Art & science | vital signs

Treating feverish illness in children

aged under five years
Penny McDougall outlines the assessment requirements nurses must follow to
enable them to identify the signs and symptoms of a potentially serious illness

unexplained fever, and an improvement in the

Abstract
experience of the child and family (NICE 2014).
Fever is the most likely reason for a child to be taken to the doctor and, All clinical areas routinely monitor and audit
occasionally, the signs may indicate the start of serious illness. The National their care delivery for quality and compliance;
Institute for Health and Care Excellence has issued a quality standard for the the standard enables nurse leaders to develop their
care of feverish illness in children aged under five years, designed to ensure that own quality assessment framework based on the
no such cases are missed. Carers, usually parents, should be offered written and four key statements, which are specific, measurable,
verbal advice if it is judged that they can safely take the child home and are happy and achievable (Box 1).
to do so. The traffic light system is designed to assist assessment of the child on
presentation and throughout the illness journey. Traffic light system
The traffic light system (TLS) is an assessment tool
Keywords that can support nurses’ clinical decision making
Child assessment, child fever, children’s nursing, NICE quality standard, vital signs when judging the risk of serious illness in a child.
Initially developed for the original 2007 guideline,
Correspondence FEVER IS the most common reason for a child it has since been amended and updated (NICE 2013a).
penny.mcdougall@nhs.net
to be taken to the doctor and the second most The TLS is designed to empower nurses and other
Penny McDougall is modern common reason a child is admitted to hospital front line staff, who make the difficult decisions
matron, Variety Children’s (National Institute for Health and Care Excellence about whether to refer to hospital or leave a child at
Hospital, King’s College
(NICE) 2013a). Most cases of fever are caused home. The TLS was not designed to replace clinical
Hospital, London
by self-limiting viral illnesses that can be judgement or experience, but to assist nurses in their
Date of submission safely managed at home. assessment of the child.
August 28 2014
Occasionally, a fever may indicate serious
Date of acceptance or life-threatening illness such as meningitis or Vital signs
October 8 2014 septicaemia (McDougall and Harrison 2014). It is, The measuring and recording of vital signs is an
Peer review therefore, essential that nurses have the skills and essential step in assessing the risk of serious illness,
This article has been subject to knowledge to identify the signs and symptoms of aiding diagnosis and ensuring the correct course
open peer review and checked serious disease and assess each child’s level of risk. of action (NICE 2014). In the past, many children
using antiplagiarism software
presenting in primary care did not have their vital
Author guidelines Quality standard signs measured or documented, despite evidence
rcnpublishing.com/r/ Last July, NICE released a quality standard for to underpin the value of measuring heart and
ncyp-author-guidelines
feverishness illness in children aged under respiratory rates in children with fever (NICE 2013a).
five years. It supports NICE clinical guideline Careful evaluation of temperature, heart rate,
160, published in 2013, and consists of a concise respiratory rate and capillary refill time enables a
set of statements to drive measurable quality nurse to assess the child’s level of hydration and
improvements. It is envisaged that compliance peripheral perfusion, and identify any early signs of
with the standard will promote high quality, shock. It is essential to use correct, age-appropriate
consistent care, contributing in turn to a reduction equipment (Royal College of Nursing (RCN)
in hospital admissions, a decrease in the mortality 2013a, NICE 2013a) and to document the results
and morbidity rates in infants and children with accurately (RCN 2013b).

