DCH Core Tools

Why

Age under 3 months with a temperature of 38°C or more is itself a red feature. All infants under 3 months with fever of 38°C or more need paediatric specialist assessment, whatever they look like.

Why not the others

• Age-softens-it — A well appearance does not downgrade the risk — being under 3 months with 38°C or more is red by itself.
• Reassured-by-looks — Amber safety-netting is not enough for a febrile infant under 3 months; the age criterion mandates specialist assessment.
• Source-hunt-delay — Urine testing is appropriate but must not delay the specialist assessment this age band requires.

Why

Mottled skin, grunting, a respiratory rate above 60 and not staying awake when roused are each red features. Any red feature means urgent face-to-face paediatric specialist care.

Why not the others

• Rounds-down-to-amber — These are red features, not amber — mottling and grunting sit firmly in the high-risk column.
• Looks-can-settle — A grunting, poorly rousable child is never green; green needs normal colour, activity and cry.
• Treat-the-number — Antipyretics are for distress and do not change red-feature risk; delaying escalation to reassess is unsafe.

Why

Tachypnoea over 50 at 6 to 12 months, a capillary refill time of 3 seconds or more and dry mucous membranes are amber features. With no diagnosis, either arrange face-to-face specialist assessment or give a structured safety-net.

Why not the others

• Over-calls-red — None of these findings are red features; a refill of 3 seconds and RR of 52 are intermediate-risk amber.
• Under-calls-green — Dry membranes and a prolonged refill mean the child cannot be green, which requires moist membranes and normal circulation.
• Wrong-age-threshold — The amber tachypnoea threshold is over 50 for 6 to 12 months, so 52 is abnormal, not normal.

Why

Use paracetamol or ibuprofen when a feverish child is distressed, not routinely just to lower temperature. Do not give both simultaneously; alternate only if distress persists or recurs before the next dose.

Why not the others

• Double-dose — The two antipyretics should not be given at the same time.
• Treat-the-thermometer — Antipyretics are given for distress, not routinely to lower a number.
• Alternate-from-the-start — Alternating is only for persisting or recurring distress before the next dose, not a default plan.

Why

NICE NG143 now points to the NICE guideline on urinary tract infection in under 16s (NG224, 2022) for when to test the urine. In a feverish child with no obvious source, a urinary tract infection is the classic hidden cause, so urine testing is the step not to miss.

Why not the others

• Duration-lulls-you — Do not use duration of fever alone to decide risk; a shorter fever still warrants urine testing when the source is unclear.
• Blind-antibiotics — Empirical antibiotics without identifying the source skip the step of finding the hidden focus.
• Safety-net-only — A safety-net alone leaves the classic occult urinary source unlooked-for.

Why

Any immediately life-threatening feature — ABC compromise or a decreased conscious level — means an emergency 999 response, above the standard red-feature referral route.

Why not the others

• Too-slow-a-route — A routine specialist appointment is far too slow for a child with ABC compromise.
• Wrong-pathway — Benzylpenicillin belongs to the meningococcal pathway and there is no non-blanching rash here; observing in the surgery delays 999.
• Fatal-reassurance — Safety-netting an unrousable, compromised infant misses a life-threatening emergency.

Why

Fever plus a non-blanching rash means you suspect meningococcal disease and arrange immediate 999 transfer. For strongly suspected meningococcal disease, NICE NG240 (2024) advises IV or IM ceftriaxone or benzylpenicillin as soon as possible outside hospital, unless giving it would delay transfer.

Why not the others

• Antibiotic-before-transfer — Give benzylpenicillin at the earliest opportunity, but never delay the 999 transfer to do so.
• Confirm-before-act — A glass test does not need to precede transfer and can falsely reassure; the transfer comes first.
• Investigate-first — Bloods and swabs delay definitive care in a time-critical emergency.

Why

Benzylpenicillin is dosed by age (BNF doses for suspected meningococcal disease before hospital; NG240 gives no doses): under 1 year 300 mg, 1 to 9 years 600 mg, and 10 years and over 1200 mg. A 5-year-old receives 600 mg.

Why not the others

• Infant-dose — 300 mg is the under-1-year dose, too low for a 5-year-old.
• Older-child-dose — 1200 mg is reserved for 10 years and over.
• Wait-for-confirmation — Antibiotics are given at the earliest opportunity on suspicion, not withheld pending confirmation.

