A5V4d

Feverish illness in children
Quality of evidence
The evidence ranged from high to very low in quality. There were a number of common issues which
influenced the quality of the evidence, including lack of blinding of the clinicians and the use of
different tests to confirm serious illness. However, the GDG highlighted that while much of the
evidence was low quality, it was the best that is available on signs and symptoms.
The number of studies for most of the symptoms or signs was limited and not all of the reported
evidence was directly relevant to the review question. This affected how applicable the data was to
changing the traffic light table and meant that, for some symptoms and signs, the GDG did not have
enough relevant data to make a decision on recommendations. In addition, the included studies
varied in their approach, including which illnesses were being detected, the definition and
measurement of symptoms and signs, the temperature cut-off for inclusion into the trial, the way in
which inclusion temperature was measured (such as tympanic, rectal, axillary), the age of the
included children, and the setting of the study (for example GP offices, hospital). These variations in
the studies meant that data could not be pooled and made it difficult for the GDG to compare
evidence from multiple studies for a symptom or sign. These variations also made it difficult for the
GDG to compare the efficacy of different symptoms and signs with each other to inform decisions
about whether a symptom or sign should be in the green, amber or red column of the traffic light table.
Some symptoms and signs were not well defined and the GDG did not believe it could add them to
the traffic light table. In these cases, the GDG concluded that the details in the traffic light table
provided a better definition of the symptoms or signs than the new evidence in the studies.
Some studies only included children who had experienced a febrile convulsion prior to presentation to
a healthcare professional. These were included as there was a lack of data for the majority of
symptoms and signs; however, the GDG emphasised that these children do not necessarily represent
every child presenting to a healthcare professional with fever.
Due to these limitations with the studies, and without a sound clinical reason to alter the traffic light
table, the majority of recommendations remained as they were in the 2007 guideline.
Other considerations
There were no other considerations specific to this section.
Equalities
The GDG acknowledged that special consideration needs to be made when assessing children with
learning disabilities. Healthcare professionals should be aware that it may not be possible to apply all
parts of the traffic light table to these children, and that care should be taken in interpreting the table
when assessing these children.
The GDG also highlighted that care should be taken in interpreting the traffic light table when a
complete history is not available, for example when a child presents without parents or caregivers.
This may happen if the child is brought to a healthcare professional by a teacher or child minder, for
example. It does not prevent the traffic light table from being used, but healthcare professionals
should exercise caution in their approach.
The GDG stated that it can be difficult to assess pallor or a pale/mottled/ashen/blue appearance in
children who have darker skin. Therefore, the GDG altered the wording of the existing
recommendation to clarify that a pale/mottled/ashen/blue appearance can be identified on the lips or
tongue of a child, as well as their skin. The wording of the green column heading and criteria was then
edited to avoid repetition.
Similarly, capillary refill time may be a less useful test in children with darker skin tones. Peripheral
measures may have to be used rather than central measures, for example in the beds of nails. Nonblanching
rash may also be harder to detect, and clinicians should be aware of where a rash can be
more easily identified, such as palms of hands, conjunctivae and soles of feet. For further details,
please refer to the guideline Bacterial meningitis and meningococcal septicaemia (NICE, 2010).
Recommendations
The recommendations covering colour, activity, respiratory, hydration and other non-specific
symptoms and signs are presented at the end of Section 5.5.
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2013 Update