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Feverish illness in children overview

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Feverish illness in children

About

What is covered

This pathway covers the assessment and initial management of feverish illness in children younger than 5 years.
A significant number of children have no obvious cause of fever despite careful assessment. These children with fever without apparent source are of particular concern to healthcare professionals because it is especially difficult to distinguish between simple viral illnesses and life-threatening bacterial infections in this group.
As a result, there is a perceived need to improve the recognition, assessment and immediate treatment of feverish illnesses in children. This pathway aims to assist healthcare professionals in the initial assessment and immediate treatment of young children with fever presenting to primary or secondary care. These recommendations should be followed until a clinical diagnosis of the underlying condition has been made. The child should then be treated according to national or local guidance for that condition.

Updates

Updates to this pathway

8 December 2015 Link to intravenous fluid therapy in hospital pathway added.
6 October 2015 Procalcitonin testing for diagnosing and monitoring sepsis (NICE diagnostics guidance 18) added to identifying symptoms and signs of specific diseases.
17 August 2015 Link to NICE pathway on antimicrobial stewardship added.
17 July 2015 'Bacterial meningitis and meningococcal septicaemia in children and young people (NICE quality standard 19) added to this pathway.
2 April 2015 Minor maintenance updates.
23 July 2014 Feverish illness in children under 5 years (NICE quality standard 64) added to this pathway.
20 January 2014 Minor maintenance updates.
19 December 2013 Minor maintenance updates.
17 December 2013 Minor maintenance updates.
4 July 2013 Minor maintenance update.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Assessment and initial management in children younger than 5 years

What is covered

This pathway covers the assessment and initial management of feverish illness in children younger than 5 years.
A significant number of children have no obvious cause of fever despite careful assessment. These children with fever without apparent source are of particular concern to healthcare professionals because it is especially difficult to distinguish between simple viral illnesses and life-threatening bacterial infections in this group.
As a result, there is a perceived need to improve the recognition, assessment and immediate treatment of feverish illnesses in children. This pathway aims to assist healthcare professionals in the initial assessment and immediate treatment of young children with fever presenting to primary or secondary care. These recommendations should be followed until a clinical diagnosis of the underlying condition has been made. The child should then be treated according to national or local guidance for that condition.

Updates

Updates to this pathway

8 December 2015 Link to intravenous fluid therapy in hospital pathway added.
6 October 2015 Procalcitonin testing for diagnosing and monitoring sepsis (NICE diagnostics guidance 18) added to identifying symptoms and signs of specific diseases.
17 August 2015 Link to NICE pathway on antimicrobial stewardship added.
17 July 2015 'Bacterial meningitis and meningococcal septicaemia in children and young people (NICE quality standard 19) added to this pathway.
2 April 2015 Minor maintenance updates.
23 July 2014 Feverish illness in children under 5 years (NICE quality standard 64) added to this pathway.
20 January 2014 Minor maintenance updates.
19 December 2013 Minor maintenance updates.
17 December 2013 Minor maintenance updates.
4 July 2013 Minor maintenance update.

Sources

NICE guidance and other sources used to create this pathway.
Feverish illness in children (2013) NICE guideline CG160
Feverish illness in children under 5 years (2014) NICE quality standard 64

Quality standards

Feverish illness in children under 5 years

These quality statements are taken from the feverish illness in children under 5 years quality standard. The quality standard defines clinical best practice for feverish illness in children under 5 years and should be read in full.

Quality statements

‘Safety netting’ information

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Parents and carers of children and young people presenting with non-specific symptoms and signs are given ‘safety netting’ information that includes information on bacterial meningitis and meningococcal septicaemia.

Quality measure

Structure: Evidence of local arrangements for parents and carers of children and young people presenting with non-specific symptoms and signs to be given ‘safety netting’ information that includes information on bacterial meningitis and meningococcal septicaemia.
Process: Proportion of parents or carers of children and young people presenting with non-specific symptoms and signs who are given ‘safety netting’ information that includes information on bacterial meningitis and meningococcal septicaemia.
Numerator – the number of people in the denominator who are given ‘safety netting’ information that includes information on bacterial meningitis and meningococcal septicaemia.
Denominator – the number of parents or carers of children and young people presenting with non-specific symptoms and signs.
Outcome: Parent/carer satisfaction with information received.

What the quality statement means for each audience

Service providers ensure systems are in place for parents and carers of children and young people presenting with non-specific symptoms and signs to be given ‘safety netting’ information that includes information on bacterial meningitis and meningococcal septicaemia.
Healthcare professionals give ‘safety netting’ information to parents and carers of children and young people presenting with non-specific symptoms and signs, including information on bacterial meningitis and meningococcal septicaemia.
Commissioners ensure they commission services that enable parents and carers of children and young people presenting with non-specific symptoms and signs to be given ‘safety netting’ information that includes information on bacterial meningitis and meningococcal septicaemia.
Parents and carers of children and young people with general symptoms are given ‘safety netting’ information (for example, advice on what symptoms to look out for and how and when to seek further care) that includes information on bacterial meningitis and meningococcal septicaemia (blood poisoning).

Source guidance

Feverish illness in children NICE guideline CG160, recommendations 1.4.2.3 (key priority for implementation), 1.5.8.2 and 1.7.2.1.

Data source

Structure: Local data collection.
Process: Local data collection.
Outcome: Local data collection.

