Surveillance decision

Surveillance decision

We will not update the guideline on fever in under 5s at this time.

During surveillance, editorial or factual corrections were identified:

  • We will add a footnote to recommendation 1.2.2.10 of the guideline, as well as the traffic light system for identifying risk of serious illness, to highlight that some vaccinations have been found to induce fever in children younger than 3 months.

  • We will add a recommendation that cross-refers to the NICE guideline on sepsis: recognition, diagnosis and early management (NG51) so that clinicians can determine what considerations should be made, and what diagnostic tests should be performed, if they suspect that a febrile child has sepsis.

  • We will add a recommendation to the non-paediatric section of the guideline highlighting that clinicians should not rely solely on a response to antipyretics to differentiate between serious and non-serious illness.

Reason for the decision

We found 41 new studies through surveillance of this guideline.

This included new evidence on symptoms and signs of specific illnesses that is consistent with current recommendations.

We also identified new evidence or information in the following areas that was inconsistent with, or not covered by, current recommendations. We considered these areas in detail to determine the most appropriate action:

Clinical assessment of children with fever

Topic experts highlighted that a new protein-based meningococcal B vaccination induced fever in children less than 3‑months old. Intelligence gathering revealed a Public Health England publication which highlights that fever is an adverse reaction associated with a new protein-based meningococcal B vaccine. Furthermore, an NHS England publication targeted at parents highlights that fever is a common side effect after some vaccinations. Topic experts pointed out that recommendation 1.2.2.10, in NICE guideline CG160 states that clinicians should recognise that children younger than 3 months with a temperature of 38°C or higher are in a high-risk group for serious illness. They expressed some concern that many children under 3 months who develop fever after immunisation will be admitted to hospital and subjected to a full septic screen because the guideline suggests that they are treated this way. Overall, topic experts felt that the addition of a footnote to the guideline recommendations would not address this issue. This feedback was considered in detail. No evidence was identified through surveillance that included children post vaccine aiming to identify the likelihood of serious bacterial infection in the presence of a post-vaccine fever. Therefore, adding a footnote to NICE guideline CG160 to notify clinicians that certain vaccinations can induce fever in children younger than 3 months was considered to be the most appropriate action.

Management by the paediatric practitioner

Topic experts highlighted that recommendations about lactate testing are in the NICE sepsis guideline (NG51) but not in NICE guideline CG160, and there is much cross-over between the 2 guidelines. They felt that although lactate testing is used to stratify risk in people who are thought to have sepsis, it is not used for detecting infection. Experts highlighted that children with sepsis comprise a subset of children presenting with fever. Furthermore, they pointed out that most trusts will screen for sepsis first, then fever, unless they are assured that the initial screening process in the fever guideline covers sepsis red flags. As a result, experts felt it is important that NICE guideline CG160 redirects clinicians to NICE guideline NG51 if they suspect a febrile child has sepsis. They suggested that a recommendation could be added to NICE guideline CG160; cross-referring to NICE guideline NG51 so that clinicians can determine what considerations should be made if they suspect that a febrile child has sepsis. Experts suggested the following recommendation could be added after 1.2.1.1 of NICE guideline CG160:

"Think 'could this be sepsis?' and refer to the NICE sepsis guidance if a child presents with fever and symptoms or signs that indicate possible sepsis."

Management by the non-paediatric practitioner

Although no evidence was found at any surveillance time point, substantive feedback from topic experts indicated that the guideline should be amended. Experts highlighted a coroner's report that indicated that the guideline provides advice for paediatric specialists (section 1.5) on assessment of children who respond, or fail to respond, to antipyretic therapy but no recommendations are provided in the advice for non-paediatric practitioners section (section 1.4). As a result, experts suggested that the section on management by non-paediatric practitioners should be amended to include a recommendation highlighting that when a child has been given antipyretics, clinicians should not rely on a decrease or lack of decrease in temperature to differentiate between serious and non-serious illness. Experts suggested that the following recommendation could be added to section 1.4:

"When a child has been given antipyretics, do not rely on a decrease or lack of decrease in temperature to differentiate between serious and non-serious illness."

Other clinical areas

We did not find any new evidence in areas not covered by the original guideline.

Equalities

No equalities issues were identified during the surveillance process.

Overall decision

After considering all the new evidence and views of topic experts, we decided that an update is not necessary for this guideline.

See how we made the decision for further information.


This page was last updated: 24 April 2017