Fever: NICE to get guidance

16 December, 2010 by: colinparker

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Three years ago the National Institute for Clinical Excellence in the UK released their guidance on the assessment and initial management of feverish illness in young children (CG47).  Most of the world outside of Britain has not been using this guidance, but we thought it would be useful to delve a bit deeper to see whether we could all benefit from the insights of their expert panel.

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Outline of this PEMcast

CP: Intro, hello, disclaimer

NICE CG47 Issued in May 2007, referenced in:

Richardson M, Lakhanpaul M; Guideline Development Group and the Technical Team.
Assessment and initial management of feverish illness in children younger than 5 years: summary of NICE guidance.
BMJ. 2007; 334: 1163-4

Richardson M, Lakhanpaul M.
Feverish illness in children under 5 years.
Arch Dis Child Educ Pract Ed. 2008; 93: 26-9

Main part of discussion centres around NICE CG47 (Full Guideline) Section 4:
Clinical assessment of the child with fever

CP: 4.1 Introduction

SF: 4.2 Priorities in Clinical Assessment

KB: 4.3 Life-Threatening features of Illness in Children

CP: 4.4.1-4.4.2 Assessment of Risk of Serious Illness and Traffic Light system

KB: Traffic lights: green components

SF: Traffic lights: orange

CP: Traffic lights: red

All: comments & discussion on traffic light components

CP: 4.5 Non-Specific symptoms and signs of Serious Illness

Big sections:

SF: 4.5.1 General Symptoms and Signs

KB 4.5.2 Predictive Values of common Physiological Measurements

CP 4.5.3 Height and Duration of Fever

SF 4.5.4 Assessment of Dehydration

CP 4.6 Specific Serious Illnesses – not discussing (will discuss on future episodes though)

With reference to Quick Reference Guideline:

SF: Overview of care pathway – page 4

KB: Assessment – page 8

CP: Introduction to management remote vs normal doctor vs paediatrician

Perspective from position of:

  • KB: remote assessment
  • CP: non-paediatric doctor
  • SF: paediatrician

Would you use the guideline, would you stick to it?
Would you feel protected if something went wrong?

CP/ All: Outcomes / impact of NICE CG47, discussion, perspective & experience from clinical experience.

CP/All: Summary

Goodbye, thanks, see you next time…

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3 Responses to “Fever: NICE to get guidance”
  1. Colin says:

    There seems to be a bit of uncertainty about the use of alternating antipyretics, with some clinicians routinely recommending the practice, and some who are totally against it…
    A short piece on the question of safety, which looks at a few small trials, can be found on Medscape:
    http://www.medscape.com/viewarticle/738903
    While there are theoretical reasons why alternating ibuprofen and paracetamol (acetaminophen, APAP) can be harmful, I am not aware of any studies or case reports indicating harmful outcomes.

    My main concerns are more related to antipyretic use in general:
    -Increasing fever phobia in parents, by emphasising the apparent role of lowering the temperature
    -Antipyretics may prolong the duration of illness and are not free of side-effects
    When it comes to combining different agents, there is a possibility of doing errors, especially for tired/stressed parents, with multiple different formulations and strengths for both agents.

    Both the American Academy of Pediatrics and the NICE Guideline on Feverish Illness condemn the practice of alternating antipyretics.
    http://www.healthychildren.org/English/health-issues/conditions/fever/Pages/Medications-Used-to-Treat-Fever.aspx
    http://egap.evidence.nhs.uk/CG47/section_1#section_1_6

    Until we see some definite evidence of harm, it’s up to you, the clinician, to balance these concerns against the perceived benefits of comfort, for symptomatic children with fever.

  2. colinparker says:

    Well, here’s another paper on combined or alternating antipyretics:

    Purssell E.
    Systematic review of studies comparing combined treatment with paracetamol and ibuprofen, with either drug alone. Arch Dis Child. 2011 Aug 24. [Epub ahead of print] PubMed PMID: 1868405.
    http://www.ncbi.nlm.nih.gov/pubmed/21868405

    There are 2 things in Dr Purssell’s conclusions that I love:
    “While it is tempting to conclude that further research should be undertaken, based on the small
    size and short duration of most existing studies, this is not really necessary.”
    and
    “there is little to recommend the unnecessary use of polypharmaceutical methods to treat a symptom that does not require treatment, when effective monotherapies exist.”

    This systematic review included six studies looking at potential benefits and harms of combining antipyretic agents. Unfortunately the small sample size, heterogeneity and inpatient setting of these studies all stand in the way of being able to combine their data and generalise to our ED patient population. Although there was no evidence of harm, the included studies were underpowered (and not specifically designed) to detect adverse effects. The author correctly points out that it would be uncool to embark on a large study to look for evidence of harm, when the potential benefits are dubious. Nice work.

  3. Colin says:

    You probably already know… that NICE updated their Feverish Illness in Children guideline recently. CG47 has been replaced by CG160. Dr Tessa Davis gives a great summary on LITFL, here:
    http://lifeinthefastlane.com/2013/05/nice-fever-guidelines-for-kids/
    The full NICE CG160 (Feverish Illness in Children) can be found here:
    http://guidance.nice.org.uk/CG160
    Despite the lack of rigorous evidence out there, the NICE guideline is a good concensus on how to risk stratify kids with Fever Without Source (FWS).

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