Definitions

Non-specific symptoms and signs are detailed in table 1 of NICE guideline CG102.
‘Safety netting’ information comprises oral and/or written information on what symptoms to look out for, how to access further care, likely time course of expected illness and, if appropriate, the uncertainty of the diagnosis.
Information on warning symptoms should include a specific instruction for parents and carers looking after a feverish child to seek further advice if any of the following occur:
  • The child develops a non-blanching rash.
  • The parent or carer feels that the child is less well than when they previously sought advice.
  • The parent or carer is more worried than when they previously sought advice.
  • The fever lasts longer than 5 days.
  • The parent or carer is distressed, or concerned that they are unable to look after the child.
  • The child is lethargic or irritable.
  • The child stops feeding (infants only).
  • The child has a fit.

Monitoring

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia have their temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition monitored at least hourly until stable.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia to have their temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition monitored at least hourly until stable.
Process: Proportion of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia who have their temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition monitored at least hourly until stable.
Numerator – the number of people in the denominator who have their temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition monitored at least hourly until stable.
Denominator – the number of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia to have their temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition monitored at least hourly until stable.
Healthcare professionals monitor the temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia at least hourly until stable.
Commissioners ensure they commission services for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia to have their temperature, respiratory rate, pulse, blood pressure, urine output, oxygen saturation and neurological condition monitored at least hourly until stable.
Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia (blood poisoning) have their temperature, breathing, pulse, blood pressure, urine production, blood oxygen levels and level of consciousness monitored at least every hour until they are stable.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendations 1.1.6 and 1.4.47.
Feverish illness in children NICE guideline CG160, recommendation 1.2.1.1.

Data source

Structure: Local data collection.
Process: Local data collection. Contained within NICE guideline CG102 audit support (clinical and organisational criteria), criterion 1.

Definitions

Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia have the physiological observations described in the statement assessed regularly throughout their care pathway, whether presenting in primary care or after they have been admitted to hospital.
Neurological condition is assessed using observations that include pupillary reactions, motor function and levels of consciousness (Glasgow Coma Scale or AVPU [Alert, Voice, Pain, Unresponsive]).

Management of petechial rash

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people presenting with a petechial rash receive antibiotics in accordance with NICE guidance.

Quality measure

Structure: Evidence of local arrangements for children and young people presenting with a petechial rash to receive antibiotics in accordance with NICE guidance.
Process: Proportion of children and young people presenting with a petechial rash who receive antibiotics in accordance with NICE guidance.
Numerator – the number of people in the denominator who receive antibiotics in accordance with NICE guidance.
Denominator – the number of children and young people presenting with a petechial rash.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people presenting with a petechial rash to receive antibiotics in accordance with NICE guidance.
Healthcare professionals give antibiotics to children and young people presenting with a petechial rash in accordance with NICE guidance.
Commissioners ensure they commission services that ensure children and young people presenting with a petechial rash receive antibiotics in accordance with NICE guidance.
Children and young people with a rash of small red or purple spots that doesn’t fade when a glass is pressed firmly against the skin (a non-blanching rash) have appropriate investigations and receive antibiotics if their healthcare professional considers them at risk of bacterial meningitis or meningococcal septicaemia (blood poisoning).

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendations 1.3.2 (key priority for implementation) and 1.3.3–1.3.6.

Data source

Structure: Local data collection.
Process: Local data collection.

Definitions

NICE guideline CG102 provides information on the correct prescribing of antibiotics for children and young people presenting with a petechial rash.
NICE guidance on the management of petechial rash is also available in diagrammatical form in the NICE pathway on bacterial meningitis and meningococcal septicaemia.

Initiation of antibiotics

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people with suspected bacterial meningitis or meningococcal septicaemia receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected bacterial meningitis or meningococcal septicaemia to receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.
Process: Proportion of children and young people with suspected bacterial meningitis or meningococcal septicaemia who receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.
Numerator – the number of people in the denominator who receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.
Denominator – the number of children and young people with suspected bacterial meningitis or meningococcal septicaemia arriving in hospital.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected bacterial meningitis or meningococcal septicaemia to receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.
Healthcare professionals give children and young people with suspected bacterial meningitis or meningococcal septicaemia intravenous or intraosseous antibiotics within an hour of arrival at hospital.
Commissioners ensure they commission services for children and young people with suspected bacterial meningitis or meningococcal septicaemia to receive intravenous or intraosseous antibiotics within an hour of arrival at hospital.
Children and young people with suspected bacterial meningitis or meningococcal septicaemia (blood poisoning) are given antibiotics intravenously (directly into a vein through a needle or thin tube) or intraosseously (directly into the bone through a needle or thin tube) within an hour of arrival at hospital.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendations 1.2.4 and 1.4.1–1.4.3.

Data source

Structure: Local data collection.
Process: Local data collection. Contained within NICE guideline CG102 audit support (pharmacological interventions), criteria 2–4.

Definitions

Antibiotics should be administered for children and young people with suspected bacterial meningitis or meningococcal septicaemia as soon as possible in order to optimise chances of recovery, and within an hour of arrival in secondary care.
While antibiotics should be given at the earliest opportunity, either in primary or secondary care (without delaying urgent transfer to hospital to do so), this statement concerns children and young people with suspected bacterial meningitis or meningococcal septicaemia for whom there has been no delay in their transfer to hospital, either from their GP or through attendance at an accident and emergency department.
For children and young people for whom urgent transfer to hospital is not possible (for example, in remote locations or adverse weather conditions), antibiotics may be given in primary or community care (see NICE guideline CG102 recommendations 1.2.3 and 1.2.4).

