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Assessment and Initial Management of Feverish Illness in Children Younger Than 5 YearsSummary of NICE GuidanceBMJ  2007;334:1163-1164
What this presentation coversBackground to the guidelineKey recommendations Suggested actions Resources from NICE
Background: why this guideline mattersFeverish illness in children:is the most common reason for children to be taken to the doctoris a cause of concern for parents and carerscan be a result of a simple self-limiting infection or a      life-threatening infectioncan have no apparent source.
Key recommendations
The Traffic Light SystemTool for identifying the likelihood of serious illnessChildren with only symptoms and signs in the ‘green’ column are at low riskChildren with one or more symptom or sign in the ‘amber’ column are at intermediate riskChildren with one or more symptom or sign in the ‘red’ column are at high risk
Traffic light system:
Traffic light system:
Traffic light system:
Detection of feverIn children aged 4 weeks to 5 years measure body temperature by:electronic thermometer in the axilla orchemical dot thermometer in the axilla orinfra-red tympanic thermometer. Use an electronic thermometer in the axilla for children younger than 4 weeks.
Clinical assessmentCheck for any immediately life-threatening features.Use traffic light system to check for symptoms and signs that predict the risk of serious illness.Look for a source of fever and check symptoms and signs associated with specific diseases.Measure and record temperature, heart rate, respiratory rate, capillary refill time and assess for dehydration.
Symptoms and signs of specific diseases
Symptoms and signs of specific diseases (2)
Do symptoms and/or signs suggest an immediately life-threatening illness? YesNoRefer immediately to emergency medical careLook for traffic light symptoms and signsIf all green features and no amber or redIf any amber features and no redIf any red featuresSend child for urgent assessment in a face-to-face setting within 2 hoursChild can be managed at home with appropriate care adviceSend child for assessment in a face-to-face setting.  Management by remote assessment
Management by a non-paediatric practitionerDo symptoms and/or signs suggest an immediately life-threatening illness?NoYesLook for traffic light features and symptoms and signs of specific diseasesRefer immediately to emergency medical careIf all green features and no amber or redIf any amber features and no diagnosis reachedIf any red featuresChild can be managed at home with appropriate care adviceProvide parents/carers with a safety net or refer to a paediatric specialist for further assessmentRefer child urgently to the care of a paediatric specialist
Management of children 3 months to 5 years by a paediatric specialist  Perform test for urinary tract infection.
  Assess for pneumonia.
  Do not perform routine blood tests or chest X-ray.Perform (unless deemed unnecessary)  urine test for urinary tract infection
  full blood count
  blood culture
  C-reactive protein.Perform chest x-ray if fever higher than 39°C and white blood cell count greater than 20 x 109/litre.Consider lumbar puncture if child is younger than 1-year old.Perform:  blood culture
  full blood count
  urine test for urinary tract infection
  C-reactive protein.Consider the following, as guided by clinical assessment:  lumbar puncture in children of all ages
  chest X-ray

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Fever in Children Younger Than 5 Years

  • 1. Assessment and Initial Management of Feverish Illness in Children Younger Than 5 YearsSummary of NICE GuidanceBMJ 2007;334:1163-1164
  • 2. What this presentation coversBackground to the guidelineKey recommendations Suggested actions Resources from NICE
  • 3. Background: why this guideline mattersFeverish illness in children:is the most common reason for children to be taken to the doctoris a cause of concern for parents and carerscan be a result of a simple self-limiting infection or a life-threatening infectioncan have no apparent source.
  • 5. The Traffic Light SystemTool for identifying the likelihood of serious illnessChildren with only symptoms and signs in the ‘green’ column are at low riskChildren with one or more symptom or sign in the ‘amber’ column are at intermediate riskChildren with one or more symptom or sign in the ‘red’ column are at high risk
  • 9. Detection of feverIn children aged 4 weeks to 5 years measure body temperature by:electronic thermometer in the axilla orchemical dot thermometer in the axilla orinfra-red tympanic thermometer. Use an electronic thermometer in the axilla for children younger than 4 weeks.
  • 10. Clinical assessmentCheck for any immediately life-threatening features.Use traffic light system to check for symptoms and signs that predict the risk of serious illness.Look for a source of fever and check symptoms and signs associated with specific diseases.Measure and record temperature, heart rate, respiratory rate, capillary refill time and assess for dehydration.
