Guidelines endorsed by RCPCH - Respiratory medicine

The College reviews high quality guidelines and standards produced and published by other organisations against the RCPCH Standards for Endorsement. We believe the following publications will be of interest to paediatricians working in this respiratory medicine.

The following have been endorsed by the College.

Endorsed guidelines

Allergy Care Pathways (RCPCH)

The RCPCH has developed care pathways for children with allergic conditions following the Department of Health publication on the "Review of allergy services" (2006).  These can be dowloaded below.

  • Anaphylaxis
  • Food allergy
  • Asthma/Rhinitis
  • Eczema
  • Urticaria/Mastocytosis/Angio-oedema
  • Drug allergy
  • Venom allergy
  • Latex allergy

Further information including leaflets and videos for families can be found at

Anaphylaxis (NICE)

This guideline concerns assessment with a view to confirming an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode. The patient groups covered by the guideline are adults, young people and children who receive emergency treatment for suspected anaphylaxis.

RCPCH notes:

The College asks members to note that:

The scope of the guideline covers confirmation of an anaphylactic reaction in an emergency setting and subsequent referral. As such the scope is quite narrow and excludes longer-term management of children who have experienced an anaphylactic episode (e.g. management through diet). Management of associated co-morbidities with anaphylaxis, such as asthma are also not included in the scope of the guideline. NICE however do refer readers to their related Food Allergy in Children and Young People guideline for information on allergy diagnosis and assessment. 

Date of Publication: December 2011
Date of Endorsement: March 2012

NICE guideline (PDF, 164KB, 25 Pages)

Antimicrobial stewardship (NICE)

This quality standard covers the effective use of antimicrobials (antibacterial, antiviral, antifungal and antiparasitic medicines) to reduce the emergence of antimicrobial resistance (loss of effectiveness of antimicrobials).

It covers all settings, all formulations of antimicrobials (oral, parenteral and topical agents) and is for health and social care practitioners, organisations that commission, provide or support the provision of care, as well as people using antimicrobials and their carers.

RCPCH notes:

The College endorses the quality standards and notes that the document would have benefitted from specifying the route of administration and by adding a reminder that sometimes more than one microbiological sample (or none) might be need to be collected. The option of offering back-up (delayed) prescribing in Primary care would have been preferred to be suggested as a last resort and only in situations where the doctor has a clear opinion as to a likely bacterial cause of an illness that may not be self-limiting.

Date of Publication: April 2016 
Endorsed on: August 2016

Full Quality Standard (PDF, 177KB, 39 Pages)

Bronchiolitis in children (NICE QS)

This quality standard covers the assessment, diagnosis and management of bronchiolitis in children.

Bronchiolitis is a condition that affects the lower respiratory tract. It is caused by infection with one of several different viruses. At the start of the infection, symptoms are usually those of a common cold, including a blocked or stuffy nose, cough and sneezing. After several days, breathing and feeding difficulties develop. Until this point, it is not possible to tell that the infection will cause bronchiolitis. If there are wheeze and/or crackles heard on clinical examination, a diagnosis of bronchiolitis can be made.

The quality standard is expected to contribute to improvements in the following outcomes:

  • antibiotic use
  • parent and carer experience of primary and secondary care
  • hospital admissions.

RCPCH notes:

This quality standard is welcomed, however it does not provide a distinction between babies who need readmission and those who need reassurance. As noted in the standard, further guidance is needed on admission avoidance and early supported discharge of children with bronchiolitis.

Date of Publication: June 2016
Endorsed on: August 2016

Full Quality Standard (PDF, 133KB, 26 Pages) 

Bronchiolitis in children (NICE CG)

Bronchiolitis is the most common disease of the lower respiratory tract during the first year of life. It usually presents with cough with increased work of breathing, and it often affects a child's ability to feed. In primary care, the condition may often be confused with a common cold, though the presence of lower respiratory tract signs (wheeze and/or crackles on auscultation) in an infant in mid‑winter would be consistent with this clinical diagnosis. The symptoms are usually mild and may only last for a few days, but in some cases the disease can cause severe illness.