Lumbar puncture for suspected bacterial meningitis

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people with suspected bacterial meningitis have a lumbar puncture.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected bacterial meningitis to have a lumbar puncture.
Process: Proportion of children and young people with suspected bacterial meningitis who have a lumbar puncture.
Numerator – the number of people in the denominator who have a lumbar puncture.
Denominator – the number of children and young people with suspected bacterial meningitis.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected bacterial meningitis to have a lumbar puncture.
Healthcare professionals perform a lumbar puncture for children and young people with suspected bacterial meningitis.
Commissioners ensure they commission services for children and young people with suspected bacterial meningitis to have a lumbar puncture.
Children and young people with suspected bacterial meningitis have a procedure called a lumbar puncture, in which a sample of the fluid surrounding the brain and spinal cord is taken using a hollow needle inserted into the lower part of the back.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendations 1.3.18 (key priority for implementation) and 1.3.19.

Data source

Structure: Local data collection.
Process: Local data collection. Contained within NICE guideline CG102 audit support (clinical and organisational criteria), criterion 7.

Definitions

It is important that children and young people with suspected bacterial meningitis have a lumbar puncture as soon as possible, but only when it is safe to do so. Contraindications to lumbar puncture include:
  • signs suggesting raised intracranial pressure:
    • reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more)
    • age-relative bradycardia and hypertension
    • focal neurological signs
    • abnormal posture or posturing
    • unequal, dilated or poorly responsive pupils
    • papilloedema
    • abnormal ‘doll’s eye’ movements
    • tense, bulging fontanelle
  • shock
  • extensive or spreading purpura
  • convulsions until stabilised
  • coagulation abnormalities:
    • coagulation results (if obtained) outside the normal range
    • platelet count below 100 x 109/litre
    • receiving anticoagulant therapy
  • superficial infection at the lumbar puncture site
  • respiratory insufficiency (lumbar puncture is considered to have a high risk of precipitating respiratory failure in the presence of respiratory insufficiency).

CSF microscopy for suspected bacterial meningitis

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people with suspected bacterial meningitis have their cerebrospinal fluid (CSF) microscopy result available within 4 hours of lumbar puncture.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected bacterial meningitis to have their CSF microscopy result available within 4 hours of lumbar puncture.
Process: Proportion of children and young people with suspected bacterial meningitis who have their CSF microscopy result available within 4 hours of lumbar puncture.
Numerator – the number of people in the denominator who have their CSF microscopy result available within 4 hours of lumbar puncture.
Denominator – the number of children and young people with suspected bacterial meningitis who have had a lumbar puncture.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected bacterial meningitis to have their CSF microscopy result available within 4 hours of lumbar puncture.
Healthcare professionals ensure children and young people with suspected bacterial meningitis have their CSF microscopy result available within 4 hours of lumbar puncture.
Commissioners ensure they commission services for children and young people with suspected bacterial meningitis to have their CSF microscopy result available within 4 hours of lumbar puncture.
Children and young people with suspected bacterial meningitis have the results of their lumbar puncture within 4 hours of the procedure being done.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendation 1.3.20.

Data source

Structure: Local data collection.
Process: Local data collection. Contained within NICE guideline CG102 audit support (clinical and organisational criteria), criterion 8.

Definitions

CSF microscopy provides the CSF white blood cell count, which is the most important investigation for a diagnosis of meningitis. Samples should also be routinely processed for total protein and glucose concentrations.
It is important that samples are processed rapidly given that white cell counts decrease significantly with time.

Blood tests

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people with suspected bacterial meningitis or meningococcal septicaemia have whole blood meningococcal polymerase chain reaction (PCR) testing.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected bacterial meningitis or meningococcal septicaemia to have whole blood meningococcal PCR testing.
Process: Proportion of children and young people with suspected bacterial meningitis or meningococcal septicaemia who have whole blood meningococcal PCR testing.
Numerator – the number of people in the denominator who have whole blood meningococcal PCR testing.
Denominator – the number of children and young people with suspected bacterial meningitis or meningococcal septicaemia.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected bacterial meningitis or meningococcal septicaemia to have whole blood meningococcal PCR testing.
Healthcare professionals carry out whole blood meningococcal PCR testing for children and young people with suspected bacterial meningitis or meningococcal septicaemia.
Commissioners ensure they commission services for children and young people with suspected bacterial meningitis or meningococcal septicaemia to have whole blood meningococcal PCR testing.
Children and young people with suspected bacterial meningitis or meningococcal septicaemia (blood poisoning) have a blood sample taken for a type of DNA laboratory test called PCR that will help confirm the diagnosis.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendation 1.3.8 (key priority for implementation).

Data source

Structure: Local data collection.
Process: Local data collection. Contained within NICE guideline CG102 audit support (clinical and organisational criteria), criterion 3.

Definitions

PCR is a DNA-based diagnostic test.
PCR testing may not always be appropriate (for example, if the diagnosis has been confirmed by positive blood or cerebrospinal fluid cultures).
:title Access to specialists

Access to specialists

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia, who have signs of shock or raised intracranial pressure, are assessed by a consultant paediatrician.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia who have signs of shock or raised intracranial pressure to be assessed by a consultant paediatrician.
Process: Proportion of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia who have signs of shock or raised intracranial pressure that are assessed by a consultant paediatrician.
Numerator – the number of people in the denominator who are assessed by a consultant paediatrician.
Denominator – the number of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia who have signs of shock or raised intracranial pressure.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia who have signs of shock or raised intracranial pressure to be assessed by a consultant paediatrician.
Healthcare professionals ensure that children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia who have signs of shock or raised intracranial pressure are assessed by a consultant paediatrician.
Commissioners ensure they commission services for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia who have signs of shock or raised intracranial pressure to be assessed by a consultant paediatrician.
Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia (blood poisoning) who have signs of shock (for example unusual skin colour or breathing difficulty) or raised pressure in the brain are assessed by a consultant paediatrician.

