Clinical risk reduction: Acute febrile illness in children

FEW GPs will have not at some time experienced anxiety and diagnostic uncertainty when faced with an ill and feverish child. The vast majority of childhood fevers are self limiting, usually viral in origin, and do not require much intervention other than analgesia, fluids and parental support. But rarely there may be severe underlying illness such as septicaemia. Longer lasting, relapsing fever may also be associated with very rare conditions, such as Kawasaki disease.

The GP needs to see such patients promptly, make a safe diagnosis and take appropriate action to identify any more serious underlying disease. This can be a difficult task and calls for some degree of organisation in approach and calm assessment of the child and (often) their parents..

GPs may readily differentiate the clearly very ill, high-risk child from the relatively well, low-risk child. Of greater concern can be those children who are not sufficiently ill to require admission to hospital but nevertheless show signs which raise concerns as to their overall risk. The NICE guidance, Feverish illness in children: Assessment and initial management of children younger than 5 years, provides some useful guidelines.

History and examination

Nothing beats a careful history. In young children this is almost always via the parent and means exploration of the course of the illness. Careful record keeping is essential. Vomiting which has lasted three days, six or eight times a day, is clearly different to a single episode five days ago, yet often such details are not recorded. Listening to the parent’s account provides invaluable insight into the history as well as the parent’s concerns and ability to cope.

When assessing a child with fever the doctor should measure and record:

• temperature
• heart rate
• respiratory rate
• capillary refill time.

Irrespective of history it would also be usual to examine the ENT, chest, abdomen and skin, recording that this had been done and relevant findings.

A raised heart rate and capillary refill time of greater than three seconds in children with fever can be a sign of serious illness, particularly septic shock. In children younger than three months a temperature of over 38° Celsius should be considered high risk, and the same should be said of children with a temperature of 39° or higher between three to six months of age. Apart from this, body temperature alone should not be used to identify children with serious illness nor should the duration of fever.

It is also important that children who have fever should be assessed to eliminate the possibility of dehydration. Common signs include abnormal skin turgor, abnormal respirations, weakness or rapidity of the pulse, cool extremities and prolonged capillary refill time. In severe situations dry mucous membranes may be noted along with a history of reduced or absent micturition.

Assessment

NICE guidelines set out three categories which help to define high, intermediate or low risk for serious illness. These are summarised in the table opposite.

Management by the GP

It is important to identify any lifethreatening features such as compromise of the airway, breathing or circulatory problems and decreased levels of consciousness (ABCD). Supportive action and admission to hospital as soon as possible is essential.

The presence of high-risk signs or a characteristic meningococcal nonblanching rash requires immediate attention with appropriate treatment such as benzylpenicillin and referral to hospital. Do not be falsely reassured by a rash that blanches on pressure, if there are intermediate or high-risk signs present. Children with high-risk signs not considered to be immediately life threatening should nevertheless be referred urgently for assessment by the local paediatric specialist.

Greater care is required in managing the child with intermediate risk and the outcome will often depend on assessment of the child, parents and their ability to cope or identify any subsequent worsening in the child.

The vast majority of children with some intermediate features will nevertheless settle but care should be taken to consider if they require admission to hospital. NICE guidelines state it is important to also consider:

• the social and family circumstances
• other illnesses the child or family members have
• parents’ or carers’ anxiety and instinct
• contact with people with serious infectious diseases
• parents’ or carers’ concern, causing them to seek help repeatedly
• recent travel abroad to tropical/subtropical areas, or any highrisk areas for endemic infectious diseases
• previous family experience of serious illness or death due to feverish illness which has increased their anxiety levels
• whether the child’s fever has no obvious cause but is lasting longer than you would expect for a selflimiting illness.

Children with only low-risk features can be managed safely at home with appropriate advice for the parents.

Medico-legal issues

The possibility of making a clinical mistake is a daily hazard for GPs but legal risk is relatively low provided that you listen patiently, take a careful history, examine appropriately and seek to explain the condition to the parents while maintaining rapport. Clear and comprehensive notes are invaluable, both to the examining doctor and to anyone who subsequently sees the child. In the unlikely event of disaster, they also aid legal defence.

Part of the assessment of the child should also include an assessment of the parents, including their level of awareness, tiredness, prior knowledge of their general coping abilities and family support, and also their understanding and agreement with the GP’s proposed action. When rapport seems very poor or the parent seems unduly anxious or unable to cope, it may be prudent to request a further opinion from a paediatric specialist or temporary admission to hospital. Doctors working in out-of-hours situations will almost certainly have no prior knowledge of the parents and should consider a lower threshold for onward referral (see Case study on page 20 of this issue).

In the majority of cases the GP will decide to manage the child out of hospital and here it is particularly important to safety net – give specific advice about what to look out for and what to do if the child’s condition should worsen. Here it is crucial to understand the ability of a parent or carer to cope and tailor advice accordingly. Particularly stoical parents may delay seeking further help if overly reassured and may need to be encouraged to return. Having a set phrase for advice may be useful but should not prevent the doctor engaging the brain before safety netting. NICE suggests:

• Provide the parent or carer with verbal and/or written information on warning symptoms and how further healthcare can be accessed.
• Arrange a follow-up appointment at a certain 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.

While there is no generally accepted rule, it is prudent to recognise that if a child is presenting for the second or third time in a very short period then either they are unwell or their parents may be struggling to cope. Onward referral should be considered in such a situation.

Dr David Willox is a GP and medicolegal expert in primary care