GPAtlas🧭 When to suspect
Fever – a body temperature above the normal daily variation – is one of the commonest reasons a child is brought to primary care, and in the great majority it reflects a self-limiting viral infection. The clinical task is not to treat the temperature but to identify the small number of children with a serious bacterial infection or sepsis hidden within that large, mostly well group.
The structured way to do this is the NICE traffic light system, which sorts every feverish child under 5 into a green (low-risk), amber (intermediate-risk) or red (high-risk) group from their colour, activity, breathing, circulation/hydration and a few other features. Always begin by asking ‘could this be sepsis?’ and looking for any immediately life-threatening problem with the airway, breathing, circulation or conscious level.
Three temperature-and-age rules sit alongside the table: a child under 3 months with a temperature ≥38°C is high-risk (red); a child aged 3–6 months with a temperature ≥39°C is at least intermediate-risk (amber); and fever lasting 5 days or longer should always prompt assessment for Kawasaki disease. Beyond 6 months, the height of the fever alone does not predict serious illness.
| Domain | 🟢 Green – low risk | 🟡 Amber – intermediate risk | 🔴 Red – high risk |
|---|---|---|---|
| Colour |
• Normal colour of skin, lips and tongue |
• Pallor reported by parent/carer |
• Pale, mottled, ashen or blue |
| Activity |
• Responds normally to social cues • Content or smiles • Stays awake / wakes quickly • Strong normal cry or not crying |
• Not responding normally to social cues • No smile • Wakes only with prolonged stimulation • Decreased activity |
• No response to social cues • Appears ill to a clinician • Does not wake, or if roused does not stay awake • Weak, high-pitched or continuous cry |
| Respiratory |
• Normal breathing pattern |
• Nasal flaring • Tachypnoea: RR >50/min (6–12 months) or >40/min (over 12 months) • SpO2 ≤95% in air • Crackles in the chest |
• Grunting • Tachypnoea: RR >60/min • Moderate or severe chest indrawing (recession) |
| Circulation & hydration |
• Normal skin and eyes • Moist mucous membranes |
• Tachycardia (APLS): >160/min (under 12 months), >150/min (12–24 months), >140/min (2–5 years) • CRT ≥3 seconds • Dry mucous membranes • Poor feeding in infants • Reduced urine output |
• Reduced skin turgor |
| Other |
• None of the amber or red features |
• Age 3–6 months, temperature ≥39°C • Fever ≥5 days • Rigors • Swelling of a limb or joint • Non-weight bearing / not using a limb |
• Age under 3 months, temperature ≥38°C • Non-blanching rash • Bulging fontanelle • Neck stiffness • Status epilepticus • Focal neurological signs • Focal seizures |
A child with any red feature is high-risk; a child with any amber but no red feature is intermediate-risk; a child with only green features is low-risk. The level of risk drives the whole management plan.
Source: NICE NG143 · NICE NG254 (suspected sepsis in under 16s)
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