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Red Flags

Clinical Features that suggest severe life threatening conditions:

Sepsis

  • Complete non-weight bearing
  • Pseudo-paralysis of limb
  • Any attempt to passively move the limb is resisted and causes extreme distress
  • Pain severe and non-remitting
  • Limb held in a position which accommodates increased joint volume due to effusion ; e.g a flexed knee with a mild effusion
  • Night pain and waking
  • Fever
  • Immunocompromised child - due to primary disease or medications
  • Back pain in the unwell child

Malignancy

  • Night pain
  • Pain severe and non-remitting
  • Bone pain
  • Pallor
  • Bruising
  • Lymphadenopathy
  • Hepatosplenomegaly
  • Anaemia, thrombocytopenia
  • Systemic symptoms (lethargy, weight loss, night sweats, fever)
  • Complete non-weight bearing
  • Back pain in the unwell child
  • Weight loss

Non-accidental injury

  • Delay in seeking medical attention
  • History inconsistent with pattern of injury
  • Explanation of injury incongruent with developmental stage of child
  • Repeated presentations
  • Un-witnessed injury
  • Patterns of injury suggestive of non-accidental injury (e.g. bruising over soft tissue areas, multiple bruises, bruises that carry the imprint of an implement or instrument)
  • Distinctive burns e.g. round cigarette burn, forced immersion burn
  • Complete non-weight bearing with occult fracture
  • Type of fracture  e.g. metaphyseal fracture, posterior rib fractures, skull fracture, any type of fracture in a non-ambulant child
  • Multiple injuries
  • Unkempt appearance and poor hygiene

Further information is available

NICE guidance regarding non-accidental injury

NICE Guidance on suspecting cancer in children 

NICE guidance on fever in young children 

We provide further information about red flags in the history and red flags in the examination.

The picture below shows red inflamed right shoulder due to septic arthritis

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