GPAtlas🧭 When to suspect (and how to risk-stratify)
Fever is one of the commonest reasons a child under 5 is brought to a clinician, affecting up to half of pre-school children each year.
The great majority are self-limiting viral illnesses, but fever can also be the first sign of serious bacterial infection:
• Meningitis
• Septicaemia
• Urinary tract infection (UTI)
• Pneumonia
The few serious cases hide among many benign ones, and are hard to find because young infants, especially those under 3 months, often present non-specifically.
NICE NG143 provides the traffic-light system: a structured way to predict the risk of serious illness, sorting children into green (low risk), amber (intermediate risk) and red (high risk) – often abbreviated red, amber, green (RAG).
Assessment runs across four domains – colour, activity, respiratory and circulation/hydration – plus an "other" group of high-risk pointers.
The vital signs that feed into it are respiratory rate (RR), heart rate, capillary refill time (CRT) and oxygen saturation (SpO2).
Tachycardia is judged against Advanced Paediatric Life Support (APLS) thresholds.
Two principles frame every assessment:
• First, always identify any immediately life-threatening features (compromise of airway, breathing or circulation, or a decreased level of consciousness) and ask "could this be sepsis?" (see NICE NG254).
• Second, management follows the highest-risk feature present.
Note the two age–temperature rules:
• A child under 3 months with a temperature ≥38°C is red
• A child 3–6 months with a temperature ≥39°C is amber
Above 6 months the height of the fever alone does not predict serious illness, and a parent's report of fever should always be taken seriously.
| 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 or 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 or 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 |
Source: NICE NG143 · NICE NG254
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