Name

Date of Birth
Hospital Number
Consultant
Ward

West Suffolk Hospital NHS Trust

WEIGHT

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 ( Check box in each category to obtain highest risk colour - green, amber or red )
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

38 in under 3/12
39 in over 3/12

>38 in under 3/12

>39 in over 3/12

CRT 2-3 seconds

CRT over 3 seconds

Skin
(CRT on chest)

CRT <2 seconds

Normal colour skin, lips
and tongue
Moist mucous membrane

Pale / mottled

Pale / mottled / ashen

blue
Cold extremities
Weak peripheral
pulses
Cyanotic lips and
tongue
Periphery pulses weak

Traffic Light
Category

Behaviour
Activity

Dry mucous membrane

Pallor colour reported by

parent/carer

Respiratory rate

Normal breathing
(see table below)

Under 1 year <60

Over 1 year <50

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 <140

Under 1 year >190

Over 1 year >140

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
120-170
80-110
70-110
70-110

Urgent Paediatric Care Pathway, RBFT

Mean resp rate

40
35
31
27

For children 1 year and over

Estimated weight = (age in yrs +4) x2

Version 1.2 November 2010

Kg

West Suffolk Hospital NHS Trust

Name
Date of Birth
Hospital Number
Consultant
Ward

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

Weight

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
Urgent Paediatric Care Pathway, RBFT
Version 1.2 November 2010
parents/carers.

Kg