NICE traffic light system

Question 1

Red flag for colour

Answer 1

Pale/mottled/ashen/blue skin

Question 2

Red flags for activity

Answer 2

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

Question 3

Red flags for respiratory

Answer 3

Grunting

Tachypnoea: respiratory rate >60 breaths/minute

Moderate or severe chest indrawing

Question 4

Red flags for circualtion

Answer 4

Reduced skin turgor

Question 5

Other red flags

Answer 5

Age <3 months, temperature >=38°C

Non-blanching rash

Bulging fontanelle

Neck stiffness

Status epilepticus

Focal neurological signs

Focal seizures

Question 6

Amber for colour

Answer 6

Pallor reported by parent/carer

Question 7

Amber for activity

Answer 7

Not responding normally to social cues

No smile

Wakes only with prolonged stimulation

Decreased activity

Question 8

Amber for resp

Answer 8

Nasal flaring

Tachypnoea: respiratory rate

> 50 breaths per minute, age 6 to 12 months;

> 40 breaths per minute, age more than 12 months

Oxygen saturation less than or equal to 95% in air

Crackles in the chest

Question 9

Amber for circualtion

Answer 9

More than 160 beats per minute, age less than 12 months

More than 150 beats per minute, age 12 to 24 months

More than 140 beats per minute, age 2 to 5 years

Capillary refill time more than or equal to 3 seconds

Dry mucous membranes

Poor feeding in infants

Reduced urine output

Question 10

Amber for other

Answer 10

Age 3 to 6 months, temperature more than or equal to 39°C

Fever for more than or equal to 5 days

Rigors

Swelling of a limb or joint

Non-weight bearing limb or not using an extremity