  • 11. Symptoms and signs of specific diseases
  • 12. Symptoms and signs of specific diseases (2)
  • 13. Do symptoms and/or signs suggest an immediately life-threatening illness? YesNoRefer immediately to emergency medical careLook for traffic light symptoms and signsIf all green features and no amber or redIf any amber features and no redIf any red featuresSend child for urgent assessment in a face-to-face setting within 2 hoursChild can be managed at home with appropriate care adviceSend child for assessment in a face-to-face setting. Management by remote assessment
  • 14. Management by a non-paediatric practitionerDo symptoms and/or signs suggest an immediately life-threatening illness?NoYesLook for traffic light features and symptoms and signs of specific diseasesRefer immediately to emergency medical careIf all green features and no amber or redIf any amber features and no diagnosis reachedIf any red featuresChild can be managed at home with appropriate care adviceProvide parents/carers with a safety net or refer to a paediatric specialist for further assessmentRefer child urgently to the care of a paediatric specialist
  • 15. Management of children 3 months to 5 years by a paediatric specialist Perform test for urinary tract infection.
  • 16. Assess for pneumonia.
  • 17. Do not perform routine blood tests or chest X-ray.Perform (unless deemed unnecessary) urine test for urinary tract infection
  • 18. full blood count
  • 19. blood culture
  • 20. C-reactive protein.Perform chest x-ray if fever higher than 39°C and white blood cell count greater than 20 x 109/litre.Consider lumbar puncture if child is younger than 1-year old.Perform: blood culture
  • 21. full blood count
  • 22. urine test for urinary tract infection
  • 23. C-reactive protein.Consider the following, as guided by clinical assessment: lumbar puncture in children of all ages
  • 24. chest X-ray
  • 25. serum electrolytes
  • 26. blood gas.
  • 27. If no diagnosis is reached, manage the child at home with appropriate care advice. Consider admission. If admission is not necessary but no diagnosis has been reached, provide a safety net for the parents/carers. Assess: look for life-threatening, traffic light and specific diseases symptoms and signs
  • 28. The safety netThe safety net should be one or more of the following:verbal and/or written information on warning symptoms and how further healthcare can be accessedarranging further follow-up liaising with other healthcare professionals, including out-of-hours providers, to ensure direct access for the child if required.
  • 29. Management of children under 3 months by a paediatric specialistAssess: look for life-threatening, traffic light and specific diseases symptoms and signs
  • 32. heart rate
  • 33. respiratory rate.
  • 35. full blood count
  • 36. C-reactive protein
  • 37. blood culture
  • 38. urine test for urinary tract infection
  • 39. chest X-ray if respiratory signs are present
  • 40. stool culture if diarrhoea is present.
  • 41. Admit, perform lumbar puncture and start parenteral antibiotics if the child is:
  • 42. younger than 1-month old
  • 43. 1–3 months old appearing unwell
  • 44. 1–3 months old and with a white blood cell count of less than 5 or greater than 15 x 109/litre
  • 45. Whenever possible, perform lumbar puncture before the administration of antibioticsAntipyreticsAntipyretics do not prevent febrile convulsions and should not be used specifically for this purpose. Do not routinely give antipyretic drugs to a child with fever with the sole aim of reducing body temperatureDo not administer paracetamol and ibuprofen at the same time but consider using the alternative agent if the child does not respond to the first drug.
  • 46. Implementation AdviceFeedback to NICE suggests that there are likely to be three key areas for successful implementation: Traffic light system
  • 47. Providing the safety net
  • 48. Training for non-specialist and non-clinical staffSuggested actions: traffic light systemReview clinical assessment tools to ensure that they include the features of the traffic light system.Review care pathways and protocols to ensure that they reflect the traffic light system.The ‘green’ section of the Traffic Light System could be used to help staff feel confident when making the decision to advise that a child is managed at home
  • 49. Suggested actions: providing the safety netReview protocols to ensure that information is provided about the treatment and care of children with fever.Patient information is available from a variety of sources, including a booklet about this guideline for parents/carers, ‘Understanding NICE guidance’.When a child is discharged give the parents/carers an advice sheet about how to care for their child and potential warning signs.Develop protocols for staff on when children are safe to be cared for at home.
  • 50. Suggested actions: trainingUse the traffic light system when developing training.Review training needs to identify whether training in body temperature measurement is required.Training should be available for healthcare professionals working with children in the potential diagnoses of fever and other symptoms in children.Ensure that either electronic, chemical dot or infra-red tympanic thermometers are available for staff to use.Ensure that staff are confident in measuring body temperature using these thermometers.
