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
Behaviour
Activity
Green – low risk
Amber – intermediate
risk
Red – high risk
Alert
Responding normally to
social cues
Stays awake /
awakens quickly
Content / smiles
Miserable
Not responding normally
to social cues
Decreased activity
Difficulty waking
No response to social
Clues
Floppy
No smile
Strong normal cry /
happy
Grumpy
Weak, high pitched or
continuous cry
Appears ill to a health
professional
Temperature
Normal
Skin
(CRT on chest)
CRT <2 seconds
Normal colour skin, lips
and tongue
Moist mucous membrane
≥38 in 3-6 months olds
≥39 in over 6 month olds
≥38 in under 3 months
≥39 in 3-6 months olds
CRT 2-3 seconds
CRT over 3 seconds
Pallor reported by
parent/carer
Dry mucous membrane
Pale / mottled / ashen
blue
Cold extremities
Reduced skin turgor
Cyanotic lips and
tongue
Periphery pulses weak
Respiratory rate
Normal breathing
(see table below)
Under 1 year ≥50
Over 1 year ≥40
Under 1 year ≥60
Over 1 year ≥50
SATS in air
Chest recession
Nasal flaring
Grunting
95% and above
None
Absent
Absent
92-94%
Mild – moderate
Occasionally present
Absent
<92%
Severe
Constantly present
Present
Pulses/heart rate
Normal heart rate
(see table below)
Under 1 year <190
Over 1 year <160
Under 1 year ≥190
Over 1 year ≥160
50-75% fluid intake over
3-4 feeds +/- vomiting
Reduced urine output
<50% fluid intake over
2-3 feeds +/- vomiting
Significantly reduced
urine output
Normal – no vomiting
Feeding/hydration Normal urine output
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
Apnoeas
Normal parameters
Infants <1 year
Toddler 1-2 years
Pre-school 3-4 years
School 5-11 years
No apnoea
Heart rate
110-160
100-150
95-140
80-120
© Urgent Paediatric Care Pathway, RBFT
Mean resp rate
40
35
30
25
For children 1 year and over
Estimated weight = (age in yrs +4) x2
Version 2.0 July 2013
Table 1
Symptoms and signs of specific diseases
Diagnosis to be considered
Meningococcal disease
Meningitis1
Herpes simplex encephalitis
Pneumonia
Urinary tract infection (in
children >3 months)2
Septic arthritis/osteomyelitis
Kawasaki disease3
Symptoms and signs in conjunction with fever
Non blanching rash, particularly with one or more of the
following:
- An ill looking child
- Lesions larger than 2mm in diameter (purpura)
- CRT >3 seconds
- Neck stiffness
- Neck stiffness
- Bulging fontanelle
- Decreased level of consciousness
- Convulsive status epilepticus
- Focal neurological signs
- 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
- Crackles in the chest
- Nasal flaring
- Chest drawing
- Cyanosis
- Oxygen saturation <95%
- Vomiting
- Poor feeding
- Lethargy
- Irritability
- Abdominal pain or tenderness
- Urinary frequency or dysuria
- Offensive urine or haematuria
- Swelling of a limb or a joint
- 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.
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.