Red Flag Conditions

Red flag features in children with musculoskeletal symptoms may indicate serious or life-threatening disease, including malignancy (e.g. leukaemia), infection (e.g. septic arthritis or osteomyelitis), or non-accidental injury. They may also be seen in inflammatory joint or muscle disease.

Children who are immunosuppressed (due to underlying disease or treatment) may not show typical features of sepsis. For these children, a low threshold for concern and early specialist advice is essential.

Clinical approach

Any child presenting with red flag features should be assessed urgently and managed as potentially serious until a clear alternative diagnosis is established. The differential diagnosis should remain broad and include infection, malignancy, non-accidental injury and inflammatory disease.

Clinicians should be particularly vigilant in children with systemic symptoms, rapidly progressive disease, or unexplained functional decline.

Further information is available:

• NICE guidance on child maltreatment
• NICE guidance on suspecting cancer in children 
• NICE guideline: fever in under 5s - assessment and initial management
• Cancer Research UK: signs and symptoms of childhood cancer

Key points for healthcare professionals

• Treat all red flag presentations as potentially serious until proven otherwise
• Consider infection, malignancy, non-accidental injury and inflammatory disease in the differential diagnosis
• Be aware that immunosuppressed children may not show typical signs of sepsis
• Use national guidance and escalate early to specialist teams when concerned