When I am driving and see a traffic light ahead the first thought is, "Am I supposed to stop or go?" My next thought is, "what might it change to and what do I do then?" Assessing the unwell child is like that. It's not just about the snapshot. Guidelines look a moment in time but the unwell child is in constant flux making that approach problematic.
The traffic light system for unwell children has been around for a very long time. It is used across Primary and Secondary care to aid clinicians in their attempts to risk assess febrile and unwell children with all of the non-specific signs and symptoms with which they present.
I am often asked if I use the traffic light system in my own practice. The answer is yes and no. Yes - the system is a useful hierarchy of signs and symptoms. No - because most childhood illnesses are too dynamic for a snapshot to be completely valid. Things change constantly. A risk assessment based on a moment in time is far too simplistic.
That doesn't mean that observation of the child is necessary for decision making. In most cases it's simply a question of asking how the lights are changing and what I'm going to do with that.
Amber turning green
A 2 year old child presents with a cough, runny nose and a fever. The parent reports that a couple of hours ago they looked pale and lethargic. They were shivering, felt hot centrally but had cold hands and feet. Now they have none of those things happening. They are walking, talking and cheerfully interactive.
This is a very common scenario. Parents and carers will often express a certain paradoxical frustration with the apparent wellness of the child. The child appeared seriously unwell a couple of hours ago and the parent is now feeling that you will think that they have over-reacted. It is a good thing to acknowledge how unwell the child was and use that as an opportunity to explain why you as a clinician are happy with the child despite how concerning the child's appearance was.
Giving or signposting to something written is also important.
Green turning amber
A 2 year old child presents with a cough, runny nose and a fever. When you see them they are miserable but alert and interactive. They have a temperature of 39.5, heart rate of 160 and are refusing to drink. They last had any symptomatic treatment 6 hours ago. The parent reports (you have to ask about this - it won't usually be volunteered) that 2 hrs ago they looked much better and were drinking a bit.
Unlike actual traffic lights, unwell children swing from green to amber and back to green quite normally during uncomplicated self-limiting infections. There is a reason that we mostly see unwell children between the age of 6 months and six years. It's not because they are high risk for dangerous infections. In fact quite the opposite - it is a stage of life characterised by extreme response to simple infections. The normal physiological response can look bad but usually resolves to reveal a reassuring baseline. In many ways, a febrile unwell 2 week old is easier from a decision making point of view - that is a very high risk presentation. A febrile unwell 2 year old is low risk but that presents a different problem - how to recognise the small number that do have a serious illness.
What can be terribly inconvenient is the above situation. The snapshot we are given is not green but also not red. Red is also easier from a decision making point of view. Amber presentations make us have to decide what to do next. Here are your options:
Every clinician will have a preferred option. Many working in Primary Care do not feel the need to have a face to face reassessment if the child improves in behaviour and activity. That is completely valid as such improvement is a good demonstration of physiological change and evidence that the baseline state of the child (active, interactive, good oral intake and no increased work of breathing) is not consistent with sepsis or meningitis for example.
Really good safety-netting advice empowers the parent to make that assessment in a way that is dynamic and continuous. A reassessment in whatever form (face to face or remote) facilitates documentation of improvement and adds value to the safety-netting advice by giving the opportunity for the parent to further discuss the illness, what to expect and when to worry.
Amber children are a fair bit of work but they are a great opportunity to do what we should consider core business. We can take a group of children who are reasonably low risk and look for signs (e.g. increased work of breathing, meningism or unexplained tachycardia) that this one is the one with something that needs immediate intervention. For those that are within what is expected of an uncomplicated infection we can make sure that they have symptomatic treatment in the assumption that they will demonstrate a baseline state of reasonable wellness that effectively rules out serious illness. Finally we can equip the person caring for that child with the ability to recognise signs of serious illness should those develop later. That is a lot of great care.
Edward Snelson
Paediatric off-roader
@sailordoctor
Disclaimer - drive on the road when you can, off the road when you have to but always get home safely. If you need help, call.