The guideline covers children with bronchiolitis but not those with other respiratory conditions, such as recurrent viral induced wheeze or asthma.
Date of Publication: May 2015
Endorsed on: June 2015
Full clinical guideline (PDF, 148KB, 29 Pages)

Children Presenting with Acute Breathing Difficulties (PAERG)

The guideline aims to provide clinicians with recommendations for the management of children presenting with acute breathing difficulties based on the available evidence. It also aims to promote consistency of care of patients with similar clinical problems and to guide the decision-making process of junior doctors seeing the majority of patients in the first instance.

RCPCH notes: 

This guideline is due for review by the Paediatric Accident and Emergency Research Group.

Date of Publication: January 2002
Date of Endorsement: December 2002

Full guideline (PDF, 942KB, 112 Pages)

Diabetes in children and young people (NICE)

Diabetes is a long-term condition that can have a major impact on the life of a child or young person, as well as their family or carers. In addition to insulin therapy, diabetes management should include education, support and access to psychological services. Preparations should also be made for the transition from paediatric to adult services, which have a different model of care and evidence base.

This quality standard covers the diagnosis and management of type 1 and type 2 diabetes in children and young people aged under 18. It is expected to contribute to improvements in the following outcomes:

  • prompt diagnosis of type 1 diabetes
  • glycaemic control: blood glucose and HbA1c levels
  • diabetes complications
  • quality of life
  • patient, parent and carer satisfaction
  • life expectancy

Date of Publication: July 2016
Endorsed on: August 2016

Full Quality Standard (PDF, 194KB, 40 Pages) 

Drug allergy - diagnosis and management (NICE)

This quality standard covers the diagnosis and management of drug allergy in adults, young people and children.
Diagnosing drug allergy can be challenging and there is considerable variation in management and in access to specialist drug allergy services. This can lead to under diagnosis, misdiagnosis and self-diagnosis. This variation may be caused by a lack of local drug allergy centres or awareness of available services. Some people are never offered a referral to specialist services and stay in primary care. Others have their drug allergy managed in other disciplines. Only a small proportion of people are treated in specialist allergy centres.
The quality standard is expected to contribute to improvements in the following outcomes:
  • patient experience of care
  • patient safety incidents reported
  • mortality from causes considered preventable
  • patient exposure to unnecessary broad-spectrum antibiotics
  • antibiotic prescribing and antimicrobial resistance rates.
Date of Publication: July 2015
Endorsed on: September 2015
Full Quality Standard (PDF, 206KB, 40 Pages)

Feverish illness in children (NICE)

This quality standard the assessment and initial management of unexplained feverish illness in infants and children (from birth to 5 years).
Feverish illness is very common in young children (under 5), with between 20 and 40% of parents reporting such an illness each year. Fever is the most likely reason for a child to be taken to the doctor and the second most common reason for a child being admitted to hospital.
The quality standard is expected to contribute to improvements in the following outcomes:
  • Mortality in infants and children under 5 years
  • Morbidity in infants and children under 5 years
  • Number of emergency admissions to hospital of infants and children under 5 years
  • Parent and carer experience of services.
Date of Publication: July 2014
Endorsed on: February 2015
Full quality standard (PDF, 196KB, 32 Pages)

Gastro-oesophageal reflux disease (GORD) in children and young people (NICE QS)

GOR is a normal physiological process that usually happens after eating in healthy infants, children, young people and adults. In contrast, GORD starts when symptoms of reflux become severe and need medical treatment. 
GOR and GORD affect many children and families in the UK, who commonly seek medical advice. In clinical practice, it may be difficult to differentiate between GOR and GORD. There is no reliable and accurate diagnostic test to confirm whether the condition is GOR or GORD, and this affects research and clinical decisions. The term GORD covers a number of specific conditions that have different effects and present in different ways - this makes it difficult to identify GORD and to estimate its real prevalence.
This quality standard covers managing symptoms of gastro-oesophageal reflux (GOR) and recognising, diagnosing and managing gastro-oesophageal reflux disease (GORD) in children and young people under 18. It contributes to improvements in the following outcomes:
  • Change in symptoms and signs
  • Investigative findings, including healing of erosive oesophagitis
  • Adverse events of interventions (diagnostic or treatment)
  • Unnecessary prescribing
Date of Publication: January 2016
Endorsed on: Febraury 2016
Full quality standard (PDF, 165KB, 34 Pages) 