Why

Give parenteral benzylpenicillin at the earliest opportunity. NICE NG240 (2024, 1.2.6) withholds antibiotics outside hospital only if the person has a severe allergy to ceftriaxone or benzylpenicillin — a previous mild rash alone is not a reason to withhold.

Why not the others

• Rash-equals-allergy — A previous mild rash is not a severe allergy and does not justify withholding a potentially life-saving antibiotic.
• Over-cautious-hold — Only a severe antibiotic allergy warrants withholding (NG240); a mild reaction history does not.
• Delays-the-drug — The antibiotic is given at the earliest opportunity before or during transfer, not deferred until after arrival.

Why

Early meningococcal disease often begins with a blanching maculopapular rash or none at all. A negative glass test does not exclude it, and parents must be told this explicitly.

Why not the others

• False-all-clear — A negative glass test does not rule out early meningococcal disease.
• Blanching-equals-benign — A blanching rash can be the early phase of meningococcal disease, so a safety-net is still essential.
• Wait-and-repeat — Deferring assessment to repeat the test lets a rapidly progressive illness advance untreated.

Why

Petechiae confined to the superior vena cava distribution, above the nipple line, in a well and afebrile child with vigorous coughing or vomiting are usually mechanical — but only if the child is entirely well. Even then, there is no good evidence that the pattern alone makes it safe to send a child home without a period of observation or blood tests, so local paediatric guidance applies.

Why not the others

• Over-calls-sepsis — In a well, afebrile child with a clear mechanical cause and SVC-distribution petechiae, definite meningococcal disease is not the most likely explanation — but the safe plan is still observation under local guidance, not discharge on the pattern alone.
• Wrong-mechanism — The distribution and cough or vomiting history point to a mechanical cause, not allergy.
• Drops-the-guard — Even a mechanical pattern is only benign while the child stays entirely well, so vigilance remains.

Why

Meningococcal disease is a notifiable disease. Notify the local health protection team so contacts can be given chemoprophylaxis; the duty sits with the doctor who suspects it.

Why not the others

• Wait-for-confirmation — Notification is on suspicion of a notifiable disease, not after laboratory confirmation.
• Passes-the-buck — The duty sits with the doctor who suspects it, not solely with the receiving hospital.
• Informal-only — Contacts need formal chemoprophylaxis arranged through the health protection team, not word of mouth.

Why

In bronchiolitis, NICE NG9 (1.1.9) advises immediate referral for emergency care, usually by 999, for apnoea, a child who looks seriously unwell, severe respiratory distress such as grunting, marked chest recession or a rate over 70, or central cyanosis. This baby has all three signs of severe distress. Persistent saturations below 92% in air are, on their own, a reason to consider hospital referral (1.1.8), not a 999 criterion.

Why not the others

• Bronchodilator-reflex — Salbutamol has no role in bronchiolitis and delays the emergency response this child needs.
• Steroid-reflex — Steroids are not used in bronchiolitis, and discharge is unsafe with saturations of 90 percent.
• Too-slow-a-route — Severe distress with hypoxia needs an immediate 999 response, not a routine admission.

Why

Bronchiolitis management is supportive only. Do not give antibiotics, salbutamol, ipratropium, nebulised adrenaline, montelukast, steroids or hypertonic saline; give feeding, fluid and red-flag advice and address smoke exposure.

Why not the others

• Antibiotic-reflex — Antibiotics are not indicated in bronchiolitis, which is viral and self-limiting.
• Nebuliser-reflex — Salbutamol and ipratropium have no role in bronchiolitis.
• Steroid-reflex — Steroids are not used in bronchiolitis; management is supportive only.

Why

A single dose of oral dexamethasone 0.15 mg/kg is given regardless of severity, then home with a safety-net. Oral prednisolone or nebulised budesonide are alternatives.

Why not the others

• Withholds-in-mild — Dexamethasone is given regardless of severity, not only for stridor at rest.
• Over-treats — Nebulised adrenaline and antibiotics are not the management of mild croup.
• Examines-the-throat — Do not examine the throat in a child with possible upper-airway obstruction.

Why

Drooling, a toxic appearance, sitting forward, a quiet stridor and inability to swallow point to epiglottitis or bacterial tracheitis. Call 999 without distressing the child and do not examine the throat.

