2 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group's full set of research recommendations is detailed in the full guideline.

2.1 Symptoms and signs of serious illness

The GDG recommends a UK-based epidemiological study on the symptoms and signs of serious illness. [new 2013]

Why this is important

The current recommendations on symptoms and signs in the NICE guideline are based on a series of heterogeneous studies (using different methods, populations, outcomes and of varying quality) and a degree of subjectivity was needed to bring these together in the guideline. Therefore, the GDG recommends that a large prospective UK-wide study (n=20,000 plus) should be undertaken comparing all of these symptoms and signs covered in the guideline. This would allow for a standardised comparison of each symptom and sign, and for validation of the existing 'traffic light' table.

The study should use a standardised data collection protocol. Where possible the study should link with routinely collected data sets, such as Hospital Episode Statistics. The study should include a variety of settings and locations – that is, wherever children present, including primary care. The primary outcome of the study should be the final diagnosis and results of treatment.

2.2 Management by remote assessment

The GDG recommends that a UK study is undertaken to determine the validity of symptoms reported on remote assessment for children with fever. [2007]

Why this is important

Traditionally, symptomatic patients have been assessed in a face-to-face setting but increasingly, remote assessment (for example, assessment over the telephone) determines the urgency of the patient's need, the level of care required and from that the most appropriate next step for the patient. This might include referral to emergency services, referral to acute or non-acute services or closing the call with self-care advice/support. Clinical and cost effectiveness will only be achieved through remote assessment if perceived need equates to actual need. There is currently a lack of data available that demonstrate the validity of remote assessment.

2.3 Diagnosis

The GDG recommends that a UK study of the performance characteristics and cost-effectiveness of procalcitonin versus C-reactive protein in identifying serious bacterial infection in children with fever without apparent source be carried out. [2007]

Why this is important

Many young children with fever appear well with no symptoms or signs of serious illness. The vast majority of these children will have self-limiting illnesses. However, a few will have serious bacterial infections which may not be identifiable by clinical assessment alone. Investigations that help to identify these children with serious bacterial infections could lead to prompt antibiotic treatment, which may improve their outcome. These investigations need to be both sensitive and specific so that most serious bacterial infections are identified and so that antibiotics are not given to children who don't need them. The inflammatory markers C-reactive protein and procalcitonin have shown varying performance characteristics for identifying bacterial infection in a variety of populations. If either or both were found to be sensitive and specific for identifying serious bacterial infection in children with fever without apparent source, there would be evidence for their more widespread use. The cost effectiveness of this approach would need to be calculated.

2.4 Antipyretics

The GDG recommends that studies are conducted in primary care and secondary care to determine whether examination or re-examination after a dose of antipyretic medication is of benefit in differentiating children with serious illness from those with other conditions. [2007]

Why this is important

Antipyretic medications are widely used in primary and secondary settings by parents and healthcare professionals. Children may therefore present to healthcare facilities having had a dose of antipyretics. Furthermore, the child's response to antipyretic drugs may be used as an indication of severity of illness, the rationale being that those with milder illness will either show greater improvement in condition or a greater reduction in their fever than children with more serious illnesses. However, it is not clear if such changes in condition are a valid and reliable method of differentiating children with serious illness from those with less serious conditions.

2.5 Home-based antipyretic use

The GDG recommends studies on home-based antipyretic use and parental perception of distress caused by fever. [new 2013]

Why this is important

The current guideline recommends the use of antipyretics to relieve distress in children. However, the concept of 'distress' and how parents act on it is little understood. Therefore, the GDG recommends that a study is undertaken to investigate 'distress' in children with feverish illness. The study should include parents' and carers' interpretation of this, including: help-seeking behaviour, what triggers presentation to a healthcare professional, what triggers the decision to give a dose of antipyretic, and what triggers the decision to change from one antipyretic to another.

  • National Institute for Health and Care Excellence (NICE)