Gastro-oesophageal reflux disease (GORD) in children and young people (NICE CG)

Gastro‑oesophageal reflux (GOR) is a normal physiological process that usually happens after eating. In contrast, gastro‑oesophageal reflux disease (GORD) occurs when the effect of GOR leads to symptoms severe enough to merit medical treatment. GOR is more common in infants than in older children and young people, and it is noticeable by the effortless regurgitation of feeds in young babies.
This clinical guideline focuses on signs and symptoms and interventions for GORD. Where appropriate, clear recommendations are given as to when and how reassurance should be offered. The clinical guideline also advises healthcare professionals about when to think about investigations, and what treatments to offer.
Date of Publication: January 2015
Endorsed on: February 2015
NICE clinical guideline (PDF, 165KB, 34 Pages)
Full clinical guideline (PDF, 3,089KB, 218 Pages)

Guidelines for the Performance of the Sweat Test for the Investigation of Cystic Fibrosis in the UK (ACB)

This evidence based guideline was produced by the Association for Clinical Biochemistry & Laboratory Medicine (ACB). They are aimed at the following staff involved in the pathway for the diagnosis of cystic fibrosis by sweat test: laboratory staff, scientists and chemical pathologists, clinicians requesting the test and overseeing patient care, nursing staff involved in patient care.
The guideline applies to subjects of all ages from neonates, through infancy, childhood and adulthood; however, is primarily geared toward the paediatric population, where the majority of testing is undertaken.
It is intended that the recommendations contained in this updated guideline will be adopted for local use in the UK, wherever sweat testing for the investigation of cystic fibrosis is performed. 
This guideline outlines how to perform the sweat test for the investigation of cystic fibrosis in the UK. It outlines the evidence available and what the recommendations are (e.g. what patient information needs to be provided, which patients are suitable to a have sweat test, and how should sweat be collected and analysed).
This is an update of the 2003 Performance of the Sweat Test for the Investigation of Cystic Fibrosis.
Date of Publication: March 2014
Date of Endorsement: March 2014

Full guideline (PDF, 697KB, 121 Pages)

Management of Sore Throat and Indications for Tonsillectomy (2010 Update) (SIGN)

The guideline covers the diagnosis of acute of recurrent sore throat, as well as pain management, antibiotic use, indications for surgical management and postoperative care in children and adults.

The guideline is accompanied by a quick reference guide, patient information leaflets and a CPD training manual.

Date of Publication: April 2010
Date of Endorsement: July 2010

Full guideline (PDF, 699KB, 44 Pages)
Quick Reference Guide (PDF, 207KB, 2 Pages)

Neonatal Respiratory Distress Syndrome (BAPM)

The guideline contains both evidence-based recommendations on the obstetric and neonatal prevention and the neonatal management of respiratory distress syndrome in pre-term infants, the guidance on neonatal management being described in considerable detail.

The guideline includes implementation advice.

RCPCH notes: .

This guideline has been replaced by Early Care guidance, also produced by the British Association of Perinatal Medicine.

Date of Publication: November 1998
Date of Endorsement: November 1998

Full guideline (PDF, 175KB, 29 Pages)

Organ donation for transplantation (NICE)

This guideline recognises the complexities that arise owing to the majority of potential adult and paediatric organ donors lacking the capacity to be directly involved in decision making at the time of their death. It covers strategies for improving donor identification and consent rates for deceased organ donation.

RCPCH notes:

The College asks members to note that:

  • There are few data on the validity of trigger tools in paediatric practice. NICE’s response to this comment is as follows: ‘The GDG made their decisions using the best available evidence, and where this was not available or lacking, the GDG based their recommendations on their clinical experience.’ It should be noted that NICE has deemed the best evidence from studies investigating conversion of patients displaying clinical triggers into organ donors is of very low quality.
  • Explicit reference to contraindications to donation from a paediatric perspective is not covered by the guideline.  This is because the GDG agreed that contraindications should not be included due to the rapid pace at which changes to contraindications occur particularly in paediatric patients.

