Table 6

Identified predictors of serious bacterial infections and characteristics of the MTS (first edition)*11 14

Predictor of SBI identified by Van den Bruel et al11Positive discriminator of MTS
Global assessment
 Strong predictorsHeight of feverFever (U2–4)
Parental concern§
Clinician instinct that something is wrong
Clinical impression
Child appears ill§
 Intermediate predictorsNo obvious source of fever
Child behaviour
 Strong predictorsChanged crying behaviour§Inconsolable by parents (U3), prolonged
or uninterrupted crying (U3), not distractable (U3)
Child inconsolable§Inconsolable by parents (U3), prolonged
or uninterrupted crying (U3), not distractable (U3)
Child moaning
Child drowsyFails to react to parents (U2)
 Intermediate predictorsChild no longer smiles
Child is irritable§
Child is somnolentAltered level of consciousness (U2),
fails to react to parents (U2)
Child is reactive
Circulatory and respiratory features
 Strong predictorsCyanosisVery low SaO2 (U2), low SaO2 (U3)
Decreased breathing sounds
Short of breath§Inadequate breathing (U1), increased work of breathing (U2),
unable to talk in sentences (U2–3)
Rapid breathingIncreased work of breathing (U2)
Poor peripheral circulation**(Abnormal capillary refill), shock (U1)
 Intermediate predictorsChanged breathing pattern
Signs of URTI
 Strong predictorsMeningeal irritationSigns of meningism (U2)
Petechial rash§Non-blanching rash (U2), purpura (U2)
Seizures§Currently having a fit (U1)
UnconsciousnessAltered level of consciousness (U2), unresponsive child (U1)
 Intermediate predictorsAgeFever (U2–4),persistent vomiting (U3–4)
Underlying conditionSignificant medical history (U3),
significant cardiac history (U3)
Duration of fever or illness
Abnormal skin colour
Tummy ache§
TachycardiaAbnormal pulse (U2)
Specific predictors of meningitis
Child is irritable§
VomitingPersistent vomiting (U3–4)
Duration of fever or illness
Sought care in previous 48 h
Paresis or paralysisAcute neurological deficit (U2)
Specific predictors of meningococcal disease
VomitingPersistent vomiting (U3–4)
Specific predictors of pneumonia
WheezingWheeze (U3–4)
Specific predictors of bacteraemia
Child is irritable§
Child is lethargicUnresponsive (U1), floppy (U2),
altered level of consciousness (U2)
Functional status
AgeFever (U2–4), persistent vomiting (U3–4)
Referral status
  • * Predictors of dehydration as a result of gastro-enteritis are excluded from the table. Flowcharts not considered (as being irrelevant for febrile children at risk of SBI): burns and scalds, assault, abdominal pain in adults, collapsed adult, exposure to chemicals, falls, foreign body, GI bleeding, head injury, major trauma, mental illness, overdose and poisoning, pregnancy, PV bleeding, self-harm, sexually acquired infection, shortness of breath in adults, torso injury, unwell adult, wounds, major incidents.

  • Strong predictors are defined as LR+ >5.0 or LR– <0.2 in at least one of the studies considered in meta-analysis; intermediate predictors are defined as less helpful predictors in ruling in or ruling out the presence of SBI.11

  • Discriminators of fever: in the original MTS (first edition), the urgency of children with fever could be assessed with the positive discriminator ‘hot child’ (U2 in all relevant flowcharts); in the modified MTS (first edition), ‘hot child’ was altered to describe different urgency categories for different age groups in several commonly used flowcharts.18

  • § Predictor with flowchart describing the presenting problem (no specific urgency classification).

  • Urgency distribution of children with the discriminator ‘persisting vomiting’ depends on age in specific flowcharts in the modified first edition of the MTS18; the discriminators ‘unable to talk in sentences’ and ‘wheeze’ depend on the flowchart.

  • ** Positive discriminator only used in the special flowchart ‘major incidents’ and is not used in regular flowcharts.

  • GI, gastrointestinal; LR, likelihood ratio; MTS, Manchester triage system; PV, per vaginam; SBI, serious bacterial infection; URTI, upper respiratory tract infection.