Source guidance

Feverish illness in children NICE guideline CG160, recommendation 1.5.9.1.

Data source

Structure: Local data collection.
Process: Local data collection.

Transfer within and between hospitals

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia being transferred within or between hospitals are escorted by a healthcare professional trained in advanced paediatric life support.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia being transferred within or between hospitals to be escorted by a healthcare professional trained in advanced paediatric life support.
Process: Proportion of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia being transferred within or between hospitals who are escorted by a healthcare professional trained in advanced paediatric life support.
Numerator – the number of people in the denominator who are escorted by a healthcare professional trained in advanced paediatric life support.
Denominator – the number of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia being transferred within or between hospitals.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia being transferred within or between hospitals to be escorted by a healthcare professional trained in advanced paediatric life support.
Healthcare professionals ensure children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia being transferred within or between hospitals are escorted by a healthcare professional trained in advanced paediatric life support.
Commissioners ensure they commission services for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia being transferred within or between hospitals to be escorted by a healthcare professional trained in advanced paediatric life support.
Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia (blood poisoning) being transferred within or between hospitals are escorted by a healthcare professional trained in life saving treatment for children (advanced paediatric life support).

Source guidance

Topic Expert Group consensus.

Data source

Structure: Local data collection.
Process: Local data collection.

Transfer to intensive care

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia requiring transfer to a paediatric intensive care unit or high dependency unit in another hospital are transferred by a specialist paediatric retrieval team.

Quality measure

Structure: Evidence of local arrangements for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia requiring transfer to a paediatric intensive care unit or high dependency unit in another hospital to be transferred by a specialist paediatric retrieval team.
Process: Proportion of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia requiring transfer to a paediatric intensive care unit or high dependency unit in another hospital who are transferred by a specialist paediatric retrieval team.
Numerator – the number of people in the denominator who are transferred by a specialist paediatric retrieval team.
Denominator – the number of children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia requiring transfer to a paediatric intensive care unit or high dependency unit in another hospital.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia requiring transfer to a paediatric intensive care unit or high dependency unit in another hospital to be transferred by a specialist paediatric retrieval team.
Healthcare professionals ensure children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia requiring transfer to a paediatric intensive care unit or high dependency unit in another hospital are transferred by a specialist paediatric retrieval team.
Commissioners ensure they commission services for children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia requiring transfer to a paediatric intensive care unit or high dependency unit in another hospital to be transferred by a specialist paediatric retrieval team.
Children and young people with suspected or confirmed bacterial meningitis or meningococcal septicaemia (blood poisoning) who need to be transferred to a paediatric intensive care unit or high dependency unit in another hospital are taken by a team of healthcare professionals that specialises in caring for and transporting seriously ill children (a paediatric retrieval team).

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendation 1.4.50.

Data source

Structure: Local data collection.
Process: Local data collection. Contained within NICE guideline CG102 audit support (clinical and organisational criteria), criterion 24.

Definitions

A specialist paediatric retrieval team comprises medical and nursing staff with specialist training in the transfer of sick children and young people from hospitals to paediatric intensive care or high dependency units.

Information provision

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people who have had bacterial meningitis or meningococcal septicaemia, and/or their parents and carers, are given information before discharge about the disease, its potential long-term effects and how to access further support.

Quality measure

Structure: Evidence of local arrangements for children and young people who have had bacterial meningitis or meningococcal septicaemia, or their parents and carers, to be given information before discharge about the disease, its potential long-term effects and how to access further support.
Process: Proportion of children and young people who have had bacterial meningitis or meningococcal septicaemia, or their parents or carers, who receive information before discharge about the disease, its potential long-term effects and how to access further support.
Numerator – the number of people in the denominator or their parents or carers who receive information before discharge about the disease, its potential long-term effects and how to access further support.
Denominator – the number of children and young people who have had bacterial meningitis or meningococcal septicaemia.
Outcome: Patient and/or parent or carer satisfaction with information received before discharge.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people who have had bacterial meningitis or meningococcal septicaemia, and/or their parents and carers, to be given information before discharge about the disease, its potential long-term effects and how to access further support.
Healthcare professionals give information before discharge to children and young people who have had bacterial meningitis or meningococcal septicaemia and/or their parents and carers about the disease, its potential long-term effects and how to access further support.
Commissioners ensure they commission services for children and young people who have had bacterial meningitis or meningococcal septicaemia, and/or their parents and carers, to be given information before discharge about the disease, its potential long-term effects and how to access further support.
Children and young people who have had bacterial meningitis or meningococcal septicaemia (blood poisoning), and/or their parents and carers, are given information before leaving hospital about the disease, its potential long-term effects and how to access further support.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendations 1.5.1 and 1.5.2.

Data source

Structure: Local data collection.
Process: Local data collection.
Outcome: Local data collection.

Definitions

Further support can be provided for children and young people who have had bacterial meningitis or meningococcal septicaemia, and their parents or carers by the GP, or hospital paediatrician and by patient support organisations, including meningitis charities that can offer support, befriending, in-depth information, advocacy, counselling, and written information to signpost families to further help.

Audiological assessment

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people who have had bacterial meningitis or meningococcal septicaemia have an audiological assessment before discharge.

