A5V4d

Feverish illness in children
42 Children with ‘green’ features and none of the ‘amber’ or ‘red’ features can be cared
for at home with appropriate advice for parents and carers, including advice on
when to seek further attention from the healthcare services (see chapter 10). [2007,
amended 2013]
Number Research recommendation
RR 4 The GDG recommends that research is carried out on referral patterns between
primary and secondary care for children with fever, so the health economic impact
of this and future guidelines can be estimated. [2007]
7.3 Tests by the non-paediatric practitioner
In children with fever who are not referred to hospital, the use of investigations is determined by both
pragmatic factors and clinical value. The delay in obtaining results of blood tests may preclude their
use in non-specialist care.
Review question
In children presenting to primary care with fever and no obvious focus of infection, what is the
predictive value of the following investigations in identifying children with a serious illness?
148
urinalysis
chest X-ray
pulse oximetry
capillary glucose.
The use of pulse oximetry and capillary glucose in the evaluation of children with fever was discussed
but no evidence was found for or against their use. The GDG was unable to make a recommendation
about these two investigations. Evidence was available regarding the use of chest X-rays and urine
testing.
Chest X-rays
The GDG considered the question whether clinical acumen plus chest X-ray is better than clinical
acumen alone in diagnosing chest infection in children aged 2 months to 59 months.
Narrative evidence
One EL 1+ systematic review (SR) 152 including one randomised controlled trial (RCT) 153 investigating
the effects of chest radiography for children with acute lower respiratory infections was identified.
They found that the odds of recovery by 7 days were 1.03 (95% confidence interval [CI] 0.64 to 1.64).
The odds ratio (OR) for remaining ill at both 4 and 14 days were 0.74 (95% CI 0.45 to 1.23) and 0.82
(95% CI 0.45 to 1.48) for the study and control group, respectively. Thirty-three percent of
radiography participants and 32% of control participants made a subsequent hospital visit within
4 weeks (OR 1.02, 95% CI 0.71 to 1.48); 3% of both radiography and control participants were
subsequently admitted to hospital within 4 weeks (OR 1.02, 95% CI 0.40 to 2.60).
Evidence summary
There was one systematic review of chest radiographs in children who met the criteria for clinical
pneumonia, which included only one randomised controlled trial. This study of 522 children aged
2 months to 5 years demonstrated that children with clinical features of pneumonia based on the
World Health Organization (WHO) criteria were less likely to be prescribed antibiotics, more likely to
be diagnosed with bronchiolitis and had exactly the same rates of recovery, repeat attendance rates
and subsequent admission rates when compared with those children who underwent a chest X-ray.