A5V4d

Recommendations
Number Recommendation
Observation in hospital
Management by the paediatric specialist
60 In children aged 3 months or older with fever without apparent source, a period of
observation in hospital (with or without investigations) should be considered as part
of the assessment to help differentiate non-serious from serious illness. [2007]
Response to antipyretic medication
It has been suggested that response to antipyretic medication may help differentiate serious from
non-serious illness in febrile children. This could occur in two ways:
a difference in the response to antipyretics being reflective of the seriousness of the
underlying condition
improved clinical appearance.
Decrease in fever after antipyretics
Some healthcare professionals think that a decrease in fever with antipyretic therapy indicates a lower
likelihood of serious bacterial infection (SBI), and that a lack of response makes an SBI more likely. In
contrast to this, other healthcare professionals fear that giving antipyretics to reduce fever in febrile
children may make the detection of serious illness more difficult as the high fever and other symptoms
of SBI is ‘masked’ by antipyretics. Evidence about fever response to antipyretics in children with both
serious and non-serious illness would be useful to help in the assessment of these children.
Improved clinical appearance after antipyretics
Antipyretics may also improve the child’s general condition. Many healthcare professionals feel that
clinical review of a febrile child 1–2 hours after they have been given antipyretics improves the ability
to differentiate between serious and non-serious illness. The antipyretic and analgesic effect of
antipyretics may lead to the improvement of features which may suggest serious illness (e.g.
irritability, tachycardia, etc.). If this improvement in features occurred only in those with non-serious
illness, this would help to identify these children. However, if this improvement also occurred in
children with serious illness, then these children may not have their illness identified correctly.
Evidence about improved clinical appearance after antipyretics would be useful to help in the
assessment of children and would also be relevant to the use of observation in febrile children.
Updated review for 2013
Review question
The clinical question outlined in the scope asks for ’The predictive value of the clinical response to
paracetamol or NSAIDs’ (non-steroidal anti-inflammatory drugs). This translated to a review question
of: “What is the predictive value of the clinical response to paracetamol or NSAIDs?”
Description of included studies
Eight studies were identified (Torrey et al, 1984; Baker et al, 1989; Yamamoto et al, 1987; Mazur,
1989 et al; Weisse et al, 1987; Baker et al, 1987; Mazur et al, 1994; Bonadio et al, 1993), including
four used in the 2007 guideline.
Five of the studies were prospective (Torrey et al., 1984; Baker et al., 1989; Yamamoto et al., 1987;
Weisse et al., 1987; Baker et al., 1987) and three were retrospective (Mazur et al., 1989; Mazur et al.,
1994; Bonadio et al., 1993). Two used the same dataset (Mazur et al., 1989; Mazur et al., 1994). All
of the studies were undertaken in hospital settings in the USA, and the most recent was undertaken in
1994. All studies focused on differentiating bacterial illness from other illnesses. All studies reported
on change in temperature, four reported on change in febrile state and one reported on change in
symptomology. Studies used different definitions of fever, disease and timing of follow-up. The
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2013 Update