Quality measure

Structure: Evidence of local arrangements for children and young people who have had bacterial meningitis or meningococcal septicaemia to have an audiological assessment before discharge.
Process: Proportion of children and young people who have had bacterial meningitis or meningococcal septicaemia who have an audiological assessment before discharge.
Numerator – the number of people in the denominator who have an audiological assessment before discharge.
Denominator – the number of children and young people who have had bacterial meningitis or meningococcal septicaemia.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people who have had bacterial meningitis or meningococcal septicaemia to have an audiological assessment before discharge.
Healthcare professionals ensure children and young people who have had bacterial meningitis or meningococcal septicaemia have an audiological assessment before discharge.
Commissioners ensure they commission services for children and young people who have had bacterial meningitis or meningococcal septicaemia to have an audiological assessment before discharge.
Children and young people who have had bacterial meningitis or meningococcal septicaemia (blood poisoning) have a hearing test before they leave hospital.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendation 1.5.3.

Data source

Structure: Local data collection.
Process: Local data collection.

Definitions

It may not be possible to arrange an audiological assessment before discharge in all circumstances. Where this is the case the assessment should be undertaken within 4 weeks of the child or young person being fit to undergo testing (that is, once they are no longer critically ill).

Follow-up

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people who have had bacterial meningitis or meningococcal septicaemia have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.

Quality measure

Structure: Evidence of local arrangements for children and young people who have had bacterial meningitis or meningococcal septicaemia to have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.
Process: Proportion of children and young people who have had bacterial meningitis or meningococcal septicaemia who have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.
Numerator – the number of people in the denominator who have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.
Denominator – the number of children and young people who are discharged after having had bacterial meningitis or meningococcal septicaemia.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people who have had bacterial meningitis or meningococcal septicaemia to have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.
Healthcare professionals ensure that children and young people who have had bacterial meningitis or meningococcal septicaemia have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.
Commissioners ensure they commission services for children and young people who have had bacterial meningitis or meningococcal septicaemia to have a follow-up appointment with a consultant paediatrician within 6 weeks of discharge.
Children and young people who have had bacterial meningitis or meningococcal septicaemia (blood poisoning) have an appointment with a specialist (a consultant paediatrician) within 6 weeks of leaving hospital.

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendations 1.5.5 (key priority for implementation) and 1.5.7.
Management of invasive meningococcal disease in children and young people SIGN clinical guideline 102, recommendation 9.1.7.

Data source

Structure: Local data collection.
Process: Hospital Episode Statistics contain the data necessary for the monitoring of outpatient follow-up.
Also contained within NICE guideline CG102 audit support (clinical and organisational criteria), criterion 15.

Tracheal intubation and mechanical ventilation in meningococcal septicaemia

This quality statement is taken from the bacterial meningitis and meningococcal septicaemia in children and young people quality standard. The quality standard defines clinical best practice for the care of children and young people with bacterial meningitis and meningococcal septicaemia and should be read in full.

Quality statement

Children and young people with meningococcal septicaemia undergoing tracheal intubation and mechanical ventilation have the procedure undertaken by an anaesthetist experienced in paediatric airway management.

Quality measure

Structure: Evidence of local arrangements for children and young people with meningococcal septicaemia undergoing tracheal intubation and mechanical ventilation to have the procedure undertaken by an anaesthetist experienced in paediatric airway management.
Process: Proportion of children and young people with meningococcal septicaemia undergoing tracheal intubation and mechanical ventilation who have the procedure undertaken by an anaesthetist experienced in paediatric airway management.
Numerator – the number of people in the denominator who have the tracheal intubation and mechanical ventilation procedure undertaken by an anaesthetist experienced in paediatric airway management.
Denominator – the number of children and young people with meningococcal septicaemia undergoing tracheal intubation and mechanical ventilation.

What the quality statement means for each audience

Service providers ensure systems are in place for children and young people with meningococcal septicaemia undergoing tracheal intubation and mechanical ventilation to have the procedure undertaken by an anaesthetist experienced in paediatric airway management.
Healthcare professionals ensure that children and young people with meningococcal septicaemia undergoing tracheal intubation and mechanical ventilation have the procedure undertaken by an anaesthetist experienced in paediatric airway management.
Commissioners ensure they commission services for children and young people with meningococcal septicaemia undergoing tracheal intubation and mechanical ventilation to have the procedure undertaken by an anaesthetist experienced in paediatric airway management.
Children and young people with meningococcal septicaemia (blood poisoning) receiving help to breathe using a tube inserted into their windpipe (tracheal intubation) through which air is pushed into the lungs via a ventilator machine (ventilation), have the procedure undertaken by an experienced specialist (an anaesthetist experienced in paediatric airway management).

Source guidance

Bacterial meningitis and meningococcal septicaemia NICE guideline CG102, recommendations 1.4.30 (key priority for implementation) and 1.4.35.

Data source

Structure: Local data collection.
Process: Local data collection. Contained within NICE guideline CG102 audit support (pharmacological criteria), criterion 16.

Definitions

Tracheal intubation with mechanical ventilation is required for the following indications.
  • Threatened (for example, loss of gag reflex) or actual loss of airway patency.
  • The need for any form of assisted ventilation, for example bag–mask ventilation.
  • Clinical observation of increasingly laboured breathing.
  • Hypoventilation or apnoea.
  • Features of respiratory failure, including:
    • reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more)
    • irregular respiration (for example, Cheyne–Stokes breathing)
    • hypoxia (PaO2 less than 13 kPa or 97.5 mmHg) or decreased - oxygen saturations in air
    • hypercapnia (PaCO2 greater than 6 kPa or 45 mmHg).
  • Continuing shock following infusion of a total of 40 ml/kg of resuscitation fluid.
  • Signs of raised intracranial pressure.
  • Impaired mental status, including:
    • reduced or fluctuating level of consciousness (Glasgow Coma - Scale score less than 9 or a drop of 3 or more)
    • moribund state.
  • Control of intractable seizures.
  • Need for stabilisation and management to allow brain imaging or transfer to the paediatric intensive care unit or another hospital. An anaesthetist experienced in paediatric airway management is an anaesthetist who has maintained their skills in paediatric resuscitation to the level of advanced paediatric life support or equivalent (for example by undertaking regular supernumerary attachments to paediatric lists or secondments to specialist centres/paediatric simulator work).
In the absence of an anaesthetist, another clinician experienced in paediatric airway management may undertake tracheal intubation and mechanical ventilation for children and young people with meningococcal septicaemia.
A paediatric intensivist should be consulted by the clinician undertaking tracheal intubation and mechanical ventilation.