Date of Publication: December 2011
Date of Endorsement: February 2012

NICE guideline (PDF, 168KB, 26 pages)
Appendices (PDF, 1.7MB, 202 pages)

Paediatrics allergy action care plans (BSAC)

The plans have been designed to facilitate first aid treatment of anaphlyaxis, to be delivered by people without any special mediacl training or equipment apart from access to an adrenaline auto injector (AAI). They may also be used to provide a framework for management of anapyylactic reactions to health professionals who are less familiar with this aspect of clinical care.

Date of Publication: September 2013
Date of Endorsement: October 2013

Personal plan for individuals prescribed EpiPen (PDF, 324KB, 1 Page)
A generic plans for individuals assessed as not needing AAI (PDF, 188KB, 1 Page)
Personal plans for individuals prescribed Jext

Pleural Infection in Children (BTS)

The guideline covers the diagnosis, investigation and management of pleural infection (parapneumonic effusion and empyema) in children. This includes diagnostic imaging, microbiology and analysis of pleural fluid, and medical and surgical management options including intrapleural fibrinolytics.

Date of Publication: June 2004
Date of Endorsement: February 2005

Full guideline (PDF, 406KB, 21 Pages)

Respiratory Tract Infections (NICE)

This guideline covers the treatment of adults and children, 3 months or older, with respiratory tract infections (RTIs) for which immediate antibiotic prescribing is not indicated.

The guideline is accompanied by a quick reference guide, information for patients, slides highlighting the key messages and audit tools and includes care pathways, audit criteria and key priorities for implementation.

Date of Publication: July 2008
Date of Endorsement: January 2009

Full guideline (PDF, 628KB, 121 Pages)
Quick reference guide (PDF, 150KB, 2 Pages)
Key Messages (PDF, 28.1KB, 20 Pages) 

Standards for Services for Children with Disorders of Sleep Physiology (RCPCH)

This guideline covers the diagnosis and management of disorders of sleep physiology and respiratory control in children and the organisation of such services nationally. It is particularly relevant to parents, primary and secondary care physicians, surgeons and health service managers.

The guideline is accompanied by an executive summary and lay summaries and includes a proforma for peer review of sleep services, discussion of services and resource implications and key points for audit.

Date of Publication: September 2009
Date of Endorsement: June 2008

Full guideline (PDF, 1.15MB, 144 Pages)
Executive summary (PDF, 398KB, 40 Pages)
Lay summary 1- Sleep Services and Sleep Studies (PDF, 34KB, 3 Pages)
Lay summary 2- Obstructive Sleep Apnoea (PDF, 37KB, 3 Pages)
Lay summary 3- Obstructive Sleep Apnoea in Downs Syndrome (PDF, 21KB, 2 Pages)
Lay summary 4- Sleep Related Breathing Disorders in Children with Neuromuscular Disease (PDF, 21KB, 2 Pages)
Lay summary 5- Obstructive Sleep Apnoea in Children with Craniofacial Abnormalities (PDF 35 KB)
Lay summary 6- Sleep Related Breathing Disorders in Children with Prader-Willi Syndrome (PDF, 21KB, 2 Pages)
Lay summary 7- Congenital Central Hypoventilation Syndrome (PDF, 20KB, 2 Pages)
Lay summary 8- Narcolepsy (PDF, 20KB, 2 Pages)

The management of children and young people with an acute decrease in conscious level (RCPCH)

This guideline aims to give clinicians working acutely a framework to aid the timely and safe care of children and young people (aged four weeks to 18 years) presenting with a decreased conscious level of unknown cause.
The first guideline for 'The Management of Decreased Conscious Level' was published in 2005. Since, there have been changes in the demographics of the children and young people presenting to emergency settings with a decreased conscious level. 
Consistent with the previous guideline, this version emphasises the importance of managing this condition in a standard manner from first presentation to health services, to ensure the best outcome for patients and their families.
The continuing support of the National Reye's Syndrome Foundation UK (NRSF-UK) has allowed the work required to update the guideline.
Date of Publication: April 2015
Date of Endorsement: February 2015

