A5V4d

Clinical assessment of the child with fever
Given the quality of the evidence, the GDG members were of the clinical opinion that children with
pale/mottled/ashen/blue skin were not being incorrectly categorised as in the ‘red’ category. The GDG
decided that there was no reason to change or remove this sign from the traffic light table.
Activity
Not responding normally to social cues or no response to social cues (included in 2007
traffic light table)
‘Activity’ was included in the 2007 traffic light as part of the YOS.
The 2013 review found evidence to support assessing activity level at presentation. The reported
evidence showed that children with decreased social interaction were not more likely to have a urinary
tract infection than children with normal social interaction (not a strong positive likelihood ratio).
Children without a urinary tract infection often showed decreased social interaction (low specificity).
Children with a urinary tract infection did not usually show decreased social interaction (low
sensitivity). The evidence was of low quality.
The GDG acknowledged that it would be helpful to define ‘social cues’ for parents, caregivers or less
experienced healthcare professionals. The glossary of the guideline has been updated to outline that
this can include the parents’ perception of a baby behaving differently, response to their name,
smiling and/or giggling.
The GDG chose to keep decreased activity in the ‘amber’ column as the evidence did not support
movement into the ‘red’ category based on definitions used in the study. If the decreased activity is
severe, healthcare professionals may use their clinical judgement of ‘appears ill to a healthcare
professional’ to manage the child appropriately. Therefore, no change was made to the traffic light
table.
Appears ill to a healthcare professional (included in 2007 traffic light table) and
parents/carers
‘Appears ill to a healthcare professional’ was included in the 2007 traffic light table as part of the YOS.
The 2013 review supported the results of the 2007 review. The results of the studies were mixed, with
some studies showing that children who appeared unwell were not more likely to have a serious
illness than those who appeared well (not a strong positive likelihood ratio), and other studies showing
that children who appeared unwell were more likely to have a serious illness (convincing positive
likelihood ratio).
The GDG members acknowledged that being ‘very ill’ was more predictive than ‘appears ill’. However,
they were aware that it is hard to distinguish between the two terms. The majority of studies reporting
this sign did not define ‘appears ill’, and those that did used a combination of symptoms and signs
that are presented elsewhere in the traffic light table. As there was no separate data available on
parent/carer reports of ‘appears ill’, the GDG decided that that no recommendation could be made
specifically on parent/carer reports of ‘appears ill’. However, the GDG highlighted that parent/carer
reports of fever and other specific symptoms were covered by other recommendations in the
guideline.
Based on their expert opinion, the GDG members noted that ‘appears ill to a healthcare professional’
can be subjective and difficult to define. Therefore, the GDG concluded that for this sign, the definition
of ‘healthcare professional’ should be restricted to those who are trained in assessing children, for
example GPs, specialist nurses and paediatricians. The GDG members concluded, based on their
clinical experience, that there was not a strain on resources for children who are inappropriately
referred because of this sign.
Given the mixed quality of the evidence, the GDG did not change ‘appears ill to a healthcare
professional’ in the traffic light table.
Wakes only with prolonged stimulation or does not wake, or if roused, does not stay awake
(included in 2007 traffic light table)
‘Wakes only with prolonged stimulation or does not wake, or if roused, does not stay awake’ was
included in the 2007 traffic light table as part of the YOS.
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2013 Update