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BookmarkScienceDaily (Sep. 3, 2007) — NHS policy changes may be contributing to problems recognising serious illness in feverish young children, warns a senior doctor in the British Medical Journal.
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Anthony Harnden, a lecturer in general practice at the University of Oxford, believes we should be offering less telephone advice and more opportunities for prompt assessment by an experienced clinician.
The diagnosis and management of children with fever is an important part of primary care, he writes. Although general practitioners have substantial clinical experience of assessing febrile children, half of children with meningococcal disease are sent home at first consultation.
How can this be and what can we do to improve our assessment of febrile children?
He points to several difficulties, including the increasing rarity of serious bacterial infection and the time point in the illness that the child is seen. Changes in NHS policy have also led to the primary care of febrile children presenting outside office hours being delivered by an increasing number of professional groups with different levels of skill and experience.
This is a major concern, he warns, because the most solid evidence of recognising clinical severity in febrile children in primary care is a full assessment by an experienced clinician. This involves eliciting a clear history and careful observation of signs, including alertness, activity, colour, and respiratory effort.
Such concerns led to the recent publication of guidelines by the National Institute for Health and Clinical Excellence (NICE) for the assessment and initial management of young children with feverish illness.
But Dr Harnden believes that these guidelines, along with the "traffic light" system also proposed by NICE, rely too much on measuring vital signs and may result in the inappropriate referral of large numbers of children, while children who develop a serious illness are sent away.
General practitioners must not be persuaded to disregard their intuition, he says.
"We should recognise that we are seeing only a brief snapshot of a dynamic illness and should always empower and make it easy for parents to consult again -- even a few hours later -- if symptoms deteriorate. We should trust our clinical intuition and refer and re-refer if concerned," he concludes.
