A5V4d

Feverish illness in children
the YOS score. The negative predictive value ranged from moderate to high and was also not
correlated with the YOS score. The positive and negative likelihood ratios ranged from not strong to
convincing.
Health economic evidence statements
No health economic studies were identified and no health economic evaluation was undertaken for
this question.
Evidence to recommendations
Relative value placed on the outcomes considered
The overarching aim of the guideline is to provide a framework for healthcare professionals to enable
the early and accurate detection of serious illness in children with fever. This allows suitable treatment
to begin, thereby reducing subsequent potential mortality and morbidity.
The GDG considered the likelihood ratios, sensitivity, specificity and predictive values of each
symptom or sign when discussing the evidence. However, particular emphasis was given to likelihood
ratios, with a positive likelihood ratio of 5 or higher being used as a good indicator that a symptom or
sign should be presented in the red column of the traffic light table. In addition, the expert opinion and
experience of the GDG members also informed the final decision about whether to include, remove or
move a symptom or sign in the traffic light table.
Consideration of clinical benefits and harms
The traffic light table was created in order to encourage healthcare professionals to consider signs or
symptoms in their totality and not in isolation. Therefore, the evidence for any individual symptom or
sign had to be balanced by its contribution to the overall clinical picture and practical clinical
application. Furthermore, the GDG highlighted that studies assessing the use of combinations of
signs and symptoms show they have better predictive values than symptoms in isolation (for example
Van Den Bruel et al, 2007 and Thompson et al., 2012). This concept was incorporated into the
recommendation of ‘none of the amber or red symptoms or signs’ in the green column, and the
‘appears ill to a healthcare professional’ in the red column, without the need to specify the absence of
particular symptoms or signs.
For each symptom and sign presented below, the GDG has stated:
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why the symptom or sign was included in the 2007 traffic light table (if applicable)
the GDG’s interpretation of the diagnostic outcome measures presented in the evidence
statements for the symptom or sign
the GDG’s expert opinion on the inclusion of the symptom or sign in the traffic light
table, and
whether the symptom or sign was included in the 2013 update of the traffic light table.
Colour
Pallor reported by parent/carer or pale/mottled/ashen/blue (included in 2007 traffic light
table)
‘Colour’ had been included in the 2007 traffic light as part of the YOS.
Low quality evidence from two studies was identified in the 2013 review. The reported evidence
showed that children with cyanotic, pale or flushed/mottled skin were not more likely to have a serious
illness than children with normal colour skin (not a strong positive likelihood ratio). Children with a
serious illness did not usually have cyanotic, pale or flushed/mottled skin (low sensitivity). However,
the evidence for children without serious illness was mixed, with one study showing they did not
usually have cyanotic, pale or flushed/mottled skin (high specificity) and one study showing that they
usually did have cyanotic, pale or flushed/mottled skin (low specificity). One of the studies used colour
to detect urinary tract infection and the GDG members were not convinced of the relevance of colour
to this diagnosis.
2013 Update