Paediatric triage - behaviour breathing and body colour BBB
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How to Quickly Assess an Unwell Child Using the BBB Approach
The BBB Approach — Behaviour, Breathing, and Body Colour — is a simple and highly effective method for recognising a seriously unwell child. It helps you identify early warning signs before advanced monitoring or medical help arrives.
This assessment method is based on the Resuscitation Council UK and ERC 2025 paediatric guidelines.
🔵 B1: Behaviour
Start by observing how the child is acting. Behaviour often gives the earliest and clearest indication that something is wrong.
Ask yourself: Are they alert, interactive, and behaving normally for their age?
Concerning Behaviour Includes:
- Reduced consciousness or difficulty waking
- Floppiness or unusual stiffness
- Seizures or abnormal movements
- Confusion, agitation, or unusual behaviour
- Inconsolable crying
- Inability to move one or more limbs
- Sudden inability to speak or walk
- Appearing to be in severe pain
Abnormal behaviour suggests that the brain may not be receiving enough oxygen, blood flow, or glucose, meaning urgent assessment is required.
🟢 B2: Breathing
Next, assess how the child is breathing. Breathing changes are often seen in serious illness or injury.
Warning Signs to Look For:
- Struggling to take a deep breath
- Working hard to breathe — fast breathing, grunting, flaring nostrils, or chest indrawing
- Extra noises such as wheezing or stridor
- Breathing that is too fast, too slow, or irregular
- Stopping breathing altogether
- Adopting an unusual posture to help breathing, such as leaning forward
If any of these signs are present, treat the situation as an emergency. The child may be becoming tired or close to respiratory failure, so immediate support is essential.
🟡 B3: Body Colour
Finally, examine the child's body colour to assess their circulation and oxygenation.
Concerning Body Colour Signs:
- Cyanosis — blue or grey colouring of the lips, tongue, or fingertips
- Pale, ashen, or mottled skin
- Cool or unusually cold skin
- For darker skin tones, check lips, gums, or palms for changes
These signs may indicate poor circulation, shock, or low oxygen levels and require urgent medical review.
Understanding the BBB Triangle
Think of the BBB assessment as a triangle where each side is linked:
- Behaviour reflects brain function
- Breathing reflects oxygen delivery
- Body Colour reflects circulation
A problem in one can quickly affect the others. If two or more areas are abnormal, the child is likely to be seriously unwell and needs immediate medical help.
Why the BBB Approach Matters
The BBB assessment is a fast and reliable way to identify a sick child before their condition deteriorates. Always remember:
Behaviour • Breathing • Body Colour
If you are ever unsure, treat it as an emergency and get help straight away. Early recognition truly saves lives.
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