  • 51. Access the guideline onlineQuick reference guide – a summary http://guidance.nice.org.uk/CG47/quickrefguide/pdf/English NICE guideline – all of the recommendations http://guidance.nice.org.uk/CG47/niceguidance/pdf/English Full guideline – all of the evidence and rationale http://guidance.nice.org.uk/CG47/guidance/pdf/English ‘Understanding NICE guidance’ – a plain English version http://guidance.nice.org.uk/CG47/publicinfo/pdf/English
  • 52. thank you for your attention••••••••••••••••••••••••••••••••

Editor's Notes

  1. Custom animation effects: object spins on end(Advanced)To reproduce the background effects on this slide, do the following:On the Home tab, in theSlides group, click Layout, and then click Blank.Right-click the slide background area, and then click Format Background. In the Format Background dialog box, click Fill in the left pane, and then select Solid fill in the Fill pane. Click the button next to Color, and then under Theme Colors click White, Background 1 (first row, first option from the left).To reproduce the rectangle on this slide, do the following:On the Home tab, in the Drawing group, click Shapes, and then under Rectangles click Rounded Rectangle (second option from the left). On the slide, drag to draw a rounded rectangle.Select the rectangle. Drag the yellow diamond adjustment handle to the left to decrease the amount of rounding on the corners. With the rounded rectangle still selected, under Drawing Tools, on the Format tab, in the Size group, do the following:In the Shape Height box, enter 3.5”.In the Shape Width box, enter 0.25”.Under Drawing Tools, on the Format tab, in the bottom right corner of the Shape Styles group, click the Format Shape dialog box launcher. In the Format Shape dialog box, click Fill in the left pane. In the Fill pane, select Solid fill, click the button next to Color, and then under Theme Colors click White, Background 1, Darker 15% (third row, first option from the left).Also in the Format Shape dialog box, click Line Color in the left pane. In the Line Color pane, select No line. Also in the Format Shape dialog box, click Shadow in the left pane. In the Shadow pane, click the button next to Presets, under Outer select Offset Bottom (first row, second option from the left), and then do the following:In the Transparency box, enter 0%.In the Sizebox, enter 100%.In the Blur box, enter 8.5 pt.In the Angle box, enter 90°.In the Distance box, enter 1 pt.Also in the Format Shape dialog box, click 3-D Format in the left pane. In the 3-D Format pane, do the following:Under Bevel, click the button next to Top, and then under Bevel click Circle (first row, first option from the left). Next to Top, in the Width box, enter 5 pt, and in the Height box, enter 5 pt.Under Surface, click the button next to Material, and then under Standard clickMatte (first row, first option from the left).Click the button next to Lighting, and then under Neutral click Soft (first row, third option from the left).On the slide, select the rounded rectangle. On the Home tab, in the Clipboard group, click the arrow under Paste, and then click Duplicate.Select the duplicate rectangle. On the Home tab, in the Drawing group, do the following:Click the arrow next to Shape Fill, and then click No Fill.Click the arrow next to Shape Outline, and then click No Outline.Drag the second rectangle above the first rectangle until the lower edge overlays the top edge of the first rectangle. (Note: When the spinning animation effect is created later for these rectangles, the spin will center where the edges of the rectangles meet.)Press and hold CTRL, and then select both rectangles. On the Home tab, in the Drawing group, click Arrange, and do the following:Point to Align, and then click Align Selected Objects.Point to Align, and then click Align Center.Click Group. On the slide, drag the group until it is centered horizontally on the left edge of the slide (straddling the edge).On the Home tab, in the Drawing group, click Arrange, point to Align, and then do the following:Click Align to Slide.Click Align Middle.To reproduce the dashed arc on this slide, do the following:On the Home tab, in the Drawing group, click Shapes, and then under Basic Shapes click Arc (third row, 12th option from the left). On the slide, drag to draw an arc.Select the arc. Under Drawing Tools, on the Format tab, in the Size group, do the following:In the Shape Height box, enter 7.5”.In the Shape Width box, enter 7.5”.With the arc still selected, on the Home tab, in the Drawing group, click the arrow next to Shape Outline,and then do the following:Under Theme Colors, click White, Background 1, Darker 15% (third row, first option from the left).Point to Dashes, and then click Dash (fourth option from the top).On the slide, drag the yellow diamond adjustment handle on the right side of the arc to the bottom of the