A5V4d

Clinical assessment of the child with fever
not have decreased consciousness (high specificity). However, children with a serious bacterial
infection did not usually present with decreased consciousness (low sensitivity).
The reviewed evidence was based on a population outside the intended guideline population; that is,
children older than 5 years or those with febrile convulsions. Furthermore, the GDG believed that this
sign was already included in the traffic light table as ‘does not wake, or if roused, does not stay
awake’.
Based on the quality of the available evidence and its discussion, the GDG decided that no changes
relating to decreased consciousness and/or coma were needed to the traffic light table.
Restlessness (identified in 2013 review)
The evidence regarding restlessness was reported in one study. Children who were restless were not
more likely to have a serious illness than children who were not restless (not a strong positive
likelihood ratio). Children with a serious illness were often restless (moderate sensitivity); however,
children without a serious illness were also often restless (low specificity).
Based on the limited evidence, the GDG did not believe restlessness was a useful symptom to detect
serious illness. Therefore, restlessness was not added to the traffic light table.
Respiratory
The majority of respiratory symptoms were originally included in the traffic light table as indicators of
pneumonia.
Nasal flaring and grunting (included in 2007 traffic light table)
No new evidence was found for nasal flaring or grunting in the 2013 review.
The GDG emphasised that clinical judgment should be used to distinguish between nasal flaring
(amber symptom/sign) and grunting (red symptom/sign).
Based on the available evidence and its discussion, the GDG decided that no changes relating to
nasal flaring and grunting were needed to the traffic light table.
Tachypnoea (included in 2007 traffic light table)
Abnormal respiratory rate was included in the 2007 traffic light table as a non-specific marker of
serious illness, a specific feature of pneumonia and required for the assessment of dehydration. A
statement about measuring respiratory rate was combined with the statement about the physiological
parameters which should be documented as part of the assessment.
The 2013 review of the evidence showed that children who had tachypnoea were not more likely to
have a serious illness than children who did not have tachypnoea (not a strong positive likelihood
ratio). In addition, the evidence showed that children without a serious illness often did not have
tachypnoea (moderate specificity). However, the evidence showed that children with a serious illness
also did not usually have tachypnoea (low sensitivity). The available evidence was of low quality.
The cut-offs proposed by Fleming et al. (2011) and Nijman et al. (2012) were reviewed, but there was
no significantly clear evidence on specific rates to alter the categories.
The GDG members concluded from their experience that respiratory rate is an important physiological
parameter which needs to be assessed by healthcare professionals.
Given the low quality of the evidence, the GDG did not believe the evidence was strong enough to
change or remove an existing recommendation. Therefore, no changes relating to tachypnoea were
made to the traffic light table.
Oxygen saturation (included in 2007 traffic light table)
Oxygen saturation was included in the original traffic light table as a specific sign of pneumonia.
The current review did not find any evidence regarding oxygen saturation for detecting serious illness.
However, the GDG members were aware that the measurement of oxygen saturation is becoming
more common amongst GPs and non-paediatric accident and emergency departments. Using their
expert opinions, the GDG members believed that oxygen saturation should be retained in the traffic
light table.
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2013 Update