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Doctors need to take note of parental concern, one of several red flags that can indicate a serious childhood infection

3 February 2010

A set of warning signs – or red flags – that can be used routinely by doctors to help spot the few children that may have a serious infection from the many with minor coughs and colds, has been identified by a European team led by researchers at the Katholieke Universiteit Leuven in Belgium and Oxford University.

They were able to put together the list of red flags through a review of the available research evidence. Their systematic review is published in the medical journal, the Lancet.

Serious infections like meningitis, pneumonia or sepsis are rare in developed countries and can be difficult to diagnose among the many children coming into GP surgeries, paediatric assessment units and emergency departments. Detecting serious infections rapidly improves prognosis by allowing appropriate actions to be taken, such as referral to hospital.

‘For doctors, it’s a bit like finding a needle in a haystack,’ says Dr Matthew Thompson of the Department of Primary Health Care at the University of Oxford, a co-author of the study. ‘Serious infections are rare and getting increasingly rarer thanks to vaccinations. Identifying that one child out of all those many with minor ailments is difficult. It is complicated further as the child may be seen at any early stage of infection before it is possible to recognise its severity.

’Rapid breathing, poor blood circulation at the skin and extremities, and rashes of small purple red spots were identified as red flags that can help confirm the possibility of a serious infection. A high temperature over 40°C is a warning sign among children seen in surgeries and paediatric assessment units. However, the absence of these clinical signs could not rule out serious illness.

‘Doctors should routinely check for these warning signs in every sick child they see,’ says lead author Dr Ann Van den Bruel, who has just moved to the University of Oxford from KU Leuven and who is also a GP. ‘For example, not all GPs will check a child’s temperature, whereas we would now suggest this is done on all occasions.

The doctor’s instinct or gut feeling is the best clinical predictor of serious infection. Parental concern is also a good warning sign that an illness is serious among children being assessed at GP surgeries.

‘As a GP, it’s important to always be alert to parents who are especially concerned about their child,’ says Dr Thompson, who is also a GP. ‘We should usually trust parents’ instincts, after all they will have nursed their child through many minor illnesses before and often can tell when something is different.

’ Dr Van den Bruel adds: ‘Parents shouldn’t try to assess these red flags themselves, it would only add to any uncertainty or anxiety they may already be feeling. However, parents can take heart that we found they are very good at picking up signs that their child is unwell.

‘Parental concern is a good diagnostic indicator for something being seriously wrong, and doctors need to take that into account in combination with other clinical information.

’Having identified these red flags, the research team now aims to develop guidelines for what actions should then be taken for the best outcomes, so that children are referred to hospitals quickly and only where appropriate.

For more information please contact the Press Office, University of Oxford on +44 (0)1865 280530 or press.office@admin.ox.ac.uk.

Notes to Editors:

Infections account for 1 in 5 childhood deaths in England, Wales and Northern Ireland, with the greatest number being among children aged 1–4 years.

Yet minor ailments are very common in children: each month, more than half of all children experience some illness (though not all of these illnesses would involve going to see a doctor). In GP surgeries, less than 1% of children assessed will have a serious illness.

Doctors need to do their best to diagnose the rare cases of serious infection while also reassuring potentially anxious parents of children with minor ailments.
In separate, previously published, research, Dr Thompson and colleagues found that half of meningitis cases are missed at first consultation in primary care. They showed that there was nothing necessarily amiss in the actions of the GPs, who followed clear guidelines, but the study highlighted the difficulties of identifying serious conditions at early stages when there may not be clear clinical signs.
The paper ‘Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: a systematic review’ by Ann Van den Bruel and colleagues is published in the Lancet.
The review was funded by the National Institute of Health Research Health Technology Assessment (NIHR HTA) programme. The full results of this review will publish in the HTA journal series in 2011. To sign up for an alert visit www.hta.ac.uk/1751.
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