Feverish illness in children Recommendations The recommendations covering Section 5.3 are presented at the end of Section 5.5. 5.4 Non-specific symptoms and signs of serious illness 2013 review of symptoms and signs Review question What is the value (as shown by likelihood ratios, sensitivity, specificity, positive predictive value and negative predictive value) of the following symptoms and signs, alone or in combination, as initial indications of serious illness? 54 abnormal skin or mucosal colour (for example pallor or cyanosis) appearing ill to a healthcare professional or parent/carer altered responsiveness or cry altered breathing (for example nasal flaring, grunting, chest indrawing) abnormal respiratory rate, pulmonary (lung) crackles and other sounds oxygen desaturation dehydration prolonged capillary refill time, cold hands and feet poor feeding persistent fever (5 days or more) height of fever limb or joint swelling unwillingness to bear weight or use a limb bulging fontanelle rash (blanching or non-blanching) focal neurological signs focal seizures new lumps neck stiffness vomiting status epilepticus (prolonged or continuous fits). If evidence is found on additional signs and symptoms they will be added to the above list. Overview of updated review A literature search was undertaken with no restrictions on date. The bibliographies of existing systematic reviews, including a Health Technology Assessment (HTA) report, were searched for relevant studies (Thompson et al, 2012). A total of 7,977 records were identified. In addition, studies included in the 2007 guideline were reviewed for inclusion in the updated review. Description of included studies Fifty-nine studies were identified that were relevant to the 2013 review of symptoms and/or signs, of which 42 were prospective studies (Akpede et al., 1992; Andreola et al., 2007; Baker et al., 1989; Baskin et al., 1992; Berger et al., 1996; Bleeker et al., 2007; Brent et al., 2011; Craig et al., 2010; 2013 Update
Clinical assessment of the child with fever Crain et al., 1982; Crocker et al., 1985; Factor et al., 2001; Galetto-Lacour et al., 2003; Ghotbi et al., 2009; Haddon et al., 1999; Hewson et al., 2000; Hsiao et al., 2006; Lacour et al., 2001; Morris et al., 2007; McCarthy et al., 1985; Nademi et al., 2001; Newman et al., 2002; Nielsen et al., 2001; Nijman et al., 2001; Owusu-Ofori et al., 2004; Pantell et al., 2004; Pratt et al., 2007; Rabasa Al et al., 2009; Rudinsky et al., 2009; Salleeh et al., 2010; Shaw et al., 1998; Shettigar et al., 2011; Shin et al., 2009; Singhi et al., 1992; Tal et al., 1997; Taylor et al., 1995; Thompson et al., 2009; Trautner et al., 2006; Weber et al., 2003; Wells et al., 2001; Yeboah-Antwi et al., 2008; YICSSG, 2008; Zorc et al., 2005) 17 were retrospective (Alpert et al., 1990; Batra et al., 2011; Bleeker et al., 2001; Bonadio et al., 1994; Chen et al., 2009; Fouzas et al., 2010; Gomez et al., 2010; Gomez et al., 2012; Joffe et al., 1983; Nguyen et al., 2002; Offringa et al., 1992; Olaciregui et al., 2009; Schwartz et al., 2009; Stanley et al., 2005; Stathakis et al., 2007; Teach et al., 1997; Zarkesh et al., 2011) and two studies used data that was collected both prospectively and retrospectively (Mandl et al., 1997;Maniaci et al., 2008). The smallest study included 92 children (Offringa et al., 2002) and the largest study included 12,807 children (Craig et al., 2010). Studies reported on children of a variety of age ranges, and some studies included children older than 5 years. The settings of the studies varied, including GP surgeries, emergency departments and paediatric wards of general hospitals, emergency departments of paediatric hospitals, tertiary care paediatric units and tertiary care medical centres. The definition of fever used for inclusion ranged from higher than 37.2°C to higher than 41.1°C. Some of the studies looked at specific illnesses, including bacterial meningitis, bacteraemia, urinary tract infection, pneumonia, meningococcal disease and salmonella enteritis. Some studies looked at a group of diagnoses, for example ‘serious illness’ or ‘serious bacterial infection’. Twenty-one of the studies were undertaken in the USA (Alpert et al., 1990; Baker et al., 1989; Baskin et al., 1992; Bonadio et al., 1994; Crain et al., 1982; Crocker et al., 1985; Hsiao et al., 2006; Joffe et al., 1983; Mandl et al., 1997; Maniaci et al., 2008; McCarthy et al., 1985; Newman et al., 2002; Nguyen et al., 1984; Pantell et al., 2004; Pratt et al., 2007; Rudinsky et al., 2009; Shaw et al., 1998; Stanley et al., 2005; Teach et al., 1997; Trautner et al., 2006; Zorc et al., 2005), five in Australia (Craig et al., 2010; Haddon et al., 1999; Hewson et al., 2000; Stathakis et al, 2007; Taylor et al., 1995), five in the Netherlands (Berger et al., 1996; Bleeker et al., 2001; Bleeker et al., 2007; Nijman et al., 2011; Offringa et al., 1992), four in the UK (Brent et al., 2011; Nademi et al., 2001; Thompson et al., 2009; Wells et al., 2001), three in India (Batra et al., 2011; Shettigar et al., 2011; Singhi et al., 1992), three in Spain (Gomez et al., 2010; Gomez et al., 2012; Olaciregui et al., 2009), two each in Switzerland (Galetto-Lacour et al., 2003; Lacour et al., 2001), Ghana (Owusu-Ofori et al., 2004; Yeboah-Antwi et al., 2008), Nigeria (Akpede et al., 1992; Rabasa Al et al., 2009), Israel (Schwartz et al., 2009; Tal et al., 1997), and Iran (Ghotbi et al., 2009; Zarkesh et al., 2011), and one each in Bangladesh (Factor et al., 2001), Canada (Salleeh et al., 2010), Denmark (Nielsen et al., 2001), Greece (Fouzas et al., 2010), Italy (Andreola et al., 2007), Papua New Guinea (Morris et al., 2007), South Korea (Shin et al., 2009) and Taiwan (Chen et al., 2009). One study was conducted in Bangladesh, Bolivia, Ghana, India, Pakistan and South Africa (YICSSG, 2008) and another in Ethiopia, the Gambia, Papua New Guinea and the Philippines (Weber et al., 2003). Twelve studies were found that reported evidence on the Yale Observational Scale (Andreola et al., 2007; Baker et al., 1990; Bang et al., 2009; Galetto-Lacour et al., 2003; Haddon et al., 1999; Hsiao et al., 2006; McCarthy et al., 1980; McCarthy et al., 1981; McCarthy et al., 1982; Teach et al., 1995; Thayyil et al., 2005; Zorc et al., 1995). More details on each individual study can be found in the evidence tables. The GDG is aware of an HTA relevant to this review (Thompson et al., 2012). However, the review was completed before the HTA was published. All relevant studies cited in the HTA were included in this review. Evidence profiles The GRADE profiles in the tables that follow show results of included studies for various aspects of the review question. Table 5.3 – evaluation of colour Table 5.4 – evaluation of social cues 55 2013 Update
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