Our healthcare courses make everyone better

The Traffic Light System: Identifying Children at Risk of Deterioration

« Back to Articles

Children are not just small adults. They have different physiological and developmental characteristics that make them more vulnerable to serious illness and complications. Recognising and responding to children who are at risk of deterioration is a vital skill for health care providers, especially in primary care settings where most children are seen.

However, assessing children who are unwell can be challenging, as they may present with vague or non-specific symptoms, or mask their true condition until they reach a critical point. Moreover, there are many factors that can influence the decision to refer a child to a higher level of care, such as parental anxiety, clinical uncertainty, availability of resources, and local policies.

To help health care providers confidently assess unwell children, the National Institute for Health and Care Excellence (NICE) created the ‘traffic light’ system. This tool categorises children into ‘green’, ‘amber’, or ‘red’ depending on their consulting clinical features, corresponding to a low, intermediate, or high risk of serious illness, respectively.

The traffic light system is based on the best available evidence and expert consensus, and covers four domains: behaviour, circulation, respiratory, and other features. Each domain has a list of signs and symptoms that indicate the level of risk for the child. For example, in the behaviour domain, a child who is alert and responsive is green, a child who is not responding normally to social cues or has a decreased activity level is amber, and a child who is unconscious or has a weak or high-pitched cry is red.

The traffic light system is intended to be used as a guide, not a substitute for clinical judgement. It does not provide a diagnosis or a definitive management plan for the child. It simply helps to identify those children who need urgent attention and referral, and those who can be safely managed in primary care or at home.

The traffic light system has been widely adopted and endorsed by various organisations and authorities in the UK, such as the Royal College of Paediatrics and Child Health (RCPCH), NHS England, NHS Improvement, and the Healthcare Improvement Studies Institute (THIS Institute). It has also been incorporated into several training programmes and quality improvement initiatives for health care providers.

However, the traffic light system is not without limitations and challenges. Some of the issues that have been raised include:

Therefore, further research and development are needed to update or replace the system with more reliable and user-friendly tools that can support health care providers in paediatric telephone triage.

In addition to the traffic light system, health care providers should also be aware of other factors that may affect their assessment and decision-making in paediatric telephone triage. These include:

Health care providers should also be able to communicate effectively with children and their parents or caregivers over the phone. They should be able to establish rapport, elicit relevant information, provide clear advice, address any questions or concerns, and document the encounter accurately.

In conclusion, the traffic light system is a useful tool that can help health care providers identify children who are at risk of deterioration and decide on the appropriate level and location of care. However, it is not a perfect tool and it requires ongoing evaluation, regulation, education, and research to ensure its quality, safety, effectiveness, and sustainability. Health care providers should also consider other factors that may affect their paediatric telephone triage skills and outcomes.

Our virtual The Deteriorating Child course is designed for healthcare providers who want to improve their ability to identify and manage a child who is at risk of deterioration. You can find a summary of the course content and a registration application on our website.


Accuracy of the NICE traffic light system in children presenting to primary care: a retrospective cohort study. (2012, July 1). Retrieved from https://bjgp.org/content/72/719/e398

Traffic light system for identifying risk of serious illness in under 5s. (2019, November). Retrieved from https://www.nice.org.uk/g