A5V4d

Rigor and/or chills (identified in 2013 review)
Clinical assessment of the child with fever
The evidence suggested that children with rigors were not more likely to have a bacterial illness than
children who did not have rigors (not strong positive likelihood ratio). The evidence showed that
children without bacterial illness often did not have rigors (moderate specificity); however, children
with a bacterial illness also usually did not have rigors (low sensitivity). The evidence was of very low
quality.
The GDG highlighted that rigors are caused by a high body temperature, and are therefore associated
with high temperatures in children. The GDG acknowledged that there was evidence of a link between
higher temperatures in children and serious illness, and therefore rigors could be an indicator of
serious illness. The GDG was aware that rigors are an uncommon symptom/sign in children under 5
years, but there was insufficient evidence that rigors alone signal the need for urgent attention.
The GDG stated that the quality of the evidence and positive likelihood ratio meant that rigors could
not be added to the red column of the traffic light table. However, the GDG did feel it was an important
feature and the decision was therefore made to add rigors to the amber category of the traffic light
table.
Cold hands and feet (identified in 2013 review)
No evidence regarding cold hands and feet was reported in the 2013 review.
The GDG noted clinical overlap with poor peripheral circulation but that the NICE Bacterial meningitis
and meningococcal septicaemia guideline (NICE, 2010) had identified cold hands and feet as a
relevant sign when considering a diagnosis of meningitis.
The GDG was aware that the symptoms of cold hands and feet are included in the list of clinical
features found in meningococcal disease and meningitis in the NICE 2010 meningitis guideline.
However these symptoms were taken from uncontrolled studies and did not therefore fulfil the
inclusion criteria of the updated Feverish illness guideline. Moreover, a study of these symptoms and
signs in children with self-limiting viral illness found that cold hands and feet were reported in 20% to
24% of young children. The specificity of this symptom for detecting meningococcal disease would
therefore be low. The GDG emphasised that in isolation, for undifferentiated children with fever, other
features of the traffic light table were sufficient to identify high risk children and therefore did not add
this symptom or sign to the traffic light table.
A child presenting with cold hands and feet should be diagnosed as outlined in the guideline Bacterial
meningitis and meningococcal septicaemia (NICE, 2010).
Based on the available evidence and its discussion, the GDG decided that no changes relating to cold
hands and feet were needed to the traffic light table.
Yale Observation Score
The evidence suggests that the Yale Observation Score was good at identifying children who do not
have a serious illness. However, it was less good at identifying children who do have a serious illness.
This was in line with the evidence found for the 2007 review that the YOS alone was not a good
detector of serious illness. As highlighted in the 2007 review, the GDG acknowledged that the
usefulness of the YOS was increased when it was used in combination with a history taken by a
physician and examination.
Consideration of health benefits and resource uses
The GDG highlighted that the traffic light system would improve the initial management of
examinations and reduce variation in practice. This would ensure that resources are focused on those
who need further investigations and treatment, and not wasted on investigations or treatments that
are not needed. It will also prevent unnecessary stress and anxiety for the child and their caregivers.
The GDG stated that the traffic light system was a quick and non-invasive method of identifying
children with fever who may have a serious illness. Therefore, very little additional cost was
associated with its use over and above a standard clinical examination, but its value was in the
accuracy of the signs and symptoms that it contains.
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2013 Update