurrent UTI**.

Cautions and counselling ♦ To prevent recurrence of UTI:

address dysfunctional elimination syndromes and constipation, encourage ad equate fluid intake,

emphasise the importance of not delaying voiding. low-up – see full guideline. Fol

♦ No follow-up is required: in children who do not in asymptomatic bacteriuria, in children who are asymptomatic following a UTI.

information. See full guide

This bulletin summarises key prescribing points from NICE guidance. Please refer to the full guidance at www.nice.org.uk for further detail This is an NHS document not to be used for commercial or marketing purposes.