Duration of Fever and Course of Symptoms in Young Febrile Children Presenting with Uncomplicated Illness

Methods

The study was performed at a GP out-of-hours service (OHS) in the southern part of Rotterdam, a large multiethnic city in the Netherlands. This GP OHS covers an area with approximately 300,000 inhabitants.

During midweek evenings and nights between December 13, 2004, and January 16, 2006, consecutive children aged 3 months to 6 years presenting with fever (as reported by the parents) were eligible for inclusion at the moment of presentation to the OHS. Fever had to be the main reason for encounter. Children were excluded if adequate communication in Dutch was impossible; if the child had already been enrolled in the study in the past 2 weeks; if there was no informed consent; or if they had a complicated illness at presentation (Figure 1).

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Figure 1.

Flow chart of children eligible for study analysis. GP, general practitioner.

A complicated illness was defined as a serious infection at presentation or admission to a hospital immediately after presentation. Serious infections included pneumonia, sepsis, meningitis, encephalitis, pyelonephritis, dehydration (caused by gastroenteritis or unknown cause), osteomyelitis, cellulitis, erysipelas, abscess, febrile convulsion, asthma exacerbation with fever, and, in children ≤1 year old, bronchiolitis. Diagnosis of a serious infection was based on the diagnostic codes (registered according to the International Classification of Primary Care) noted by the GP in the OHS records. If a contact was not coded, a team of 3 GPs provided an International Classification of Primary Care code based on the (uncoded) diagnosis made by the GP at the OHS or, if the diagnosis was missing, based on noted symptoms and findings during the history or physical examination. The team was blinded for triage result and the management by the GP at the OHS. Final coding was based on consensus. Children who were immediately referred at initial presentation were defined as having a serious infection if the pediatrician diagnosed the child as such. During follow-up, a complicated illness was defined as a serious infection diagnosed by a GP or a pediatrician or admission to hospital.

When parents phoned the OHS concerning their febrile child, the nurses performed their usual triage based on the triage guidelines of the Dutch College of General Practitioners⁷ and filled out a structured triage questionnaire in which parental concern (among other topics) was noted. According to these guidelines, a child was invited for consultation if the child was younger than 3 months of age, was very ill, was rapidly deteriorating, drank less than half of their normal consumption, had a rash that occurred during fever, was crying inconsolably, had a change in skin color, had a change in breathing pattern, was moaning or had apnea, had relevant comorbidity, had fever for >3 days or that was increasing after a fever-free period. In addition, a child was seen when the parents showed agitation, aggression, or persistent anxiety. A child was triaged as “self-care advice” if none of the above were present.

Based on this triage, the triage nurse gave advice over the telephone and arranged a face-to-face contact at the OHS or a home visit by a GP. GPs were free to prescribe treatments of their choice or to refer the patient.

An additional home visit by a trained research nurse was arranged as soon as possible after the evening or night of inclusion—but within 24 hours of inclusion—for all children included in this study. Using a structured questionnaire, the research nurse recorded demographic data, symptoms and signs at time of presentation, and medication use reported by the parents. In addition, the research nurse performed a structured physical examination, including rectal temperature. Parents received a thermometer and instructions to measure rectal temperature. During 1 week of follow-up, parents recorded in a structured diary rectal temperature twice a day and symptoms and medication use daily, starting at the day of the home visit. Diaries were returned by mail. If the parents did not return the diary, they were contacted by telephone within 1 month after the end of their follow-up and asked whether the child had had fever 1 week after the initial contact. Fever was defined as a temperature of ≥38.0°C.

On the basis of national and international guidelines and before analyses, we defined 5 alarming symptoms.^2,7 Drowsiness was defined as dull or difficult to awaken, no eye contact, or no or little reaction toward the parent. Inconsolable was defined as crying inconsolably, crying when picked up, very or very much irritated, or groaning. Abnormal circulation was defined as pale, ashen, or mottled skin. Dehydration was defined as drinking less than half that of normal or much less or no urine voiding. Shortness of breath was defined as rapid breathing.

Before the analyses we established cut offs for multiple choice questions. “No or little reaction toward the parent” was contrasted with “normal or almost normal reaction toward the parent.” “Very or very much irritated” was contrasted with “not or slightly irritated.” “Drinking less than half that of normal” was contrasted with “drinking half to two-thirds that of normal” or “drinking two-thirds or more that of normal.” “Much less or no urine voiding” was contrasted with “normal or slightly less than normal urine voiding.” All other variables were dichotomous.

Antipyretic use before follow-up was defined as reported use of antipyretics at triage or reported use of antipyretics during this fever episode before presentation to the OHS. Daily antipyretic use during follow-up was defined as use of antipyretics reported in the diaries. Total antipyretic use was defined as antipyretic use before and during follow-up.

The Dutch Central Committee on Research Involving Human Subjects approved this study.