arc to create a half circle.Drag the arc until the yellow diamond adjustment handles are on the left edge of the slide.With the arc still selected, on the Home tab, in the Drawing group, click Arrange, point to Align, and then do the following:Click Align to Slide. Click Align Middle. To reproduce the half circle on this slide, do the following:On the slide, select the arc. On the Home tab, in the Clipboard group, click the arrow under Paste, and then click Duplicate.Select the duplicate arc. Under Drawing Tools, on the Format tab, in the Size group, do the following:In the Shape Height box, enter 3.33”.In the Shape Width box, enter 3.33”.With the second arc still selected, under Drawing Tools, on the Format tab, in the Shape Styles group, click the arrow next to Shape Fill, and then under Theme Colors click White, Background 1, Darker 5% (second row, first option from the left).Under Drawing Tools, on the Format tab, in the Shape Styles group, click the arrow next to Shape Outline,and then click No Outline.Under Drawing Tools, on the Format tab, in the Shape Styles group, click Shape Effects, point to Shadow, and then click ShadowOptions. In the Format Shape dialog box, click Shadow in the left pane. In the Shadow pane, click the button next to Presets, under Inner click Inside Right (second row, third option from the left), and then do the following:In the Transparency box, enter 86%.In the Blur box, enter 24 pt.In the Angle box, enter 315°.In the Distance box, enter 4 pt.On the slide, drag the second arc until the yellow diamond adjustment handles are on the left edge of the slide. On the Home tab, in the Drawing group, click Arrange, and then do the following:Point to Align, and then click Align to Slide. Point to Align, and then click Align Middle. Click Send to Back.To reproduce the button shapes on this slide, do the following:On the Home tab, in the Drawing group, click Shapes, and then under Basic Shapes click Oval (first row, second option from the left). On the slide, drag to draw an oval.Select the oval. Under Drawing Tools, on the Format tab, in the Size group, do the following:In the Shape Height box, enter 0.34”.In the Shape Width box, enter 0.34”.Under Drawing Tools, on the Format tab, in the Shape Styles group, click More, and then click Light 1 Outline, Colored Fill – Dark 1 (third row, first option from the left).Under Drawing Tools, on the Format tab, in the bottom right corner of the Shape Styles group, click the Format Shape dialog box launcher. In the Format Shape dialog box, click Fill in the left pane. In the Fill pane, select Solid Fill. Click the button next to Color, and then under Theme Colors click Olive Green, Accent 3, Lighter 80°(second row, seventh option from the left).Also in the Format Shape dialog box, click Line Color in the left pane. In the Line Color pane, select No line. Also in the Format Shape dialog box, click Shadow in the left pane. In the Shadow pane, click the button next to Presets, under Outer click Offset Bottom (first row, second option from the left), and then do the following:In the Transparency box, enter 0%.In the Size box, enter 100%.In the Blur box, enter 8.5 pt.In the Angle box, enter 90°.In the Distance box, enter 1 pt.Also in the Format Shape dialog box, click 3-D Format in the left pane, and then do the following in the 3-D Format pane:Under Bevel, click the button next to Top, and then under Bevel click Art Deco (third row, fourth option from the left). Next to Top, in the Width box, enter 5 pt, and in the Height box, enter 5 pt.UnderContour, click the button next to Color, and then under Theme Colors click White, Background 1 (first row, first option from the left). In the Size box, enter 3.5 pt.Under Surface, click the button next to Material, and then under Standard click Matte (first row, first option from the left). Click the button next to Lighting, and then under Neutral click Soft (first row, third option from the left).On the slide, select the oval. Under Drawing Tools, on the Format tab, in the bottom right corner of the Size group, click the Size and Position dialog box launcher. In the Size and Position dialog box, on the Position tab, do the following:In the Horizontal box, enter 2.98”.In the Vertical box, enter 1.5”.Select the oval. On the Home tab, in the Clipboard group, click the arrow under Paste, and then click Duplicate.Select the duplicate oval. Under Drawing Tools, on the Format tab, in the bottom right corner of the Size group, click the Size and Position dialog box launcher. In the Size and Position dialog box, on the Position tab, do the following:In the Horizontal box, enter 3.52”.In the Vertical box, enter 2.98”. Repeat step 9 two more times, for a total of four ovals. Under Drawing Tools, on the Format tab, in the bottom right corner of the Size group, click the Size and Position dialog box launcher. In the Size