22 December 2014 | Volume 26 | Number 10 NURSING CHILDREN AND YOUNG PEOPLE

Urinary tract infections
The early identification of urinary tract infections
(UTIs) is crucial in young children, yet these are
often not detected because of the difficulty of
obtaining urine specimens from small children.
Undiagnosed and untreated UTIs can have a serious
long-term consequence, and the quality standard
aims to ensure prompt diagnosis and treatment,
thereby minimising the risk of long-term morbidity.
All infants aged under three months, presenting
with a fever greater than 38°C, should be referred
to hospital for assessment (as recommended in the
traffic light system) and their urine should be tested
in hospital. Older children in the green or amber
category, who are not referred, should have their
urine tested in primary care. The best method of
urine collection remains a ‘clean catch’ in a sterile
bowl; however, urine-collecting pads and bags are
often the more practical alternative in the community.
‘Safety-net’ advice
It is envisaged that ‘safety-net’ advice – what to do
and what to look out for – will empower parents
and carers to seek help if the child’s condition
deteriorates further or if they need more support.
Essential advice should include the management
of the child with fever, and signs and symptoms of
serious illness, and when and where to seek further
help (McDougall and Harrison 2014).
Any healthcare professional making an assessment
who considers it safe for the child to be managed at
home should ensure parents and carers are provided
with written and verbal advice. NICE has produced a
‘safety-net’ discharge advice template, available for
download from its website, which should be given to
families (NICE 2013b) (Box 2). It is imperative, however,
that the nurse discusses the ‘safety-net’ information
with the child’s carers to ensure that they understand,
and that they are happy to take the child home.
Conclusion
The NICE quality standard features the key
recommendations of the NICE fever guideline.
It aims to enable nurses and other healthcare
professionals to identify the main signs and
symptoms of serious illness in children presenting
with fever. This is vital, as early detection will
significantly reduce the risk of death or serious
long-term consequences (NICE 2013a).
The standard seeks to ensure that children are
managed safely at home when appropriate and
recommends that parents and carers are provided
with ‘safety-net’ advice on discharge to give them
confidence and empower them to seek further
medical advice should the child deteriorate.
NURSING CHILDREN AND YOUNG PEOPLE
Box 1 Quality standard for feverishness illness in children aged under five years
■  Infants and children with an ■  Those presenting with unexplained
unexplained fever should have their fever of 38°C or higher should have a
risk of serious illness assessed and urine sample tested within 24 hours.
recorded using the traffic light system. ■  Parents and carers who are advised
■  Young patients who are seen in that they can care for an infant
person by a healthcare professional or child aged under five with
should have their temperature, unexplained fever at home should
heart rate, respiratory rate and be given ‘safety-net’ advice on
capillary refill time measured and discharge, including information
recorded if fever is suspected. about when to seek further help.
(National Institute for Health and Care Excellence 2013a)
Box 2 Essential safety-net advice for children well enough to be managed at home
Parents and carers should be given ■  The child develops a
advice on how to seek further help if: non-blanching rash.
■  They are more concerned than when ■  The fever lasts longer than five days.
they previously sought advice. ■  The child looks dehydrated.
■  The child’s health gets worse. ■  They feel unable to look after
■  The child has a fit. their child at home.
(National Institute for Health and Care Excellence 2013a)
Key points
■  Fever is the most likely reason for a child to be
taken to the doctor, but is usually a minor illness.
■  The NICE quality standard can enable identification
of the signs and symptoms of serious illness (Box 1).
■  The standard comprises four key
statements (Box 1).
■  Essential ‘safety-net’ advice should be followed for
children managed at home (Box 2).
Finally, the standard sets a benchmark for
measuring quality improvement, which will allow
nurse leaders to develop local audit tools.
It is hoped that all nurses working with children
will embrace the standard and use it as a foundation
to ensure high quality, consistent care for infants
and children with fever, while improving the patient
experience and patient safety.
References
McDougall P, Harrison M (2014) Fever and feverish illness in children under
five years. Nursing Standard. 28, 30, 49-59.
National Institute for Health and Care Excellence (2013a) Feverish Illness in
Children: Assessment and Initial Management in Children Younger than 5 Years.
Clinical Guideline No 160. NICE, London.
National Institute for Health and Care Excellence (2013b) Feverish Illness Online archive
in Children: Discharge Advice Template. tiny.cc/5bmbpx (Last accessed:
November 14 2014.) For related information, visit
our online archive and search
National Institute for Health and Care Excellence (2014) Feverish Illness in
Children Under 5 Years. Quality Standard No 64. NICE, London.
using the keywords
Royal College of Nursing (2013a) Standards for Assessing, Measuring and
Monitoring Vital Signs in Infants, Children and Young People. RCN, London.
Conflict of interest
Royal College of Nursing (2013b) Caring for Children with Fever. RCN, London. None declared
December 2014 | Volume 26 | Number 10 23