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• Not so NICE guidelines
  Anthony Cohn
  Published on: 10 December 2018

• Published on: 10 December 2018

  Not so NICE guidelines

  • Anthony Cohn, Consultant Paediatrician Watford General Hospital

  Carter et al1 present interesting results which are anecdotally replicated by our local experience and is likely to be played out on a daily basis throughout the country. They conclude that there is a benefit of having senior doctors on the front line at all times when following the NICE guidelines as the majority of febrile children can be safely managed expectantly rather than with tests and treatments with a significant cost and convenience benefit. Whilst no one would doubt the benefit of having experienced doctors on the front line as much as possible- this is often not always practical given the current workforce situation.

  A different interpretation would be that this study shows that if the NICE guidelines were followed without senior involvement over 75% of children with fever would be subject to unnecessary investigations and treatment with the attendant risks – physical, experiential and financial to both patients and system. This study shows that widespread deviation from the basic guideline is safe and prudent.

  Recognising a sick child is hard whereas recognising a child who is going to become sick is almost impossible as illustrated by the numerous attempts to provide a scoring system or table that might do this. Illness is a process and each child will present at different stages. Paediatricians may be divided into those who have never sent home a child that has returned moribund or worse a few days later and those who have not done so yet....

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  Carter et al1 present interesting results which are anecdotally replicated by our local experience and is likely to be played out on a daily basis throughout the country. They conclude that there is a benefit of having senior doctors on the front line at all times when following the NICE guidelines as the majority of febrile children can be safely managed expectantly rather than with tests and treatments with a significant cost and convenience benefit. Whilst no one would doubt the benefit of having experienced doctors on the front line as much as possible- this is often not always practical given the current workforce situation.

  A different interpretation would be that this study shows that if the NICE guidelines were followed without senior involvement over 75% of children with fever would be subject to unnecessary investigations and treatment with the attendant risks – physical, experiential and financial to both patients and system. This study shows that widespread deviation from the basic guideline is safe and prudent.

  Recognising a sick child is hard whereas recognising a child who is going to become sick is almost impossible as illustrated by the numerous attempts to provide a scoring system or table that might do this. Illness is a process and each child will present at different stages. Paediatricians may be divided into those who have never sent home a child that has returned moribund or worse a few days later and those who have not done so yet.

  Expecting the NICE, or other guidelines to provide the holy grail of predicting every child that will become sick is a holy grail that does disservice to patients and clinicians alike. Furthermore given that every complaint and medicolegal case asks for reference to established guidelines, all practice is invariably judged against these guidelines and any variation may be presented as poor practice.

  If the NICE guidelines were measured as other screening tools, their poor sensitivity would lead to an early jettisoning. Maybe we should recognise that we just don't have the right tools as yet, as a minimum some clear statement as to their effectiveness should be published by NICE.

  Whilst no one would contend the benefits of a senior medical presence at all times this should be justified to provide good care rather than mitigate against the overtreatment that would be driven by the NICE guidelines in the absence of these senior doctors, recognising a sick child is hard – how good are we at recognising a sick guideline.

  1. Carter MJ, Stilwell PA, Nijman RG, et al. Identification and treatment of paediatric sepsis: getting the balance right
  Archives of Disease in Childhood Published Online First: 25 May 2018. doi: 10.1136/archdischild-2018-314865 Letters 20 November, 2018​

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  Conflict of Interest:
  None declared.

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