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Capillary refill time in sick children: a clinical guide for general practice

Authors:
Susannah Fleming at University of Oxford
Susannah Fleming
Peter John Gill at University of Toronto
Peter John Gill
Ann Van den Bruel at KU Leuven
Ann Van den Bruel
Matthew Thompson at University of Washington Seattle
Matthew Thompson
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Capillary refill time (CRT) is a simple and quick test requiring minimal equipment or time to perform. Prolonged CRT is a ‘red flag’ feature, identifying children with increased risk of significant morbidity or mortality.1–4 Although national and international guidelines, including National Institute for Health and Care Excellence guidelines, recommend the use of CRT as part of the initial assessment of unwell children,1,2 it is infrequently measured in general practice.5 As there is no evidence for a relationship between CRT and blood pressure,6 CRT should not be used as a surrogate for blood pressure in children. There is, however, limited evidence to support a relationship between CRT and arterial blood flow, as well as other invasive cardiovascular parameters, such as superior vena cava oxygenation and core–peripheral temperature gap.6 Therefore, CRT is likely to have some value as a measure of peripheral perfusion. The choice of site (for example, finger, hand, foot, or chest) at which CRT is measured can result in significantly different values. CRT can also be affected by the duration of pressure, and the ambient and skin temperatures, with longer duration of pressure and lower temperatures resulting in longer CRTs.6 The use of a timer to measure CRT is associated with greater …
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Capillary refill time in sick children:
a clinical guide for general practice
Susannah Fleming, Peter J Gill, Ann Van den Bruel and Matthew Thompson
Clinical Intelligence
British Journal of General Practice, November 2016 587
INTRODUCTION
Capillary refill time (CRT) is a simple and
quick test requiring minimal equipment or
time to perform. Prolonged CRT is a ‘red flag’
feature, identifying children with increased
risk of significant morbidity or mortality.1–4
Although national and international
guidelines, including National Institute for
Health and Care Excellence guidelines,
recommend the use of CRT as part of the
initial assessment of unwell children,1,2 it is
infrequently measured in general practice.5
WHAT DOES CRT MEASURE?
As there is no evidence for a relationship
between CRT and blood pressure,6 CRT
should not be used as a surrogate for blood
pressure in children. There is, however,
limited evidence to support a relationship
between CRT and arterial blood flow, as well
as other invasive cardiovascular parameters,
such as superior vena cava oxygenation
and core–peripheral temperature gap.6
Therefore, CRT is likely to have some value
as a measure of peripheral perfusion.
HOW SHOULD CRT BE MEASURED?
The choice of site (for example, finger, hand,
foot, or chest) at which CRT is measured can
result in significantly different values. CRT can
also be affected by the duration of pressure,
and the ambient and skin temperatures,
with longer duration of pressure and lower
temperatures resulting in longer CRTs.6
The use of a timer to measure CRT is
associated with greater inter-observer
reliability.6 Because a timer (for example, a
watch) is required for measurement of other
vital signs such as heart rate and respiratory
rate, it seems reasonable to recommend
its use in the measurement of CRT. A
consistent method of CRT measurement
should be adopted to ensure that repeated
measurements are comparable. We
recommend applying moderate pressure for
5 seconds on the finger (Figure 1), a technique
that is used in much of the existing literature.
We also suggest that clinicians understand
the upper limit of normal in healthy children.
Measurements of CRT should ideally be
documented as a precise time, for example,
‘4 seconds’, rather than using ambiguous
terminology such as ‘normal’ or ‘prolonged’.
Where a cut-off is used, we recommend the
use of inclusive textual descriptions, such as
‘2 seconds or less’ or ‘3 seconds or more’.
The use of mathematical inequality symbols
such as ‘<2s’ or ‘≥3s’ can lead to confusion as
measurements are made in whole seconds;
this terminology should be avoided (Box 1).