Risk of serious illness

This quality statement is taken from the feverish illness in children under 5 years quality standard. The quality standard defines clinical best practice for feverish illness in children under 5 years and should be read in full.

Quality statement

Infants and children under 5 years with unexplained fever have their risk of serious illness assessed and recorded using the traffic light system.

Rationale

The condition of an infant or child with a serious illness can deteriorate within hours of onset. It is therefore important that risk of serious illness is assessed when infants and children present to healthcare professionals with unexplained fever. The traffic light system helps healthcare professionals, in conjunction with their professional judgement and the information provided by the parents and carers, to assess the risk of serious illness in a child with unexplained fever.

Quality measures

Structure
Evidence of local arrangements to ensure that healthcare professionals are using the traffic light system to assess and record the risk of serious illness in infants and children under 5 years presenting with unexplained fever.
Data source: Local data collection.
Process
Proportion of infants and children under 5 years with unexplained fever who have their risk of serious illness assessed and recorded using the traffic light system.
Numerator – the number in the denominator who have their risk of serious illness assessed and recorded using the traffic light system.
Denominator – the number of infants and children under 5 years with unexplained fever.
Data source: Local data collection. NICE clinical guideline160 (feverish illness in children) audit support tool (criterion 2).
Outcome
Early identification of serious illness in infants and children under 5 years.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as general practice and emergency departments) ensure that healthcare professionals assess and record the risk of serious illness using the traffic light system in infants and children under 5 years with unexplained fever.
Healthcare professionals ensure that they assess and record the risk of serious illness using the traffic light system in infants and children under 5 years with unexplained fever.
Commissioners (clinical commissioning groups and NHS England) ensure that the services they commission can demonstrate the use of the traffic light system to assess and record the risk of serious illness in infants and children under 5 years with unexplained fever (for example, through auditing).

What the quality statement means for patients and carers

Infants and children under 5 years with unexplained fever have their risk of serious illness assessed and recorded by a healthcare professional using a system that groups signs and symptoms into high (red), medium (amber) and low (green) risk. This is called the traffic light system.

Source guidance

Definitions of terms used in this quality statement

Fever
Fever is an elevation of body temperature above the normal daily variation. Healthcare professionals should take any parental reports of suspected fever seriously. [NICE clinical guideline 160]
Serious illness
An illness that could cause death or disability if there were a delay in diagnosis and treatment. [NICE clinical guideline 160]
Traffic light system
A system that stratifies risk of serious illness in infants and children under 5 years with fever according to vital signs and clinical symptoms.
Infants and children under 5 years with fever and any of the ‘red’ symptoms or signs should be recognised as at high risk. Infants and children under 5 years with fever and any of the ‘amber’ symptoms or signs should be recognised as at intermediate risk. Those with only ‘green’ symptoms and signs are at low risk. The management of fever in infants and children under 5 years should be directed by the level of risk.
Vital signs can be measured only during face-to-face contact. If an infant or child’s condition is being assessed remotely this will rely on identifying symptoms rather than measuring vital signs.
The traffic light system can be found in table 1 of NICE clinical guideline 160. [Adapted from NICE clinical guideline 160]

Equality and diversity considerations

Care should be taken when using the traffic light system to assess the risk of serious illness in children with unexplained fever who have learning disabilities, autism spectrum disorder or other mental health problems. This is because it may not be possible to apply all parts of the system to these children.
It may be difficult to assess pallor or a pale, mottled, ashen or blue appearance in infants and children with darker skin. Healthcare professionals should be aware that it may be easier to assess pallor on the lips or tongue.
A non-blanching rash may also be harder to detect in infants and children with darker skin tones, and healthcare professionals should be aware that it may be easier to identify a rash on the palms of the hands, the conjunctivae and the soles of the feet.
Care should be taken when assessing infants and children remotely when their parent’s or carer’s first language is not English. Efforts should be made to provide an interpreter and for the infant or child to be seen in person.

Measuring and recording vital signs

This quality statement is taken from the feverish illness in children under 5 years quality standard. The quality standard defines clinical best practice for feverish illness in children under 5 years and should be read in full.

Quality statement

Infants and children under 5 years who are seen in person by a healthcare professional have their temperature, heart rate, respiratory rate and capillary refill time measured and recorded if fever is suspected.

Rationale

Measuring and recording vital signs is an essential step in assessing the risk of serious illness, aiding diagnosis and ensuring the correct course of action. Measuring vital signs includes taking the child’s temperature and measuring heart rate, respiratory rate and capillary refill time. Temperature, heart rate and respiratory rate should be measured using the correct equipment for the child’s age. To ensure an accurate reading, it is important that a healthcare professional measures the child’s temperature even if the parent or carer has already done this. Parental or carer reports of fever should be acted on.

