Clinical assessment tool for children 0-5 years

Traffic light system for identifying severity of illness

Only to be used in conjunction with pathways for gastroenteritis, bronchiolitis
and fever
Green – low risk Amber – intermediate Red – high risk
risk
Alert Miserable Difficulty waking
Responding normally to Not responding normally No response to social
social cues to social cues Clues
Behaviour Stays awake / Decreased activity Floppy
Activity awakens quickly
Content / smiles No smile Weak, high pitched or
continuous cry
Strong normal cry / Grumpy Appears ill to a health
happy professional
Temperature Normal ≥38 in 3-6 months olds ≥38 in under 3 months
≥39 in over 6 month olds ≥39 in 3-6 months olds

CRT <2 seconds CRT 2-3 seconds CRT over 3 seconds

Skin Normal colour skin, lips Pallor reported by Pale / mottled / ashen
(CRT on chest) and tongue parent/carer blue
Moist mucous membrane Dry mucous membrane Cold extremities
Reduced skin turgor
Cyanotic lips and
tongue
Periphery pulses weak

Respiratory rate Normal breathing Under 1 year ≥50 Under 1 year ≥60
(see table below) Over 1 year ≥40 Over 1 year ≥50
SATS in air 95% and above 92-94% <92%
Chest recession None Mild – moderate Severe
Nasal flaring Absent Occasionally present Constantly present
Grunting Absent Absent Present
Pulses/heart rate Normal heart rate Under 1 year <190 Under 1 year ≥190
(see table below) Over 1 year <160 Over 1 year ≥160

Normal – no vomiting 50-75% fluid intake over <50% fluid intake over
Feeding/hydration Normal urine output 3-4 feeds +/- vomiting 2-3 feeds +/- vomiting
Reduced urine output Significantly reduced
urine output

Apnoeas No apnoea Breathing slower than Frequent apnoeas

expected
CRT: Capillary Refill Time to be done on the chest; SATS: Saturations in air; Apnoea = 10-15 seconds
or shorter if accompanied by sudden drop in SATS or central cyanosis or bradycardia
*Temperature measured as per NICE guidelines (axillary up to 4 weeks old, ear thermoscan >4 weeks

Normal parameters Heart rate Mean resp rate For children 1 year and over
Infants <1 year 110-160 40 Estimated weight = (age in yrs +4) x2
Toddler 1-2 years 100-150 35
Pre-school 3-4 years 95-140 30
School 5-11 years 80-120 25

© Urgent Paediatric Care Pathway, RBFT Version 2.0 October 2016

Table 1
Symptoms and signs of specific diseases
Diagnosis to be considered Symptoms and signs in conjunction with fever
Non blanching rash, particularly with one or more of the
following:
Meningococcal disease - An ill looking child
- Lesions larger than 2mm in diameter (purpura)
- CRT >3 seconds
- Neck stiffness
- Neck stiffness
Meningitis1 - Bulging fontanelle
- Decreased level of consciousness
- Convulsive status epilepticus
- Focal neurological signs
Herpes simplex encephalitis - Focal seizures
- Decreased level of consciousness
- Tachypnoea measured as:
0-5 months – RR >60 breaths/minute
6-12 months – RR >50 breaths/minute
>12 months – RR >40 breaths/minute
Pneumonia - Crackles in the chest
- Nasal flaring
- Chest drawing
- Cyanosis
- Oxygen saturation <95%
- Vomiting
- Poor feeding
Urinary tract infection (in - Lethargy
children >3 months)2 - Irritability
- Abdominal pain or tenderness
- Urinary frequency or dysuria
- Offensive urine or haematuria
- Swelling of a limb or a joint
Septic arthritis/osteomyelitis - Not using an extremity
- Non-weight bearing
Fever lasting longer than 5 days and at least 4 of following:
- Bilateral red eyes
- Change in upper respiratory tract mucous membrane (e.g.
Kawasaki disease3 inflamed pharynx, dry cracked lips or strawberry tongue)
- Change in peripheral extremities (e.g. oedema, erythema or
desquamation)
- Polymorphous rash
- Cervical lymphadenopathy
CRT: capillary refill time
RR: respiratory rate
1
Classical signs (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants with bacterial
meningitis.
2
Urinary tract infection should be considered in any child <3 months with fever. See ‘Urinary tract infections in
children’ (NICE clinical guideline, published August 2007)
3
Note: in rare cases, incomplete/atypical Kawasaki disease may be diagnosed with fewer features

This guidance is written in the following context:

This assessment tool is based on NICE guidance, which was arrived at after careful consideration of the
evidence available. Healthcare professionals are expected to take it fully into account when exercising clinical
judgement. The guidance does not, however, over-ride the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or
parents/carers.