Susannah Fleming, MEng, DPhil, quantitative
researcher; Ann Van den Bruel, MD, PhD,
associate professo r, Nuffield Department of
Primary Care Health Sciences, University of
Oxford, Oxford. Peter J Gill, MD, DPhil, MSc,
paediatric resident, Department of Pediatrics,
the Hospital for Sick Children, University of
Toronto, Toronto. Matthew Thompson, MBChB,
DPhil, interim chair, Department of Family
Medicine, University of Washington, Seattle.
Address for correspondence
Susannah Fleming, Nuffield Department of
Primary Care Health Sciences, University
of Oxford, Radcliffe Observatory Quarter,
Woodstock Road, Oxford, OX2 6GG, UK.
E-mail: susannah.fleming@phc.ox.ac.uk
Submitted: 11 February 2016; final acceptance:
18 February 2016.
©British Journal of General Practice 2016;
66: 587–588.
DOI: 10.3399/bjgp16X687925
Figure 1. Measuring capillary refill time on the finger. © Nazir Hamid.
WHAT IS THE NORMAL RANGE OF CRT IN
CHILDREN?
Data on normal ranges of CRT in children
are complicated by variations in site and
pressing time.6 In healthy children, a CRT of
2 seconds or less should be expected when
measured on the finger. If the foot or chest
is used for assessment, CRTs of 4 seconds
or less should be considered normal. CRTs
in neonates (up to 7 days of age) may be
longer than in older infants and children,
with the upper limit of normal ranging from
5–7 seconds.6
There is no evidence that CRT varies
significantly with age after the neonatal
period. Studies suggest that core
temperature does not have a clinically
relevant effect on CRT; no correction
is required to take account of fever or
hypothermia.
WHAT IS THE DIAGNOSTIC AND
PROGNOSTIC VALUE OF CRT?
Studies assessing the diagnostic and
prognostic value of CRT in children typically
use cut-offs of between 2 and 3 seconds
to define a ‘prolonged’ measurement. This
is consistent with our suggested cut-off
of 3 seconds or more to define ‘abnormal’
CRT in infants and children over 7 days
of age. Despite widespread use of CRT in
primary care, there is very little evidence on
the diagnostic or prognostic value of CRT in
the primary care setting; recommendations
were largely generalised from data obtained
in emergency or secondary care.
Studies of children attending emergency
departments with vomiting and diarrhoea
show that prolonged CRT has high specificity
of between 88% and 94% for identifying
children with moderate dehydration (5% or
more).4 In addition, several studies show
that prolonged CRT has high specificity for
predicting a variety of serious conditions in
children, including meningitis, sepsis, and
hypoxia, along with the need for hospital
admission. Odds ratios of 2–5 are reported
for urinary tract infections and pneumonia,
supporting the suggestion that a prolonged
CRT is a red flag for serious illness in
children, but, importantly, a normal CRT
does not make a serious illness less likely.4
Although studies from settings with high
mortality (low income or high acuity) show
that prolonged CRT is predictive of death,
with a specificity of 92% (95% confidence
interval = 89 to 95%), we do not know if
these results apply to children in lower-
acuity settings.4 Again, sensitivity was low
(35%), meaning that a normal CRT should
not be used for reassurance.
CONCLUSION
A normal CRT test should not be used
to rule out serious illness in children.
However, a CRT of 3 seconds or more
should be considered a ‘red flag’, indicating
that a child is at higher risk of serious
illness, because the test has high specificity
and positive likelihood ratios for a variety of
serious outcomes. As there remain some
uncertainties around the reliability of CRT
measurements, it is appropriate to repeat
the measurement of an unexpectedly
abnormal CRT, paying particular attention
to ensure that it is measured correctly.
Funding
Ann Van den Bruel was supported by the
NIHR Diagnostic Evidence Cooperative
(DEC) Oxford.
Provenance
Commissioned; externally peer reviewed.
Competing interests
The authors have also published two
systematic reviews on the validity, normal
ranges, and diagnostic value of capillary
refill time in children, which were funded by
the European Union Seventh Framework
Programme.
Discuss this article
Contribute and read comments about
this article: bjgp.org/letters
Box 1. Recommended measurement method for CRT in children
• Use the finger as the preferred measurement site.
