A5V4d

Feverish illness in children
strong enough to add abnormal neurological findings to the traffic light table as a separate symptom
or sign. All of the included studies used abnormal neurological findings to detect bacterial meningitis,
and a child presenting with bacterial meningitis should be managed as outlined in the guideline
Bacterial meningitis and meningococcal septicaemia (NICE, 2010).Therefore, no changes relating to
abnormal neurological findings were made to the traffic light table.
Impression of tone (identified in 2013 review)
The evidence for impression of tone was limited to one study, which did not report diagnostic
accuracy data or data that would allow diagnostic accuracy data to be calculated. The evidence
stated that tone was not significantly associated with bacteraemia.
Therefore, the GDD decided that impression of tone should not be added to the traffic light table.
Tenderness on examination (identified in 2013 review)
The review results showed that children who showed tenderness on examination were not more likely
to have a urinary tract infection than children who did not show tenderness on examination (not a
strong positive likelihood ratio). In addition, the evidence showed that children without a urinary tract
infection usually did not have tenderness on examination (high specificity). However, children with a
urinary tract infection also did not usually have tenderness on examination (low sensitivity).
The GDG stated that tenderness on examination was not described in enough detail in the study to be
used, although the GDG acknowledged that it was likely to refer to abdominal tenderness, as the
study reports on urinary tract infection. In addition, the evidence was not strong enough for it to be
added to the traffic light table.
Therefore, the GDG decided that tenderness on examination should not be added to the traffic light
table.
Urinary symptoms (identified in 2013 review)
The evidence showed that children with urinary symptoms were not more likely to have a serious
bacterial infection than children without urinary symptoms (not a strong positive likelihood ratio). In
addition, the evidence showed that children without a serious bacterial infection usually did not have
urinary symptoms (high specificity). However, children with a serious bacterial infection also did not
usually have urinary symptoms (low sensitivity). There was some evidence that children with urinary
symptoms were more likely to have a serious bacterial infection than children without urinary
symptoms (strong positive likelihood ratio).
‘Urinary symptoms’ was not defined in the studies, although the GDG acknowledged that the term is
likely to refer to symptoms and signs of urinary tract infection. This suggests a definite source cause
of fever, and was not a helpful symptom or sign to add to the traffic light table. A child presenting with
urinary symptoms should be managed as outlined in the guideline Urinary tract infection in children
(NICE, 2007).
The GDG stated that two of the symptoms described in the 2007 guideline – offensive urine and
haematuria – were rare, and if present would refer to a urinary condition. Therefore, these were
removed from the recommendation. This did not result in any changes to the traffic light table.
Abnormal ear, nose and throat signs (identified in 2013 review)
The evidence was mixed for ‘abnormal ear, nose and throat signs’. One study showed that children
with abnormal ear, nose and throat signs were not more likely to have a serious illness than children
with no signs (not a strong positive likelihood ratio). In addition, the evidence showed that children
without a serious bacterial infection often had abnormal ear, nose and throat signs (low specificity),
while another study showed that children without a serious bacterial infection usually did not have ear
problems (high specificity). Both studies showed that children with a serious bacterial infection did not
usually have abnormal ear, nose and throat signs or ear problems (low sensitivity).
The GDG highlighted that the evidence was of low and very low quality, and symptoms were too
common to add ‘abnormal ear, nose and throat signs’ to the traffic light table.
The GDG therefore did not add ‘abnormal ear, nose and throat signs’ to the traffic light table.
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2013 Update