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Meta-Analysis
. 2015 Sep 16;10(9):e0138155.
doi: 10.1371/journal.pone.0138155. eCollection 2015.

The Diagnostic Value of Capillary Refill Time for Detecting Serious Illness in Children: A Systematic Review and Meta-Analysis

Susannah Fleming  1 , Peter Gill  2 , Caroline Jones  1 , James A Taylor  3 , Ann Van den Bruel  1 , Carl Heneghan  1 , Nia Roberts  4 , Matthew Thompson  5
Affiliations
Meta-Analysis

The Diagnostic Value of Capillary Refill Time for Detecting Serious Illness in Children: A Systematic Review and Meta-Analysis

Susannah Fleming et al. PLoS One. .

Abstract

Importance: Capillary refill time (CRT) is widely recommended as part of the routine assessment of unwell children.

Objective: To determine the diagnostic value of capillary refill time for a range of serious outcomes in children.

Methods: We searched Medline, Embase and CINAHL from inception to June 2014. We included studies that measured both capillary refill time and a relevant clinical outcome such as mortality, dehydration, meningitis, or other serious illnesses in children aged up to 18 years of age. We screened 1,265 references, of which 24 papers were included in this review. Where sufficient studies were available, we conducted meta-analysis and constructed hierarchical summary ROC curves.

Results: Meta-analysis on the relationship between capillary refill time and mortality resulted in sensitivity of 34.6% (95% CI 23.9 to 47.1%), specificity 92.3% (88.6 to 94.8%), positive likelihood ratio 4.49 (3.06 to 6.57), and negative likelihood ratio 0.71 (0.60 to 0.84). Studies of children attending Emergency Departments with vomiting and diarrhea showed that capillary refill time had specificity of 89 to 94% for identifying 5% dehydration, but sensitivity ranged from 0 to 94%. This level of heterogeneity precluded formal meta-analysis of this outcome. Meta-analysis was not possible for other outcomes due to insufficient data, but we found consistently high specificity for a range of outcomes including meningitis, sepsis, admission to hospital, hypoxia, severity of illness and dengue.

Conclusions: Our results show that capillary refill time is a specific sign, indicating that it can be used as a "red-flag": children with prolonged capillary refill time have a four-fold risk of dying compared to children with normal capillary refill time. The low sensitivity means that a normal capillary refill time should not reassure clinicians.

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Conflict of interest statement

Competing Interests: The study received funding from the European Union Seventh Framework Programme (FP7/2007-2013) under grant agreement no 305292 for the program "Supporting Life"; SF was funded by a fellowship award from the National Institute for Health Research School for Primary Care Research (NIHR SPCR). The views represented are those of the author(s) and not necessarily those of the NIHR, the NHS or the Department of Health. PG received studentship funding from the Rhodes Trust, Alberta Innovates—Health Solutions, and the Canadian Institute of Health Research. There are no patents, products in development or marketed products to declare. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.

Figures

Fig 1
Fig 1. Flow chart for papers identified by the search strategy.
Fig 2
Fig 2. Summary of quality of included papers.
Fig 3
Fig 3. Hierarchical summary ROC curve showing diagnostic accuracy of CRT for predicting mortality.
Fig 4
Fig 4. Pre/post test probability plot of prolonged CRT for predicting mortality.
Markers show pre-test prevalence (blue), and post-test probabilities after positive (red) and negative (green) tests. Multiple results are shown for two studies: results are shown for two different cut-offs reported by Maitland et al,[22] and results from a subgroup analysis by Pamba and Maitland showing the performance for predicting death from different conditions[23].
Fig 5
Fig 5. Pre/post test probability plot of prolonged CRT for predicting significant dehydration and severe illness.
See this image and copyright information in PMC

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