9.1. Introduction
Feverish illness in children is a normal and common event although it can cause significant anxiety for some parents and carers. Parents may seek support from healthcare services but in most cases the parents can be reassured that the child is best cared for at home. They may need support and advice to do this confidently. The overwhelming majority of children will recover quickly and without problems. However, in a few cases the child’s condition may worsen or fail to improve. Parents need information on when and how to seek further advice.
The GDG has found evidence to show that administering antipyretics can make a child look better and feel better and therefore make it easier to differentiate those with serious illness from those with non-serious illness. However, there is no evidence to show that it is desirable to administer antipyretics to reduce fever. The desirability of reducing fever is controversial.
Where no evidence was found to answer the questions, the Delphi survey was used. Full details of the survey are available in Appendix A.
9.2. Care at home
The GDG considered subjects that could usefully be included in written or verbal advice for parents and carers following an encounter with the health services regarding a febrile child.
Clinical question
What advice should be given to parents for further management of a febrile child? Need to consider:
hydration
feeding
frequency of temperature monitoring
methods of cooling
when to attend nursery or school
appearance of non-blanching rash.
9.2.2. Fluids
One SR233 reporting that there were no RCTs assessing the effect of increasing fluid intake in acute respiratory infections was found. No further studies were found meeting the inclusion criteria about giving oral fluids and thus the Delphi survey was used.
Delphi statement 1.1
Parents/carers looking after a feverish child at home should be advised to offer the child regular fluids (where a baby or child is breastfed the most appropriate fluid is breast milk).
In round 1 of the survey the rating categories were:
The statement achieved 96% agreement and thus consensus.
9.2.3. Dehydration
A lack of evidence was found about whether to advise the parents/carers to look for signs of dehydration. This then was included in the Delphi survey.
Delphi statement 1.2
Parents/carers looking after a feverish child at home should be advised how to detect signs of dehydration.
In round 1 of the survey the rating categories were:-
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| 1 to 3 | 4 to 6 | 7 to 9 | Don’t know | Missing | Total | Median |
|---|
| 0 | 6 (12%) | 42 (84%) | 2 (4%) | 3 | 50 | 8.5 |
The statement achieved 84% agreement and thus consensus.
There was some evidence about which features parents and carers should look for. Refer to Section 4.5.4 for symptoms and signs of dehydration for this purpose. The GDG decided that parents or carers should be advised to look for the most sensitive symptoms and signs of dehydration so that cases are not missed, and if signs of dehydration are detected the parents/carers should encourage their child to drink more fluids and consider seeking further advice. The relevant features are:
dry mouth
sunken eyes
absence of tears
poor overall appearance.
9.2.4. Checking temperature
A lack of relevant evidence was found about advising parents/carers to regularly measure their child’s temperature if the condition is stable. Therefore this was included in the Delphi survey.
Delphi statement 1.3
Parents/carers looking after a feverish child at home should be advised that regular measurement of the child’s temperature is not necessary if the child’s condition is stable.
In round 1 of the Delphi survey the rating categories were:
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| 1 to 3 | 4 to 6 | 7 to 9 | Don’t know | Missing | Total | Median |
|---|
| 8 (16%) | 17 (33%) | 24 (47%) | 2 (4%) | 2 | 51 | 7 |
Consensus was therefore not reached in round 1.
In round 2 the rating categories were:
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| 1 to 3 | 4 to 6 | 7 to 9 | Don’t know | Missing | Total | Median |
|---|
| 9 (18%) | 10 (20%) | 32 (63%) | | 1 | 51 | 7 |
As sufficient level of consensus was not achieved, no recommendation could be made about this statement.
There was a lack of evidence to show whether parents/carers looking after a feverish child should check their child during the night. This therefore was included in the Delphi survey.
Delphi statement 1.4
Parents/carers looking after a feverish child at home should be advised to check their child during the night.
In round 1 the rating categories were:
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| 1 to 3 | 4 to 6 | 7 to 9 | Don’t know | Missing | Total | Median |
|---|
| 2 (4%) | 11 (22%) | 35 (70%) | 2 (4%) | 3 | 50 | 8 |
Sufficient consensus was not achieved in round 1.
In round 2 the rating categories were:
Therefore sufficient consensus was achieved. As there is no evidence to show how often the parents/carers should check the child during the night, the healthcare professional assessing the child may want to advise on this.
9.2.5. School attendance
The Department for Education and Skills (DfES) has strict policies that emphasise the importance of good school attendance, and that parents should notify their school on the first day of absence through illness, for health and safety reasons. Nevertheless, although there is a document readily available in schools that shows how long a child should be absent if the child has a known infectious disease, there is no evidence that shows how long a child with a fever of unknown origin should be absent from school or nursery and, this was sent to the Delphi panel.
Delphi statement 1.5
Parents/carers looking after a feverish child at home should be advised to keep their child away from nursery or school while the child’s fever persists but to notify the school or nursery of the illness.
In round 1 the ratings categories were:
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| 1 to 3 | 4 to 6 | 7 to 9 | Don’t know | Missing | Total | Median |
|---|
| 1 (2%) | 5 (10%) | 43 (86%) | 1 (2%) | 3 | 50 | 8.5 |
Consensus was therefore achieved for this statement.
