Paediatric Fever Assessment in General Practice: The NICE Traffic Light System
A systematic approach to the febrile child — from triage to serious bacterial infection recognition
Fever is the most common reason for paediatric GP consultations. The NICE NG143 traffic light system provides a validated framework for risk stratification. This guide covers the green/amber/red system, serious bacterial infection recognition, meningococcal disease, and when to admit.
Clinical Decision Support: This article is for educational purposes and supports — not replaces — clinical judgment. Always verify with current national guidelines, BNF, and specialist consultation when needed.
Fever in children is one of the most common presentations in general practice, accounting for approximately 20–30% of all paediatric consultations. While the vast majority of febrile illnesses in children are self-limiting viral infections, a small but important minority have serious bacterial infections (SBI) requiring urgent intervention. The NICE NG143 traffic light system provides a validated, systematic approach to risk stratification.
The NICE Traffic Light System
Green (Low Risk) Features
- Normal colour (skin, lips, tongue)
- Responds normally to social cues; content/smiles
- Stays awake or awakens quickly
- Strong normal cry or not crying
- Normal skin and eyes; moist mucous membranes
- No amber or red features
Amber (Intermediate Risk) Features
- Pallor reported by parent/carer
- Not responding normally to social cues; no smile
- Wakes only with prolonged stimulation
- Decreased activity
- Nasal flaring
- Tachycardia: >160 bpm (<12 months), >150 bpm (12–24 months), >140 bpm (2–5 years)
- CRT ≥3 seconds
- Dry mucous membranes; reduced urine output
- Fever ≥5 days; rigors; swelling of a limb/joint; non-weight-bearing
Red (High Risk) Features
- Pale/mottled/ashen/blue skin, lips, or tongue
- No response to social cues; appears ill
- Does not wake or stays awake only with stimulation
- Weak/high-pitched/continuous cry
- Grunting; severe respiratory distress; apnoea
- Tachycardia: >160 bpm (<12 months), >150 bpm (12–24 months), >140 bpm (2–5 years) with other red features
- Non-blanching rash; bulging fontanelle; neck stiffness; photophobia; seizure with fever
- Age <3 months with temperature ≥38°C; age 3–6 months with temperature ≥39°C
A non-blanching rash in a febrile child is meningococcal disease until proven otherwise. Give IM/IV benzylpenicillin immediately (if no penicillin allergy) and arrange emergency transfer. Do not wait for blood results.
Meningococcal Disease: Recognition and Emergency Management
- Classic presentation: Fever + non-blanching petechial/purpuric rash + meningism (neck stiffness, photophobia, Kernig's sign)
- Early presentation: Fever + leg pain + cold hands/feet + abnormal skin colour (before rash appears)
- Immediate management: IM benzylpenicillin 1.2 g (adult), 600 mg (child 1–9 years), 300 mg (<1 year)
- Cefotaxime if penicillin allergy: 2 g IV (adult), 50 mg/kg IV (child)
- Call 999 immediately; do not delay transfer for investigations
Age-Specific Fever Thresholds
| Age | Fever Threshold | Action |
|---|---|---|
| <3 months | ≥38°C | Urgent same-day assessment; high risk of SBI |
| 3–6 months | ≥39°C | Urgent same-day assessment |
| 6 months – 5 years | ≥38°C with red features | Emergency admission |
| Any age | Fever >5 days | Investigate for Kawasaki disease, occult infection |
Kawasaki Disease: Do Not Miss
Kawasaki disease is a medium-vessel vasculitis predominantly affecting children under 5 years. It is the most common cause of acquired heart disease in children in developed countries. Diagnosis requires fever ≥5 days plus ≥4 of: bilateral non-purulent conjunctivitis, polymorphous rash, changes in lips/oral mucosa (strawberry tongue, cracked lips), changes in extremities (erythema/oedema of hands/feet, periungual desquamation), and cervical lymphadenopathy ≥1.5 cm.
Key Clinical Takeaways
- Use NICE traffic light system: green (manage at home), amber (safety net/investigate), red (admit)
- Age <3 months with fever ≥38°C = urgent same-day assessment regardless of other features
- Non-blanching rash + fever = meningococcal disease — give benzylpenicillin immediately
- Fever >5 days in a child: consider Kawasaki disease — refer urgently
- Amber features: safety net with clear written advice and when to return
- Never give aspirin to children with fever (Reye syndrome risk)