A5V4d

Traffic light system
Process used to develop the 2007 traffic light table
Clinical assessment of the child with fever
For the 2007 guideline the GDG developed an evidence based ‘traffic light’ system to highlight
graphically both non-specific and specific symptoms and signs of serious illnesses. The purpose of
the traffic light system is to aid clinicians in identifying children who may have a serious illness. The
‘red’ features are the most worrying, followed by the ‘amber’ features, whereas the ‘green’ features
are the most reassuring. It is not meant to provide a clear diagnosis of specific serious illness, but to
highlight which children need further investigation and monitoring.
Evidence based reviews were undertaken to identify the relationship of individual symptoms and signs
and the likely presence of any serious illness. The list of symptoms and signs that were identified
included being drowsy, moderate/severe chest recession, a respiratory rate greater than 60 breaths
per minute, capillary refill time, respiratory rate, height of fever, duration of fever and signs of
dehydration. The GDG members used their clinical experience to assign these symptoms and signs
to the green, amber or red column of the traffic light table.
Evidence based reviews were also undertaken to identify evidence on existing scoring systems which
determine the likelihood that serious illness was present. These found two that looked at clinical
symptoms and signs rather than laboratory values (the Yale Observation Scale [YOS] and the Young
Infant Observation Scale [YIOS]). Although neither scale alone could reliably detect serious illness,
the YOS did improve the detection of serious illness when combined with an examination and history
taken by a physician. Although designed for use with children under 3 years, the GDG agreed it was
reasonable to extrapolate symptoms and signs from the YOS to the table for children up to 5 years.
The symptoms and signs from the YOS that were associated with being well were added to the green
column of the traffic light table, and symptoms and signs that were correlated with serious illness were
added to the red column of the traffic light table (see Table 5.1 below for features of the YOS).
Finally, evidence-based reviews were undertaken to identify symptoms and signs of specific serious
illnesses, namely bacterial meningitis, septicaemia, bacteraemia, pneumonia, urinary tract infection,
encephalitis (herpes simplex), septic arthritis/osteomyelitis and Kawasaki disease. The most
predictive symptoms and signs of these specific serious illnesses were added to the traffic light table.
Table 5.1 The features of the Yale Observation Scale (YOS)
Observation
item
Normal = 1 Moderate impairment = 3 Severe impairment = 5
Quality of cry Strong or none Whimper or sob Weak or moaning, highpitched,
continuous cry or
hardly responds
Reaction to
parent
stimulation
Cries briefly or no cry
and content
State variation If awake, stays awake
or if asleep, awakens
quickly
Cries on and off Persistent cry with little
response
Eyes close briefly when
awake or awakens with
prolonged stimulation
Colour Pink Pale extremities or
acrocyanosis
Hydration Skin and eyes normal
and moist mucous
membranes
Response to
social overtures
Smiles or alerts
(consistently)
Skin and eyes normal and
mouth slightly dry
No arousal and falls asleep
Pale or cyanotic or mottled or
ashen
Skin doughy or tented and dry
mucous membranes and/or
sunken eyes
Brief smile or alert No smile, anxious, dull; no
alerting to social overtures
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2013 Update