• Communicable Diseases
• Emergency Care
• Sepsis
• Paediatric Emergency Medicine

Apart from a global reduction in attendances during the COVID-19 pandemic,1 emergency departments continue to see growth in the presentations of children and young people (CYP).2 However, there has not been a similar increase in admissions leading to the so-called ‘needle in the haystack’ phenomenon which describes the difficulty clinicians face in selecting CYP for investigation or intervention when the incidence of modifiable disease is so low.

CYP who present overtly unwell are always going to receive resuscitation regardless of the underlying cause of illness as restoration of adequate oxygenation, replenishment of circulating volume or support of cerebral function is a priority. These numbers, however, are small, likely no more than 1–2% of total attendances. A larger group of patients (perhaps 40% but with large regional and national variation) have a clinical appearance to healthcare professionals suggesting investigations are not necessary as they are deemed so low risk of serious illness or injury.

To treat all of those who are neither overtly unwell nor obviously well would arguably be a misuse of resources and perhaps lead departments being incapable of responding to the most critically unwell patients. The National Institute of Health and Care Excellence (NICE) Fever in illness in children guideline (NG 143) was designed to help clinicians in England decide on management options for those with a fever without a clear source. Both the face, and actual, validity of the tool has led to its widespread deployment. It is often (technically incorrectly) used as a marker …