A5V4d

Feverish illness in children
Non-blanching rash, bulging fontanelle and neck stiffness (included in 2007 traffic light table)
In the 2007 traffic light table there were several symptoms and signs that were included because they
are indicative of meningococcal septicaemia or bacterial meningitis, including non-blanching rash,
bulging fontanelle and neck stiffness. The evidence was of low to very low quality.
The 2013 review reported that there was some evidence that children with a non-blanching rash were
more likely to have a serious illness than children who did not have a non-blanching rash (convincing
positive likelihood ratio); however, there was also evidence that children with a non-blanching rash
were not more likely to have a serious illness than children who did not have a non-blanching rash
(not a strong positive likelihood ratio). In addition, children without a serious illness, such as
pneumonia, a urinary tract infection or bacteraemia, usually did not have a non-blanching rash (high
specificity). Children with a serious illness, such as pneumonia, a urinary tract infection or
bacteraemia, also did not usually have a non-blanching rash (low sensitivity).
The evidence for the 2013 review showed that children with a bulging fontanelle were not more likely
to have a serious illness than children without a bulging fontanelle (not a strong positive likelihood
ratio). Children without a serious illness, such as pneumonia, a urinary tract infection or bacteraemia,
usually did not have bulging fontanelle (high specificity). Children with a serious illness, such as
pneumonia, a urinary tract infection or bacteraemia, also did not usually have a bulging fontanelle
(low sensitivity).
The 2013 review reported that there was some evidence that children with neck stiffness were more
likely to have meningococcal disease than children who did not have neck stiffness (convincing
positive likelihood ratio). In addition, children without a serious illness, such as meningitis, pneumonia,
a urinary tract infection or bacteraemia, usually did not have neck stiffness (high specificity). Children
with a serious illness, such as meningitis, pneumonia, a urinary tract infection or bacteraemia, also did
not usually have neck stiffness (low sensitivity).
The 2013 review also found that there was evidence that children with focal seizures were more likely
to have bacterial meningitis than children who did not have focal seizures (strong positive likelihood
ratio). In addition, children without a serious illness, such as meningitis, pneumonia, a urinary tract
infection or bacteraemia, usually did not have focal seizures (high specificity). However, children with
a serious illness, such as meningitis, pneumonia, a urinary tract infection or bacteraemia, also did not
usually have focal seizures (low sensitivity).
Since the 2007 Fever guideline, a guideline on bacterial meningitis in children and young people has
been published. The guideline Bacterial meningitis and meningococcal septicaemia (NICE, 2010)
includes a comprehensive list of symptoms and signs of bacterial meningitis and meningococcal
septicaemia. However, it is worth noting that the bacterial meningitis guideline is relevant when
bacterial meningitis or meningococcal septicaemia is suspected, whereas the Fever guideline is
relevant for children that do not have a known source of fever. The GDG stated that the most relevant
symptoms and signs of bacterial meningitis and meningococcal septicaemia were included in the
2007 traffic light table, and the 2013 review found no strong evidence to move or remove these from
the traffic light table. The GDG was aware that the symptoms of cold hands and feet and limb pain are
included in the list of clinical features found in meningococcal disease and meningitis in the 2010
guideline.
Although it was of low quality, the available evidence supported the existing recommendation and
matched the opinion of the GDG. Therefore, it was decided that the traffic light table did not need to
be changed.
Status epilepticus (included in 2007 traffic light table)
No evidence was identified in the 2013 review for status epilepticus.
Based on their clinical experience, the GDG members stated that status epilepticus should remain in
the ‘red’ column, as it is a serious condition and a child with status epilepticus needs urgent referral.
Therefore, no changes were made to the recommendation on status epilepticus.
Focal neurological signs and focal seizures (included in 2007 traffic light table)
The GDG highlighted that focal neurological and focal seizures were included in the traffic light table
as they may be indicative of Herpes simplex encephalitis.
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2013 Update