Quality measures

Structure
Evidence of local arrangements to ensure that temperature, heart rate, respiratory rate and capillary refill time of infants and children under 5 years with suspected fever can be measured using the correct equipment and recorded.
Data source: Local data collection.
Process
Proportion of infants and children under 5 years seen by a healthcare professional and suspected of having a fever who have their temperature, heart rate, respiratory rate and capillary refill time measured and recorded.
Numerator – the number in the denominator who have their temperature, heart rate, respiratory rate and capillary refill time measured and recorded.
Denominator – the number of infants and children under 5 years seen by a healthcare professional and suspected of having a fever.
Data source: Local data collection. NICE clinical guideline160 (feverish illness in children) audit support tool (criterion 3).
Outcome
Early identification of serious illness in infants and children under 5 years.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as general practice and emergency departments) ensure that the correct equipment for measuring temperature, heart rate, respiratory rate and capillary refill time is available to healthcare professionals who see infants and children under 5 years with suspected fever.
Healthcare professionals ensure that they measure and record temperature, heart rate, respiratory rate and capillary refill time using the correct equipment in infants and children under 5 years with suspected fever.
Commissioners (clinical commissioning groups and NHS England) ensure that the services they commission provide the correct equipment and training so that healthcare professionals can measure and record the temperature, heart rate, respiratory rate and capillary refill time of infants and children under 5 years with suspected fever.

What the quality statement means for patients, service users and carers

Infants and children under 5 years with suspected fever have their temperature, pulse and breathing rate measured when they are seen by a healthcare professional. The healthcare professional also checks for signs of dehydration and shock, and makes sure that all measurements and observations are added to the patient records.

Source guidance

Definitions of terms used in this quality statement

Suspected fever
Fever is suspected when there is reason to believe that body temperature is raised above the normal daily variation. Healthcare professionals should take any parental reports of suspected fever seriously. [NICE clinical guideline 160]
Correct equipment
Temperature should be measured using appropriate thermometers as described in section 1.1 of NICE clinical guideline 160.

Urine testing

This quality statement is taken from the feverish illness in children under 5 years quality standard. The quality standard defines clinical best practice for feverish illness in children under 5 years and should be read in full.
Infants and children presenting with unexplained fever of 38°C or higher have a urine sample tested within 24 hours. See statement 1 of NICE quality standard 36 on urinary tract infection in infants, children and young people under 16 for the quality measures, what the quality statement means, source guidance and definitions.

Rationale

It is important that a urinary tract infection is considered as a possible cause of feverish illness in infants and children under 5 years. When an infant or child (under 5 years) with a temperature of 38°C or higher is taken to a healthcare professional, and there is no obvious source of infection, a urine sample should be tested within 24 hours to ensure prompt diagnosis and antibiotic treatment if needed. An infant under 3 months should be admitted to hospital if they present with fever (as outlined in the traffic light system) and the urine sample should be tested in the hospital. A child over 3 months may be cared for at home, depending on other symptoms, in which case the urine sample should be tested in primary care.

Safety net advice

This quality statement is taken from the feverish illness in children under 5 years quality standard. The quality standard defines clinical best practice for feverish illness in children under 5 years and should be read in full.

Quality statement

Parents and carers who are advised that they can care for an infant or child under 5 years with unexplained fever at home are given safety net advice, including information on when to seek further help.

Rationale

Sometimes a healthcare professional advises parents and carers to care for their child at home. This may be because the child is at low risk of serious illness or they may have been stratified as medium risk but the decision has been made to care for them at home. Advice about what to do and what to look out for (safety net advice) empowers parents and carers to seek help if the child’s condition deteriorates further or if they need more support. If a child’s condition deteriorates it is important that they are seen again quickly.

Quality measures

Structure
Evidence of local arrangements to ensure that safety net advice, which includes information on when to seek further help, is available for parents and carers who are advised they can care for an infant or child under 5 years with unexplained fever at home.
Data source: Local data collection.

Process

Proportion of infants and children under 5 years with unexplained fever who are being cared for at home after assessment by a healthcare professional, whose parents and carers are given safety net advice, including information on when to seek further help.
Numerator – the number of infants and children in the denominator whose parents and carers receive safety net advice that includes information on when to seek further help.
Denominator – the number of infants and children under 5 years with unexplained fever who are being cared for at home after assessment by a healthcare professional.
Data source: Local data collection.
Outcomes
Parent and carer experience of services.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as general practice and emergency departments) ensure that written and verbal safety net advice is given to parents and carers when infants and children under 5 years with unexplained fever are cared for at home. This information should explain when the parent or carer should seek further help and should be available in formats that take account of literacy, language and other communication barriers.
Healthcare professionals provide parents and carers with safety net advice when an infant or child under 5 years with unexplained fever is cared for at home. This advice should include information on when the parent or carer should seek further help and should be given in a format the parents and carers can understand. The advice should usually be given as written material with some verbal discussion of the content.
Commissioners (clinical commissioning groups and NHS England) ensure that the services they commission can demonstrate that parents and carers are provided with safety net advice in an appropriate format when infants and children under 5 years with unexplained fever are cared for at home. This could include evidence that the advice accounts for any literacy, language or other communication barriers.

What the quality statement means for parents and carers

Parents and carers who are caring for an infant or child under 5 years with unexplained fever at home are given advice about what to do, what to look out for and when to get further help.

Source guidance

  • Feverish illness in children (NICE clinical guideline 160), recommendations 1.3.1.5, 1.4.2.3 (key priority for implementation), 1.4.2.4 and 1.5.8.2.