9.2.6. Appearance of non-blanching rash
At the suggestion of a stakeholder, the GDG decided that parents/carers should be told how to identify a non-blanching rash. A non-blanching rash is a feature of meningococcal disease (see Section 4.6.2) and many parents and carers are aware of its significance. Advice centres around the ‘tumbler test’ in which the rash is found to maintain its colour when glass is pressed on to the skin.
GDG translation
The GDG accepted that all Delphi statements that achieved consensus should be used to make recommendations about advice for care at home following an encounter with the health services. For clarity, information about the relevant features to look for was added to the recommendation on dehydration.
Recommendations on care at home
Parents or carers should be advised to manage their child’s temperature as described in Chapter 8.
Parents or carers looking after a feverish child at home should be advised:
to offer the child regular fluids (where a baby or child is breastfed the most appropriate fluid is breast milk)
how to detect signs of dehydration by looking for the following features:
to encourage their child to drink more fluids and consider seeking further advice if they detect signs of dehydration
how to identify a non-blanching rash
to check their child during the night
to keep their child away from nursery or school while the child’s
fever persists but to notify the school or nursery of the illness.
9.3. When to seek further help
In addition to advice about how to care for their febrile child at home, parents and carers also need advice about when they should seek further attention from the health services. This should allow them to take appropriate action if their child deteriorates or does not recover as expected.
Clinical question
In children with fever at home following a clinical encounter, what indications should direct the parents or carers to seek further advice?
A lack of evidence was found about when parents should seek further advice following a contact with a healthcare professional. Therefore the following statements were included in the Delphi survey.
9.3.1. Fits
Delphi statement 3.1a
Following contact with a healthcare professional, parents/carers who are looking after their feverish child at home should seek further advice if the child suffers a fit.
The first round consensus rating categories were:
Consensus was therefore achieved for this statement.
9.3.2. Less well
Delphi statement 3.1b
Following contact with a healthcare professional, parents/carers who are looking after their feverish child at home should seek further advice if the parent/carer feels that child is less well than when they previously sought advice.
The first round ratings categories for this statement were:
Consensus was therefore achieved for this statement.
9.3.3. Increased parental concern
Delphi statement 3.1c
Following contact with a healthcare professional, parents/carers who are looking after their feverish child at home should seek further advice if they are more worried than when they previously sought advice.
The first round consensus rating categories were:
Consensus was therefore achieved for this statement.
9.3.4. Length of fever
Delphi statement 3.1d
Following contact with a healthcare professional, parents/carers who are looking after their feverish child at home should seek further advice if the fever lasts longer than 48 hours.
The first round survey ratings categories were:
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| 1 to 3 | 4 to 6 | 7 to 9 | Don’t know | Missing | Total | Median |
|---|
| 4 (8%) | 14 (27%) | 33 (63%) | 1 (2%) | 1 | 52 | 7 |
As no consensus was achieved, it went to round 2 where the ratings categories were:
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| 1 to 3 | 4 to 6 | 7 to 9 | Don’t know | Missing | Total | Median |
|---|
| 2 (4%) | 9 (17%) | 40 (77%) | 1 (2%) | | 52 | 7 |
Consensus was therefore achieved for this statement.
Delphi statement 3.1e
Following contact with a healthcare professional, parents/carers who are looking after their feverish child at home should seek further advice if the fever lasts longer than 5 days.
The first round ratings categories were:
Consensus was therefore achieved for this statement.
9.3.5. Parental distress and unable to cope
Delphi statement 3.1f
Following contact with a healthcare professional, parents/carers who are looking after their feverish child at home should seek further advice if the parent/carer is very distressed or unable to cope with their child’s illness.
The first round ratings categories were:
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| 1 to 3 | 4 to 6 | 7 to 9 | Don’t know | Missing | Total | Median |
|---|
| 1 (2%) | 5 (9%) | 46 (87%) | 1 (2%) | | 53 | 9 |
Consensus was therefore achieved for this statement.
9.3.6. Non-blanching rash
After suggestions from stakeholders, the GDG also decided that parents and carers should seek further advice if the child develops a non-blanching rash.
GDG translation
The GDG decided to include all but one of the Delphi statements that had achieved consensus as recommendations in the guideline. The exception was the statement about seeking further advice if the fever lasts for more than 48 hours. The GDG unanimously decided not to include this statement because they had found evidence on the predictive value of duration of fever after the statement had been put to the Delphi panel. This evidence, which is detailed in Section 4.5.3.2, suggests that a duration of fever of around 1–2 days is not predictive of serious illness. The GDG considered that it would therefore be contradictory to advise carers to seek medical attention if the fever lasts longer than 48 hours. The statement on seeking advice if the fever lasted longer than 5 days was retained because the GDG considered this situation to be unusual and because a fever of 5 days duration could be a marker of Kawasaki disease or other serious illnesses such as pneumonia or UTI.
Recommendation on when parents or carers should seek further help
Following contact with a healthcare professional, parents and carers who are looking after their feverish child at home should seek further advice if:
the child has a fit
the child develops a non-blanching rash
the parent or carer feels that the child is less well than when they previously sought advice
the parent or carer is more worried than when they previously sought advice
the
fever lasts longer then 5 days
the parent or carer is distressed, or concerned that they are unable to look after their child.
