NICE issues updated guidance to help assess children running high temperatures

The National Institute for Health and Care Excellence (NICE) has today published its updated clinical guideline on assessing and managing children under the age of 5 years with fever (running a high temperature - as a general rule, in children, a temperature of over 37.5°C is a fever). The guideline advises all healthcare professionals, including GPs, nurses, pharmacists and paediatricians on assessing the symptoms of a child with fever and how they should be cared for.

Fevers are very common in young children. It has been estimated that 20 to 40% of parents report a child with a raised temperature each year in the UK. As a result, fever is probably the commonest reason for a child to be taken to the doctor. Fevers are also the second most common reason, after breathing difficulty, for an acute admission to hospital. Most fevers will settle by themselves but a few are caused by serious infections such as meningitis or pneumonia and despite advances in healthcare, infections remain the leading cause of death in children under the age of 5 years in the UK.

The partially updated guideline retains the bulk of the original recommendations, including the recommendation that children with feverish illness should be assessed for symptoms and signs that can be used to predict the risk of serious illness using the traffic light system developed as part of the original guideline. However, a number of new recommendations have been added that take into account new evidence about the relationship of heart rate to fever in predicting the risk of serious illness in children and the clinical and cost-effectiveness of therapy with paracetamol and ibuprofen in the management of fever in children. The guideline also includes a summary table of symptoms and signs suggestive of specific diseases such as meningitis and pneumonia.

Key priorities for implementation include:

  • Assess children with feverish illness for the presence or absence of symptoms and signs that can be used to predict the risk of serious illness using the traffic light system
  • Recognise that children with tachycardia (raised heart rate) are in at least an intermediate-risk group for serious illness. Use the Advanced Paediatric Life Support (APLS) criteriai to define tachycardia;
  • Antipyretic agents (drugs that reduce fever) do not prevent febrile convulsions and should not be used specifically for this purpose.
  • When using paracetamol or ibuprofen in children with fever;
    • continue only as long as the child appears distressed
    • consider changing to the other agent if the child's distress is not alleviated
    • do not give both agents simultaneously
    • only consider alternating these agents if the distress persists or if it recurs before the next dose is due.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: “Fever in young children can be difficult to diagnose because, in a significant number of children, it is often hard to identify the cause despite careful assessment. By updating the NICE guideline to take into account new evidence, this will ensure that it remains current and relevant. Potentially serious cases of feverish illness are likely to be rare, so it is important that information is in place to help healthcare professionals distinguish these from mild cases. This guidelinewill help doctors, nurses, pharmacists and other healthcare professionals to pick up the high-risk symptoms that indicate a child needs urgent medical attention. It will also help to empower parents so they can work in partnership with healthcare professionals to care for children with a feverish illness.”

Martin Richardson, consultant paediatrician and Chair of the guideline development group, said: “The updated guideline has two major changes. The first is a revision of the well respected traffic light table of symptoms and signs. In particular, the inclusion of raised heart rate should lead to further improvements in the recognition of seriously ill children. The second major change is that the section on the treatment of fever has been rewritten to encourage the rational, stepwise use of drugs such as paracetamol and ibuprofen."

John Crimmins, GP and member of the guideline development group, said: “While dealing with children with fever is an everyday encounter in general practice, identifying the small number of those children who are in the early stages of a serious bacterial illness remains a difficult and challenging problem. As outcomes are largely dependent on early intervention, the initial assessments of these children, which can also occur in a variety of other settings including telephone advice lines, A&E and out-of-hours services, are crucial. This guideline will provide help and guidance based on the best currently available evidence, to ensure that early assessment wherever performed, can identify those children who are likely to have a serious bacterial infection and to ensure they are managed effectively, usually by referral for expert paediatric care.”

Penny McDougall, a children's nurse and member of the guideline development group, said: “Every parent worries about their child when they have a fever, but most feverish illnesses in children resolve with minimal intervention. The revised guideline gives clear advice to parents and carers on how and when to give medication like paracetamol or ibuprofen, and when to seek further advice from their GP or other health care provider. Occasionally fever may be associated with more serious, life threatening illnesses like meningitis or septicaemia, and it is essential that these children are identified and treated as quickly as possible. The updated, evidence based traffic light table, is a fantastic tool that will enable health care professionals to recognise the signs of serious illnesses associated with fever earlier and therefore reduce the risk of death or long term harm.”

Leah Bowen, a lay member of the guideline development group, said: "This updated guideline is based on the most relevant and contemporary research evidence available. The advice concerning the use of paracetamol and ibuprofen has been clarified and will be filtered down to parents. This will be especially useful to families who will benefit from consistent advice from their health care provider about how to best to care for their child if they choose to use these medicines when treating children at home".


Notes to Editors


i. The Advanced Paediatric Life Support (APLS) criteria to define tachycardia:

Age Heart rate (bpm)
<12 months > 160
12-24 months >150
2-5 years >140

About the guidance

1. The guideline on the assessment and initial management of feverish illness in children younger than 5 years will be available on the NICE website from 22 May 2013.

2. This guidance is a partial update of NICE clinical guideline 47 Feverish illness in children - Assessment and initial management in children younger than 5 years (published May 2007) and will replace it.

About NICE

The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.

Formerly the National Institute for Health and Clinical Excellence, our name changed on 1 April 2013 to reflect our new and additional responsibility to develop guidance and set quality standards for social care, as outlined in the Health and Social Care Act (2012).

Our aim is to help practitioners deliver the best possible care and give people the most effective treatments, which are based on the most up-to-date evidence and provide value for money, in order to reduce inequalities and variation.

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This page was last updated: 21 May 2013