Definitions of terms used in this quality statement

Fever
Fever is an elevation of body temperature above the normal daily variation. Healthcare professionals should take any parental reports of suspected fever seriously. [NICE clinical guideline 160]
Safety net advice
Advise parents or carers looking after a feverish child at home:
  • to offer the child regular fluids (where a baby or child is breastfed the most appropriate fluid is breast milk)
  • how to detect signs of dehydration by looking for the following features:
    • sunken fontanelle
    • dry mouth
    • sunken eyes
    • absence of tears
    • poor overall appearance
  • to encourage their child to drink more fluids and consider seeking further advice if they detect signs of dehydration
  • how to identify a non-blanching rash
  • to check their child during the night
  • to keep their child away from nursery or school while the child's fever persists but to notify the school or nursery of the illness.
[NICE clinical guideline 160 recommendation 1.7.1.2]
When to seek further help
Following contact with a healthcare professional, parents and carers who are looking after their feverish child at home should seek further advice if:
  • the child has a fit
  • the child develops a non-blanching rash
  • the parent or carer feels that the child is less well than when they previously sought advice
  • the parent or carer is more worried than when they previously sought advice
  • the fever lasts longer than 5 days
  • the parent or carer is distressed, or concerned that they are unable to look after their child.
[NICE clinical guideline 160 recommendation 1.7.2.1]
See also the NICE clinical guideline 160 Feverish illness in children: discharge advice template.

Equality and diversity considerations

Healthcare professionals should take into consideration the communication needs of the parents and carers when deciding on the best format for safety net advice.
A non-blanching rash may be harder to detect in infants and children with darker skin tones, and healthcare professionals should inform parents and carers that it may be easier to identify a rash on the palms of the hands, the conjunctivae and the soles of the feet.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
title: Bacterial meningitis and meningococcal septicemia in children and young people: support for commissioning
:category: Commissioning
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
title: Bacterial meningitis and meningococcal septicemia in children and young people: support for commissioning
:category: Commissioning
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Traffic light system for identifying risk of serious illness

Green – low risk
Amber – intermediate risk
Red – high risk
Colour (of skin, lips or tongue)
Normal colour
Pallor reported by parent/carer
Pale/mottled/ashen/blue
Activity
Responds normally to social cues
Content/smiles
Stays awake or awakens quickly
Strong normal cry/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
Does not wake or if roused does not stay awake
Weak, high-pitched or continuous cry
Respiratory
Nasal flaring
Tachypnoea: respiratory rate:
>50 breaths/minute, age 6–12 months
>40 breaths/minute, age >12 months
Oxygen saturation ≤95% in air
Crackles in the chest
Grunting
Tachypnoea: respiratory rate >60 breaths/minute
Moderate or severe chest indrawing
Circulation and hydration
Normal skin and eyes
Moist mucous membranes
Tachycardia:
>160 beats/minute, age <12 months
>150 beats/minute, age 12–24 months
>140 beats/minute, age 2–5 years
Capillary refill time ≥3 seconds
Dry mucous membranes
Poor feeding in infants
Reduced urine output
Reduced skin turgor
Other
None of the amber or red symptoms or signs
Age 3–6 months, temperature ≥39°C
Fever for ≥ 5 days
Rigors
Swelling of a limb or joint
Non-weight bearing limb/not using an extremity
Age <3 months, temperature ≥38°C
Non-blanching rash
Bulging fontanelle
Neck stiffness
Status epilepticus
Focal neurological signs
Focal seizures
The traffic light system is also available in colour on the NICE website.
This traffic light table should be used in conjunction with the recommendations in this guideline on investigations and initial management in children with fever.

Summary of symptoms and signs suggestive of specific diseases

Diagnosis to be considered
Symptoms and signs in conjunction with fever
Meningococcal disease
Non-blanching rash, particularly with 1 or more of the following:
- an ill-looking child
- lesions larger than 2 mm in diameter (purpura)
- capillary refill time of ≥3 seconds
- neck stiffness
Bacterial meningitis
Neck stiffness
Bulging fontanelle
Decreased level of consciousness
Convulsive status epilepticus
Herpes simplex encephalitis
Focal neurological signs
Focal seizures
Decreased level of consciousness
Pneumonia
Tachypnoea: respiratory rate:
>60 breaths/minute, age 0–5 months
>50 breaths/minute, age 6–12 months
>40 breaths/minute, age >12 months
Crackles in the chest
Nasal flaring
Chest indrawing
Cyanosis
Oxygen saturation ≤95%
Urinary tract infection
Vomiting
Poor feeding
Lethargy
Irritability
Abdominal pain or tenderness
Urinary frequency or dysuria
Septic arthritis
Swelling of a limb or joint
Not using an extremity
Non-weight bearing
Kawasaki disease
Fever for more than 5 days and at least 4 of the following:
- bilateral conjunctival injection
- change in mucous membranes
- change in the extremities
- polymorphous rash
- cervical lymphadenopathy 


Glossary

In this pathway, fever is defined as an elevation of body temperature above the normal daily variation.
In this pathway, a non-paediatric practitioner is defined as a healthcare professional who has not had specific training or who does not have expertise in the assessment and treatment of children and their illnesses. This term includes healthcare professionals working in primary care, but it may also apply to many healthcare professionals in general emergency departments
In this pathway, this refers to a healthcare professional who has had specific training or has recognised expertise in the assessment and treatment of children and their illnesses. Examples include paediatricians, or healthcare professionals working in children's emergency departments.
Remote assessment refers to situations in which a child is assessed by a healthcare professional who is unable to examine the child because the child is geographically remote from the assessor (for example, telephone calls to NHS Direct). Therefore, assessment is largely an interpretation of symptoms rather than physical signs.
Note that NHS Direct will be replaced by NHS 111, which is due to be implemented nationally in 2013
A child's response to social interaction with a parent or healthcare professional, such as response to their name, smiling and/or giggling.
White blood cell count.

Paths in this pathway

Pathway created: May 2013 Last updated: June 2016

© NICE 2016

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