A5V4d

Clinical assessment of the child with fever
review was for detecting urinary tract infection, and the GDG was unsure how relevant chest findings
or abnormal chest sounds would be to this diagnosis.
Given the quality of the evidence and the fact that an item already covering this feature was already
included in the traffic light table, the GDG decided not make any changes relating to chest
findgins/abnormal chest sounds to the traffic light table.
Cough (identified in 2013 review)
The available evidence showed that children who had a cough were not more likely to have a serious
illness than children who did not have a cough (not a strong positive likelihood ratio).There was some
evidence that children without a urinary tract infection usually did not have a cough (high specificity),
but other evidence showed that children without a urinary tract infection, pneumonia, bacteraemia or
meningococcal disease often had a cough (low specificity). In addition, children with a urinary tract
infection, pneumonia, bacteraemia or meningococcal disease did not usually have a cough (low
sensitivity).
The evidence suggests cough was not a useful predictor of serious illness, although the GDG
highlighted that two of the studies were on detecting urinary tract infection and it was not clear how
relevant cough was to this diagnosis. There was not enough evidence for the GDG to determine that
cough was a useful symptom or sign in the detection of serious illness. Furthermore, the GDG stated
‘cough’ was too common to be of practical use.
Based on the available evidence and the results of its discussion, the GDG decided not make any
changes relating to cough to the traffic light table.
Circulation and hydration
In the 2007 guideline the GDG recognised that dehydration was a marker of serious illness but there
was a lack of evidence to determine the difference between mild, moderate and severe dehydration.
The most specific symptoms and signs of dehydration have been highlighted for healthcare
professionals to assess in order to ensure a low false positive rate and are included in the guideline
Diarrhoea and vomiting in children under 5 (NICE, 2009). As evidence was found relating to the use
of heart rate in the diagnosis of serious illness, the ‘hydration’ category was changed to ‘circulation
and hydration’ for greater clarity.
Dry mucous membranes and reduced skin turgor (included in 2007 traffic light table)
The GDG acknowledged that dry mucous membranes and reduced skin turgor were included in the
2007 traffic light table based on a study that reviewed signs and symptoms of dehydration, rather than
a study of serious illness associated with fever. However, the GDG members stated that, in their
experience, dehydration was a marker for serious illness and therefore should be included in the
traffic light table.
No new evidence was found for dry mucous membranes and/or reduced skin turgor in the 2013
review.
The GDG acknowledged that the recommendations regarding signs of dehydration in the 2007 Fever
guideline were intended for use primarily in children who had been sent home after seeing a
healthcare professional. Since the publication of the 2007 Feverish Illness in Children guideline, a
clinical guideline on diarrhoea and vomiting has been published (Diarrhoea and vomiting in children
under 5, NICE 2009). The Diarrhoea and vomiting guideline concluded that looking at physical signs
of dehydration was an inaccurate way of determining whether a child was moderately or severely ill,
as it is difficult to distinguish between different severities of dehydration. However, the two guidelines
consider different populations, and if a child exhibits diarrhoea and/or vomiting they are treated in
accordance with that guideline rather than the Fever guideline. The GDG also emphasised that the
purpose of the traffic light table is to raise awareness rather than to make clear definitive diagnosis.
In the absence of evidence to challenge the 2007 recommendation, the GDG did not change it.
Poor feeding (included in 2007 traffic light table)
The 2013 review did not find clear evidence relating poor feeding to an increased risk of serious
illness. Children who showed poor feeding were not more likely to have a serious illness than children
who showed normal feeding (not a strong positive likelihood ratio). The evidence was of low to very
low quality.
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2013 Update