A5V4d

Clinical assessment of the child with fever
There was no evidence identified in the 2013 review that reported on neurological signs or focal
seizures for identifying serious illness.
Based on their clinical experience, the GDG members did not know of any clinical reason to move
these signs from the ‘red’ column of the traffic light table and therefore no changes were made.
Swelling of a limb or joint, and non-weight bearing limb/not using an extremity (included in
2007 traffic light table)
The GDG highlighted that both swelling of a limb or joint and non-weight bearing limb/not using an
extremity were included in the 2007 traffic light table as they are indicative of septic arthritis.
No evidence was identified in the 2013 review regarding swelling of a limb or joint and/or non-weight
bearing limb for detecting serious illness. The GDG acknowledged that the consequences of missing
the diagnosis of septic arthritis in a child are serious. However, it was also aware that this is not a
common illness. The GDG also acknowledged that many children with swelling and/or non-weight
bearing will recover from these symptoms in a few days, and so they do not require immediate
referral.
Based on the available evidence and its discussion, the GDG decided that no changes were needed
and these two symptoms should remained in the amber category of the traffic light table.
A new lump greater than 2 cm (included in 2007 traffic light table)
There was no evidence in the 2013 review to support including ‘new lump greater than 2 cm’ in the
traffic light table. The study on which the 2007 recommendation was based was excluded as it
included non-febrile surgical patients.
The GDG highlighted that ‘new lump greater than 2 cm’ was originally included in the traffic light table
based on one study that was excluded from the update as the population included a high proportion of
children without fever. A significant number of children in this study were diagnosed with hernias and
other surgical conditions. Moreover, in a subset analysis of children with fever from this study, a new
lump larger than 2 cm did not feature in a set of risk factors for serious illness. The GDG stated that a
new lump larger than 2 cm most likely indicated a hernia or an abscess requiring surgical intervention,
and was not associated with fever.
The GDG therefore decided to remove the existing recommendation, and so removed ‘new lump
greater than 2 cm’ from the traffic light table.
Bile-stained vomiting (included in 2007 traffic light table)
There was no evidence in the 2013 review to support including ‘bile-stained vomiting’ in the traffic light
table. The study on which the 2007 recommendation was based was excluded as it included non-
febrile surgical patients.
The GDG was aware that bile-stained vomiting is more likely to indicate a surgical problem, rather
than a serious bacterial illness. It was included in 2007 based on one study that was excluded from
the updated review, as it included a high proportion of children without fever. A significant number of
children in this study were diagnosed with hernias and other surgical conditions. Moreover, in a
subset analysis of children with fever from this study, bile-stained vomiting did not feature in a set of
risk factors for serious illness.
The GDG therefore decided to remove the existing recommendation, and hence removed ‘bilestained
vomiting’ from the traffic light table.
Diarrhoea (identified in 2013 review)
The evidence relating to diarrhoea was mixed, with some studies showing that children without a
serious bacterial infection, a urinary tract infection or a bacterial illness usually did not have diarrhoea
(high and moderate specificity) and some showing that children without serious bacterial infection
often had diarrhoea (low specificity). However, children with a serious bacterial infection, a urinary
tract infection or a bacterial illness did not usually have diarrhoea (low sensitivity). Children with
diarrhoea were not more likely to have a serious illness than children without diarrhoea (not strong
positive likelihood ratio).
The GDG stated that the evidence was not consistent enough to add diarrhoea to the traffic light
table. The GDG highlighted that dehydration was already included in the traffic light table. The GDG
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2013 Update