• Evelien Kerkhof, Monica Lakhanpaul, Samiran Ray, Jan Y Verbakel, Ann Van den Bruel, Matthew Thompson, Marjolein Y Berger, Henriette A Moll, Rianne Oostenbrink, and European Research Network on recognising serious InfEctions (ERNIE) members.
• Erasmus MC-Sophia Children's Hospital, Department of General Pediatrics, Rotterdam, The Netherlands.
• Plos One. 2014 Jan 1; 9 (3): e90847.

ObjectiveEarly recognition and treatment of febrile children with serious infections (SI) improves prognosis, however, early detection can be difficult. We aimed to validate the predictive rule-in value of the National Institute for Health and Clinical Excellence (NICE) most severe alarming signs or symptoms to identify SI in children.Design, Setting And ParticipantsThe 16 most severe ("red") features of the NICE traffic light system were validated in seven different primary care and emergency department settings, including 6,260 children presenting with acute illness.Main Outcome MeasuresWe focussed on the individual predictive value of single red features for SI and their combinations. Results were presented as positive likelihood ratios, sensitivities and specificities. We categorised "general" and "disease-specific" red features. Changes in pre-test probability versus post-test probability for SI were visualised in Fagan nomograms.ResultsAlmost all red features had rule-in value for SI, but only four individual red features substantially raised the probability of SI in more than one dataset: "does not wake/stay awake", "reduced skin turgor", "non-blanching rash", and "focal neurological signs". The presence of ≥ 3 red features improved prediction of SI but still lacked strong rule-in value as likelihood ratios were below 5.ConclusionsThe rule-in value of the most severe alarming signs or symptoms of the NICE traffic light system for identifying children with SI was limited, even when multiple red features were present. Our study highlights the importance of assessing the predictive value of alarming signs in clinical guidelines prior to widespread implementation in routine practice.

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