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Feverish illness in children under five

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An updated NICE guideline offers new advice on how to manage children presenting with fever

Citation: McDougall P (2013) Feverish illness in children under five. Nursing Times; 109: 29, 17.

Author: Penny McDougall is senior sister, children’s assessment unit, Queen Alexandra Hospital, Portsmouth, and a member of the guideline development group.


Fever is one of most common reasons for children to be taken to their GP, and the second most common reason for them to be admitted to hospital. The National Institute for Health and Care Excellence has updated its clinical guideline on assessing and managing children under the age of five who are diagnosed with fever.

The updated guideline provides new tools to enable nurses and other health professionals to identify the signs of serious illness, ensuring these children receive the best care in the most appropriate setting. It will be particularly helpful to nurses working in areas that assess and treat children with feverish illnesses without the support of paediatric specialists.

There are two key revisions from the previous guideline:

  • The addition of tachycardia to the traffic-light table; and
  • A review of the advice on the use of antipyretics.


Identifying serious illness in children presenting with fever is challenging for nurses working in non-paediatric specialist areas such as GP surgeries and nurse-led walk-in centres. Most feverish illnesses are viral-induced and resolved with only minimal intervention. However, a minority of them are caused by serious life-threatening infections, such as meningitis or septicaemia and, as infections remain the leading cause of death in children under five years in the UK, it is crucial for nurses to be able to recognise serious illnesses.

Traffic-light table

The updated guideline provides a revised traffic-light table, which will help health professionals to recognise the high-risk signs and symptoms that indicate a child needs urgent medical treatment. Research shows that early identification and treatment is essential to reduce morbidity and mortality in children with fever.

The improved table now includes tachycardia as a key indicator of serious illness. New evidence shows that there is a correlation between raised heart rate and fever in predicting children’s risk of serious illness.

Safety-net advice

Most children with fever seen in primary care are unlikely to develop a serious illness and are best cared for at home. Children often show one or more signs in the “amber” section of the traffic-light table, which can cause uncertainty. For this reason, NICE recommends that health professionals must give verbal and/or written safety-net advice to the parents or carers if they decide the child is well enough to go home. This should include information on warning symptoms and how and when to access further healthcare if needed.


The use of antipyretics to reduce children’s body temperature has become controversial. While there is undoubtedly a place in reducing the distress caused by raised temperature, antipyretics should not be used solely to reduce fever. There is a growing body of evidence suggesting that reducing the fever might adversely affect the long-term outcomes of the illness.

In the revised guideline, NICE has clarified its earlier recommendations in order to give consistent advice to parents and carers (Box 1). This focuses on the principle that antipyretics should only be give when the child is distressed, and that the height or duration of fever cannot be relied on alone as a sign of serious infection.

Box 1. Parental advice

  • Consider using either paracetamol or ibuprofen in children with fever who appear distressed
  • Do not use antipyretic agents with the sole aim of reducing body temperature in children with fever
  • When using paracetamol or ibuprofen in children with fever:
    • Continue only as long as the child is distressed
    • Consider changing to the other agent if the child’s distress is not alleviated
    • Do not give simultaneously
    • Only consider alternating these agents if the distress persists or reoccurs before the next dose is due
  • Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose


The guideline’s traffic-light table will enable nurses and allied health professionals to improve the identification of children who are genuinely at a high risk of serious illness, and require urgent assessment and treatment to prevent death and serious morbidity. The revised recommendations on the use of antipyretics will enable nurses assessing and managing children with feverish illnesses to give clear, consistent advice to parents, carers and other health professionals.

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