Why not the others

• Look-in-the-throat — Examining the throat can precipitate complete airway obstruction and is contraindicated.
• Mistakes-for-croup — This is not simple croup; steroids and discharge would be dangerous.
• Under-treats — Oral antibiotics and next-day review are far too slow for an impending airway emergency.

Why

In 5 to 16 year olds under NG245, measure FeNO first and diagnose asthma if it is 35 ppb or more. If not raised or unavailable, move to spirometry with bronchodilator reversibility, then peak-flow variability or specialist tests.

Why not the others

• Symptoms-alone — Do not diagnose asthma on symptoms alone; objective testing is required.
• Treatment-trial — A trial of treatment is not an acceptable way to make the diagnosis.
• Wrong-order — Peak-flow variability is a later step, not the first-line test.

Why

First-line for 5 to 11 year olds is a twice-daily low-dose inhaled corticosteroid plus an as-needed salbutamol reliever. If uncontrolled, check technique, adherence and triggers first, then consider paediatric low-dose MART — NG245 puts MART next for a child assessed as able to manage the regimen, and reserves adding an LTRA for a child who cannot.

Why not the others

• Reliever-only — A reliever alone leaves the underlying inflammation untreated and is not first-line maintenance.
• LTRA-first — An LTRA is an add-on if uncontrolled, not the initial sole preventer.
• Jumps-to-MART — Paediatric low-dose MART is the next step if twice-daily ICS does not control asthma (NG245 1.8.2, for a child able to manage the regimen), not the starting regimen.

Why

On the UK-WHO chart, correct for gestation if born before 37 weeks: until 1 year for 32 to 36 weeks, and until 2 years for under 32 weeks. A 33-weeker is corrected until 1 year.

Why not the others

• Forgets-to-correct — A baby born before 37 weeks must have gestation corrected, or you will misread the centile.
• Over-corrects — Correcting until 2 years applies to under 32 weeks, not 32 to 36 weeks.
• Wrong-section — The preterm section is used only until 42 weeks’ gestation; after that, measurements go on the main chart with gestational correction.

Why

NG75 thresholds depend on birthweight centile: a fall of 1 or more spaces if birthweight was below the 9th, 2 or more if 9th to 91st, and 3 or more if above the 91st, or a current weight below the 2nd centile. A 50th-centile birthweight uses the 2-space threshold.

Why not the others

• Low-birthweight-rule — A 1-space fall is the threshold for a birthweight below the 9th centile, not the 9th to 91st band.
• High-birthweight-rule — A 3-space fall applies to birthweight above the 91st centile.
• Wrong-centile-floor — The absolute cut-off in NG75 is a current weight below the 2nd centile, not the 0.4th.

Why

In the early days, a loss of more than 10% of birthweight is the threshold for concern, prompting clinical assessment, a feeding history and observation of a feed. Most babies regain birthweight by around 3 weeks.

Why not the others

• Blanket-reassurance — A loss of more than 10 percent is above the threshold for concern and should not be dismissed as always normal.
• Investigation-reflex — Investigations are not routine; the first step is to look for a feeding cause, the commonest reason.
• Wrong-timescale — Most babies regain birthweight by around 3 weeks, not 6 weeks.

Why

Median milestones are just medians: walking unaided is about 12 months. Not walking by 18 months is the red flag that mandates referral, so a 13-month-old with otherwise normal development can be reassured.

Why not the others

• Median-as-deadline — The median is not a cut-off; many typically developing children walk a little after 12 months.
• Jumps-to-CK — Creatine kinase is checked for boys not walking by 18 months, not for every 13-month-old.
• Over-labels — A single milestone slightly beyond its median does not constitute global developmental delay.

Why

Hand preference before 12 months is a developmental red flag because it can indicate a hemiplegia, and it warrants referral.

Why not the others

• Early-handedness-normal — Established handedness before 12 months is abnormal, not a sign of advanced development.
• Waits-too-long — This red flag warrants referral now, not simply a review months later.
• Dismisses-the-flag — Hand preference is not expected in infancy and here should prompt concern about hemiplegia.

Why

Limited social smiling and eye contact, no response to name, reduced joint attention and pointing, delayed or unusual speech and repetitive rigid play are CG128 features that should prompt referral to the autism team.

Why not the others

• Late-talker-excuse — This cluster goes well beyond late talking and should not be watched for a year.
• Blames-hearing-only — Attributing the whole picture to hearing alone misses the social-communication features of autism.
• Delays-referral — Waiting until school entry delays access to the autism team when features are already present.