• Press for 5 seconds using moderate pressure.
• Ideally, measure at room temperature (20–25°C) irrespective of the child’s body temperature. Allow
time for skin temperature to acclimatise if the child has recently been moved from a warmer or colder
environment.
• Use a timer (for example, a watch) to count the seconds it takes for the finger to regain its original colour.
• An abnormal CRT in infants and children over 7 days of age is 3 seconds or more; a normal CRT is
2 seconds or less. A CRT measurement of between 2 and 3 seconds may be considered ‘borderline
abnormal’, but some healthy children may have CRT as long as 2.5 seconds.
• Record measurements using the actual number of seconds (for example, ‘4 seconds’ or ‘2 seconds or
less’) rather than using terms such as ‘prolonged’ or mathematical symbols.
REFERENCES
1. World Health Organization, Department
of Child and Adolescent Health and
Development.
Management of the child with
a serious infection or severe malnutrition:
guidelines for care at the first-referral level in
developing countries
. Geneva: WHO, 2000.
2. National Institute for Health and Care
Excellence.
Fever in under 5s: assessment
and initial management
.
CG160
. London:
NICE, 2013. https://www.nice.org.uk/
guidance/cg160 (accessed 4 Oct 2016).
3. Van den Bruel A, Haj-Hassan T, Thompson
M,
et al
. European Research Network on
Recognising Serious Infection investigators.
Diagnostic value of clinical features at
presentation to identify serious infection in
children in developed countries: a systematic
review.
Lancet
2010; 375(9717): 834–845.
4. Fleming S, Gill P, Jones C,
et al.
The
diagnostic value of capillary refill time for
detecting serious illness in children: a
systematic review and meta-analysis.
PLoS
One
2015; 10(9): e0138155.
5. Blacklock C, Haj-Hassan TA, Thompson MJ.
When and how do GPs record vital signs
in children with acute infections? A cross-
sectional study.
Br J Gen Pract
2012; DOI:
10.3399/bjgp12X656810.
6. Fleming S, Gill P, Jones C,
et al.
Validity and
reliability of measurement of capillary refill
time in children: a systematic review.
Arch Dis
Child
2015; 100(3): 239–249.
588 British Journal of General Practice, November 2016
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... In newborns (up to seven days old), the upper limit of normal may be 5-7 s (16), which is related to their skin immaturity. With these limits, a sensitivity of 55% and a specificity of 81% have been reported for detecting low blood flow (22)(23)(24). ...
... With these limits, a sensitivity of 55% and a specificity of 81% have been reported for detecting low blood flow (22)(23)(24). In healthy children, a normal CRT of approximately two seconds or less has been recorded when measured on the index finger, or four seconds or less if measured on the foot or chest (16). Studies in adults have found a wider variation, with an average time of 1.9 s (95th percentile 3.5 s) (21), 7% lower in men than women, and an average 3.3% increase in seconds per decade of life (6, 21) ( Table 2). ...
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Validity and reliability of measurement of capillary refill time in children: A systematic review
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  • Sep 2014
Background Most guidelines recommend the use of capillary refill time (CRT) as part of the routine assessment of unwell children, but there is little consensus on the optimum method of measurement and cut-off time. Methods We searched Medline (from 1948), Embase (from 1980) and CINAHL (from 1991) to June 2014 to identify studies with information on the normal range of CRT in healthy children, the validity of CRT compared with reference standard measures of haemodynamic status, reliability and factors influencing measurement of CRT, such as body site, pressing time and temperature. Findings We included 21 studies on 1915 children. Four studies provided information on the relationship between CRT and measures of cardiovascular status, 13 provided data on the normal range of CRT, 7 provided data on reliability and 10 assessed the effect of various confounding factors. In children over 7 days of age, the upper limit of normal CRT is approximately 2 s when measured on a finger, and 4 s when measured on the chest or foot, irrespective of whether the child is feverish or not. Longer pressing times and ambient temperature outside 20°C–25°C are associated with longer CRT. Evidence suggests that the use of stopwatches reduces variability between observers. Interpretation We recommend use of the following standardised CRT method of measurement: press on the finger for 5 s using moderate pressure at an ambient temperature of 20°C–25°C. A capillary refill time of 3 s or more should be considered abnormal.
