Traffic light system for fever management

in children

NICE clinical guideline 47 MAY 2007

Traffic light system: green

Colour

Normal colour of skin, lips and tongue

Activity

Responds normally to social cues

Content/smiles
Stays awake or awakens quickly
Strong/normal cry/not crying

Hydration

Normal skin and eyes

Moist mucous membranes

Other

None of the amber or red symptoms

or signs

Traffic light system: amber

Colour
Activity

Pallor reported by parent/carer

Respiratory

Nasal flaring
Tachypnoea: RR>50/min age 6-12 months,
RR>40/min age >12 months
Oxygen saturation 95% in air
Crackles

Hydration

Dry mucous membranes

Poor feeding in infants
CRT 3 seconds
Reduced urine output

Other

Fever for 5 days

Swelling of a limb or joint
Non-weight bearing/not using an extremity

Not responding normally to social cues

Wakes only with prolonged stimulation
Decreased activity
No smile

Traffic light system: red

Colour

Pale/mottled/ashen/blue

Activity

No response to social cues

Appears ill to a healthcare professional
Unable to rouse or if roused does not stay awake
Weak/high pitched/continuous cry

Respiratory

Grunting
Tachypnoea: RR>60 /min
Moderate or severe chest indrawing

Hydration

Reduced skin turgor

Other

Age 0-3 months, temperature 38C

Age 3-6 months, temperature 39C
Non blanching rash
Bulging fontanelle
Neck stiffness
Status epilepticus
Focal neurological signs
Focal seizures
Bile-stained vomiting

Management of children 3 months

to 5 years by a paediatric specialist
Assess: look for life-threatening, traffic light and specific diseases symptoms and signs

Perform test for urinary

tract infection.
Do not perform routine
blood tests or chest X-ray.

Perform (unless deemed unnecessary)

urine test for urinary tract infection
full blood count
blood culture
C-reactive protein.

Perform:
blood culture
full blood count
urine test for urinary tract infection
C-reactive protein.

Perform chest x-ray if fever higher

than 39C and white blood cell count
greater than 20 x 109/litre.

Consider the following, as guided by

clinical assessment:
lumbar puncture in children of all ages
chest X-ray
serum electrolytes
blood gas.

Consider lumbar puncture if child is

younger than 1-year old.
If no diagnosis is reached,
manage the child at home
with appropriate care advice.

Consider admission. If admission is not

necessary but no diagnosis has been reached,
provide a safety net for the parents/carers.

Management of children under

3 months by a paediatric specialist
Assess: look for life-threatening, traffic light and specific diseases symptoms and signs
Observe and monitor:
temperature
heart rate
respiratory rate.
Perform:
full blood count
C-reactive protein
blood culture
urine test for urinary tract infection
chest X-ray if respiratory signs are present
stool culture if diarrhoea is present.
Admit, perform lumbar puncture and start parenteral antibiotics if the child is:
younger than 1-month old
13 months old appearing unwell
13 months old and with a white blood cell count of less than 5 or greater than 15 x 10 9/litre
Whenever possible, perform lumbar puncture before the administration of antibiotics