Transition from children’s to adults' services for young people using health or social care services (NICE)

Transition occurs during the period when young people and their families are thinking about their hopes for the future. If people are likely to have care and support needs when they are 18, they need information and advice so that they can make the necessary plans. Despite this, there is evidence that the transition process is variable, with previous good practice guidance not always being implemented.
This clinical guideline focuses on young people passing through transition to adult services with health and/or social care needs. 
It covers the period before, during and after a young person moves from children's to adults' services, and aims to help young people and their carers have a better experience of transition by improving the way it’s planned and carried out.
Date of Publication: February 2016
Endorsed on: March 2016
Full Clinical Guideline (PDF, 1,710KB, 218 Pages)
NICE Clinical Guideline (PDF, 173KB, 31 Pages) 

Tuberculosis: Prevention, diagnosis, management and service organisation (NICE)

TB is a curable disease caused by a bacterium called Mycobacterium tuberculosis (‘M. tuberculosis’ or ‘M.Tb’), or other bacterium in the M. tuberculosis complex (that is, M. bovis or M. africanum). It is spread by one person inhaling the bacterium in droplets coughed out by someone with infectious tuberculosis. Not all forms of tuberculosis are infectious. 
Those with TB in organs other than the lungs are not infectious to others, nor are people with just latent tuberculosis. Some people with pulmonary tuberculosis are infectious, particularly those with bacteria which can be seen on simple microscope examination of the sputum, who are termed ‘smear positive’. The risk is greatest in those with prolonged, close household exposure to a person with infectious TB.
This guideline makes recommendations on the prevention, diagnosis and management of latent and active tuberculosis (TB), including both drug susceptible and drug resistant forms of the disease. It covers the organisation of relevant TB services. It relates to activities undertaken in any setting in which NHS or public health services for TB are received, provided or commissioned in the public, private and voluntary sectors.
Date of Publication: January 2016
Endorsed on: March 2016
Full Clinical Guideline (PDF, 4,849KB, 551 Pages) 
NICE Clinical Guideline (PDF, 575, 177 Pages)

Use of Home Oxygen in Children (BTS)

The guideline covers the practice of administering supplemental oxygen to children outside hospitals and makes recommendations for best practice. It is based on available evidence published up to March 2008 and informal consensus.

The guideline is accompanied by an algorithm and quick reference guide, and includes key priorities for audit.

The RCPCH welcomes the publication of this guideline but asks Members to note the following:

  • The guideline is particularly useful given that existing guidelines focus on adult home oxygen users, who unlike paediatric users are often housebound.
  • The recommendations are not likely to represent a significant change from existing practice. However, implementation of the guideline may have resulting cost implications should children who meet the criteria for home oxygen be discharged from children's wards and neonatal units at an earlier time.
  • The following correction to the guidelines have been made:- Page ii4 - The recommendation in the summary of recommendations (section 6, bullet point 5) should read: Continuously delivered liquid flow oxygen at flows <0.25 l/min is only available from one oxygen supply company which limits its application in children
    - Page ii18 - The recommendation for section 6.2.3 should read (bullet point 1): Continuously delivered liquid oxygen at flows <0.25 l/min is only available from one oxygen supply company which limits its application in children
    - Page ii18 - The recommendation for section 6.2.3 (bullet point 5): However, there are a number of disadvantages for the use of liquid oxygen especially with a paediatric population: Currently low flow rates (<0.25 l/min) for continuously delivered liquid is only available from one oxygen supply company in the UK (Air Liquide), which limits its use in children in the UK.
    - The sentence at bullet point 6 should be deleted.

Date of Publication: July 2009
Date of Endorsement: April 2009

Full guideline (PDF, 863KB, 29 Pages)
Quick Reference Guide (PDF, 110KB, 8 Pages)