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  • Oct 2012
  • BRIT J GEN PRACT
NICE recommendations and evidence from ambulatory settings promotes the use of vital signs in identifying serious infections in children. This appears to differ from usual clinical practice where GPs report measuring vital signs infrequently. To identify frequency of vital sign documentation by GPs, in the assessment of children with acute infections in primary care. Observational study in 15 general practice surgeries in Oxfordshire and Somerset, UK. A standardised proforma was used to extract consultation details including documentation of numerical vital signs, and words or phrases used by the GP in assessing vital signs, for 850 children aged 1 month to 16 years presenting with acute infection. Of the children presenting with acute infections 31.6% had one or more numerical vital signs recorded (269, 31.6%), however GP recording rate improved if free text proxies were also considered: at least one vital sign was then recorded in over half (54.1%) of children. In those with recorded numerical values for vital signs, the most frequent was temperature (210, 24.7%), followed by heart rate (62, 7.3%), respiratory rate (58, 6.8%), and capillary refill time (36, 4.2%). Words or phrases for vital signs were documented infrequently (temperature 17.6%, respiratory rate 14.6%, capillary refill time 12.5%, and heart rate 0.5%), Text relating to global assessment was documented in 313/850 (36.8%) of consultations. GPs record vital signs using words and phrases as well as numerical methods, although overall documentation of vital signs is infrequent in children presenting with acute infections.
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Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: A systematic review
Article
  • Mar 2010
  • LANCET
Our aim was to identify which clinical features have value in confirming or excluding the possibility of serious infection in children presenting to ambulatory care settings in developed countries. In this systematic review, we searched electronic databases (Medline, Embase, DARE, CINAHL), reference lists of relevant studies, and contacted experts to identify articles assessing clinical features of serious infection in children. 1939 potentially relevant studies were identified. Studies were selected on the basis of six criteria: design (studies of diagnostic accuracy or prediction rules), participants (otherwise healthy children aged 1 month to 18 years), setting (ambulatory care), outcome (serious infection), features assessed (assessable in ambulatory care setting), and sufficient data reported. Quality assessment was based on the Quality Assessment of Diagnostic Accuracy Studies criteria. We calculated likelihood ratios for the presence (positive likelihood ratio) or absence (negative likelihood ratio) of each clinical feature and pre-test and post-test probabilities of the outcome. Clinical features with a positive likelihood ratio of more than 5.0 were deemed red flags (ie, warning signs for serious infection); features with a negative likelihood ratio of less than 0.2 were deemed rule-out signs. 30 studies were included in the analysis. Cyanosis (positive likelihood ratio range 2.66-52.20), rapid breathing (1.26-9.78), poor peripheral perfusion (2.39-38.80), and petechial rash (6.18-83.70) were identified as red flags in several studies. Parental concern (positive likelihood ratio 14.40, 95% CI 9.30-22.10) and clinician instinct (positive likelihood ratio 23.50, 95 % CI 16.80-32.70) were identified as strong red flags in one primary care study. Temperature of 40 degrees C or more has value as a red flag in settings with a low prevalence of serious infection. No single clinical feature has rule-out value but some combinations can be used to exclude the possibility of serious infection-for example, pneumonia is very unlikely (negative likelihood ratio 0.07, 95% CI 0.01-0.46) if the child is not short of breath and there is no parental concern. The Yale Observation Scale had little value in confirming (positive likelihood ratio range 1.10-6.70) or excluding (negative likelihood ratio range 0.16-0.97) the possibility of serious infection. The red flags for serious infection that we identified should be used routinely, but serious illness will still be missed without effective use of precautionary measures. We now need to identify the level of risk at which clinical action should be taken. Health Technology Assessment and National Institute for Health Research National School for Primary Care Research.
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