Identifying serious bacterial illness in children: is it time to show the red card to NICE’s red flags?

Kevork Hopayian

doi:10.3399/bjgp23X734937

THE TRAFFIC LIGHT SYSTEM

This review analyses current evidence for the diagnostic accuracy of the Traffic Light System (TLS) in primary care, its implications for GPs, and its alternatives. Two linked studies¹^,² of the performance of the National Institute for Health and Care Excellence’s TLS concluded that it was unfit for purpose. TLS aims ‘to improve clinical assessment and help healthcare professionals diagnose serious illness among young children [under 5] who present with fever’,³ a notoriously difficult assessment since fever in children is common while serious bacterial infection (SBI) is rare. The TLS groups clinical features into three categories with corresponding recommendations: red (serious illness likely, hospital admission recommended), green (serious illness unlikely, manage at home), and amber (intermediate risk, judgement required). Clark et al² reported that the TLS was insufficiently accurate to identify infants in primary care with SBI and to exclude those without. Arguably these findings suggest abandoning the TLS. In preparing this review, all references from both studies were retrieved. Backward and forward searches from the references were cascaded until no new references were found.

WHAT CLARK AND BLYTH FOUND

Blyth et al¹ and Clark et al² mapped data from the previous prospective cohort DUTY study⁴ of over 6700 children presenting with constitutional or urinary tract infection symptoms to GPs, walk-in centres, and emergency departments (EDs) to TLS items. A third of under-5s had at least one red feature.¹ The accuracy of the TLS, using hospital-diagnosed SBI as the reference standard, was calculated for two thresholds: any red feature and either red or amber feature.² Any red feature had a sensitivity of …

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