A5V4d

Feverish illness in children
Other considerations
No equalities issue were identified in relation to this question.
Recommendations
The recommendations covering the predictive value of heart rate are presented at the end of section
5.5.
Blood pressure
Evidence summary
Blood pressure was not identified as an independent risk factor for serious illness in any of the
prospective cohort studies and scoring systems. Low blood pressure was identified as one of several
risk factors for adverse outcome in children with meningococcal disease. 119
GDG translation
The GDG agreed with stakeholder comments that blood pressure should be measured in children
with fever who are displaying features of possible serious illness. Blood pressure can be a helpful
measurement to monitor children with possible sepsis although low blood pressure is a late feature of
septic shock. Other markers such as raised heart rate and prolonged capillary refill time are present
earlier and require no special equipment to measure. The GDG concluded that blood pressure should
be measured when facilities exist to monitor blood pressure and other markers of inadequate organ
perfusion (i.e. shock) are detected.
Recommendations
The recommendations covering blood pressure are presented at the end of section 5.5.
Assessment of dehydration
A number of studies have used degree of dehydration as a marker of serious illness. However, the
symptoms and signs used in a number of studies have lacked rigour. The GDG looked for evidence
for objective symptoms and signs for dehydration.
Narrative evidence
A recent EL 2+ SR 117 looking at children 1 month to 5 years was found. Although this SR only
searched MEDLINE, it was judged to be adequate for inclusion. The authors reviewed 1603 papers,
half of which were excluded because of lack of rigour or lack of clarity in outcomes. Of the remainder,
only 26 were found to be rigorous enough to meet their criteria. Moreover, in this SR, dehydration was
measured using percentage volume lost. They found three studies that evaluated the accuracy of a
history of low urine output. A history of low urine output did not increase the likelihood of 5%
dehydration (likelihood ratio [LR] 1.3, 95% CI 0.9 to 1.9). The most sensitive signs not requiring
particular specialised tests for dehydration were dry mucous membranes, poor overall appearance,
and sunken eyes and absent tears (see Table 5.3 for the sensitivities). Prolonged capillary refill time,
cool extremities, reduced skin turgor and abnormal respiratory pattern were the most specific
individual signs of dehydration.
Evidence summary
It is difficult to detect dehydration in children with fever. Individual symptoms and parental
observations are poor predictors of dehydration. Furthermore, history of low urine output does not
increase the risk of dehydration. The results showed that prolonged capillary refill time, reduced skin
turgor and abnormal respiratory pattern are the most specific individual signs of dehydration.
Table 5.65 Summary characteristics for clinical findings to detect 5% dehydration 117
Clinical feature Sensitivity (95% CI) Specificity (95% CI)
Prolonged capillary refill time 0.60 (0.29 to 0.91) 0.85 (0.72 to 0.98)
Abnormal skin turgor 0.58 (0.40 to 0.75) 0.76 (0.59 to 0.93)
Abnormal respiratory pattern 0.43 (0.31 to 0.55) 0.79 (0.72 to 0.86)
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2013 Update