title: The Diagnostic Value of Capillary Refill Time for Detecting Serious Illness in Children: A Systematic Review and Meta-Analysis.
abstract: OBJECTIVE
  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.
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, United Kingdom.
authors.forename: Susannah
authors.initials: S
authors.lastname: Fleming
authors.affiliation: The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Gill
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, United Kingdom.
authors.forename: Caroline
authors.initials: C
authors.lastname: Jones
authors.affiliation: Child Health Institute, University of Washington, Seattle, Washington, United States of America.
authors.forename: James A
authors.initials: JA
authors.lastname: Taylor
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, United Kingdom.
authors.forename: Ann
authors.initials: A
authors.lastname: Van den Bruel
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, United Kingdom.
authors.forename: Carl
authors.initials: C
authors.lastname: Heneghan
authors.affiliation: Bodleian Health Care Libraries, University of Oxford, Oxford, Oxfordshire, United Kingdom.
authors.forename: Nia
authors.initials: N
authors.lastname: Roberts
authors.affiliation: Department of Family Medicine, University of Washington, Seattle, Washington, United States of America.
authors.forename: Matthew
authors.initials: M
authors.lastname: Thompson
mesh_terms: D001783:Blood Flow Velocity; D002196:Capillaries / Q000502:physiology*; D002648:Child; D003681:Dehydration / Q000175:diagnosis*; D019937:Diagnostic Techniques and Procedures; D005334:Fever / Q000503:physiopathology*; D006801:Humans; D012039:Regional Blood Flow / Q000502:physiology*; D012720:Severity of Illness Index