Behaviour
|
Any
|
No response to social cues
Appears ill to a healthcare professional
Does not wake, or if roused does not stay awake
Weak high-pitched or continuous cry
|
Not responding normally to social cues
No smile
Wakes only with prolonged stimulation
Decreased activity
Parent or carer concern that child is behaving differently from usual
|
Respiratory
|
Any
|
Grunting
Apnoea
Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline
See recommendation 1.4.10 for safety warnings about the use of pulse oximeters
|
Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline
Nasal flaring
See recommendation 1.4.10 for safety warnings about the use of pulse oximeters
|
Respiratory
|
Under 1 year
|
Raised respiratory rate: 60 breaths per minute or more
|
Raised respiratory rate: 50 to 59 breaths per minute
|
Respiratory
|
1 to 2 years
|
Raised respiratory rate: 50 breaths per minute or more
|
Raised respiratory rate: 40 to 49 breaths per minute
|
Respiratory
|
3 to 4 years
|
Raised respiratory rate: 40 breaths per minute or more
|
Raised respiratory rate: 35 to 39 breaths per minute
|
Circulation and hydration
|
Any
|
Bradycardia: heart rate less than 60 beats per minute
|
Capillary refill time of 3 seconds or more
Reduced urine output
For catheterised patients, passed less than 1 ml/kg of urine per hour
|
Circulation and hydration
|
Under 1 year
|
Rapid heart rate: 160 beats per minute or more
|
Rapid heart rate: 150 to 159 beats per minute
|
Circulation and hydration
|
1 to 2 years
|
Rapid heart rate: 150 beats per minute or more
|
Rapid heart rate: 140 to 149 beats per minute
|
Circulation and hydration
|
3 to 4 years
|
Rapid heart rate: 140 beats per minute or more
|
Rapid heart rate: 130 to 139 beats per minute
|
Skin
|
Any
|
Mottled or ashen appearance
Cyanosis of skin, lips or tongue
Non-blanching petechial or purpuric rash
For signs and symptoms of meningococcal disease, see the NICE guideline on bacterial meningitis and meningococcal disease.
|
Pallor of skin, lips or tongue
|
Temperature
|
Any
|
Less than 36ºC
|
-
|
Temperature
|
Under 3 months
|
38°C or more
|
-
|
Temperature
|
3 to 6 months
|
-
|
39°C or more
|
Other
|
Any
|
-
|
Leg pain
Cold hands or feet
|