and Position dialog box, on the Position tab, do the following to position the third and fourth ovals:Select the third oval on the slide, and then enter 3.52” in theHorizontal box and 4.27” in the Vertical box.Select the fourth oval on the slide, and then enter 2.99” in theHorizontal box and 5.66” in the Vertical box.To reproduce the text on this slide, do the following:On the Insert tab, in the Text group, click Text Box, and then on the slide, drag to draw the text box. Enter text in the text box and select the text. On the Home tab, in the Font group, do the following: In the Font list, select Corbel.In the Font Size list, select 22.Click the arrow next to Font Color, and then under Theme Colors click White, Background 1, Darker 50% (sixth row, first option from the left).On the Home tab, in the Paragraph group, click Align Text Left to align the text left in the text box.On the slide, drag the text box to the right of the first oval.Select the text box. On the Home tab, in the Clipboard group, click the arrow under Paste, and then click Duplicate. Click in the text box and edit the text. Drag the second text box to the right of the second oval.Repeat steps 5-7 to create the third and fourth text boxes, dragging them to the right of the third and fourth ovals. To reproduce the animation effects on this slide, do the following:On the Animations tab, in the Animations group, click Custom Animation.On the Home tab, in the Editing group, click Select, and then click Selection Pane. In the Selection and Visibility pane, select the rectangle group. In the CustomAnimation task pane, do the following:Click AddEffect, point to Emphasis, and then click More Effects. In the Add Emphasis Effect dialog box, under Basic, click Spin. Select the animation effect (spin effect for the rectangle group). Under Modify: Spin, do the following:In theStart list, selectWith Previous. In the Amount list, in the Custom box, enter 123°,and then press ENTER. Also in the Amount list, clickCounterclockwise.In the Speedlist, select Fast. On the slide, select the first oval. In the CustomAnimation task pane, do the following:Click AddEffect, point to Emphasis, and then click More Effects. In the Add Emphasis Effect dialog box, under Basic, click Change Fill Color. Select the second animation effect (change fill color effect for the first oval). Under Modify: Change Fill Color, do the following:In the Startlist, select After Previous. In the Fill Color list, click More Colors. In the Colors dialog box, on the Custom tab, enter values for Red: 130, Green: 153, Blue: 117. In the Speedlist, select Very Fast.On the slide, select the first text box. In the CustomAnimation task pane, do the following:Click Add Effect, point to Entrance,and then click More Effects. In the Add Entrance Effect dialog box, under Subtle, clickFade. Select the third animation effect (fade effect for the first text box). Under Modify: Fade, do the following:In theStart list, selectWith Previous.In the Speed list, select Very Fast. In the Selection and Visibility pane, select the rectangle group. In the CustomAnimation task pane, do the following:Click AddEffect, point to Emphasis, and then click More Effects. In the Add Emphasis Effect dialog box, under Basic, click Spin. Select the fourth animation effect (spin effect for the rectangle group). Under Modify: Spin, do the following:In theStart list, selectOn Click. In the Amount list, in the Custom box, enter 22°, and then press ENTER. Also in the Amount list, click Clockwise.In the Speed list, select Very Fast.On the slide, select the second oval. In the CustomAnimation task pane, do the following:Click AddEffect, point to Emphasis, and then click More Effects. In the Add Emphasis Effect dialog box, under Basic, click Change Fill Color. Select the fifth animation effect (change fill color effect for the second oval). Under Modify: Change Fill Color, do the following:In the Startlist, select After Previous. In the Fill Color list, click More Colors. In the Colors dialog box, on the Custom tab, enter values for Red: 130, Green: 153, Blue: 117. In the Speedlist, select Very Fast.On the slide, select the second text box. In the CustomAnimation task pane, do the following:Click Add Effect, point to Entrance and then click More Effects. In the Add Entrance Effect dialog box, under Subtle, clickFade. Select the sixth animation effect (fade effect for the second text box). Under Modify: Fade, do the following:In theStart list, selectWith Previous.In the Speed list, select Very Fast. On the slide, select the third oval. In the CustomAnimation task pane, do the following:Click AddEffect, point to Emphasis, and then click More Effects. In the Add Emphasis Effect dialog box, under Basic, click Change Fill Color. Select the seventh animation effect (change fill color effect for the third oval). Under Modify: Change Fill Color, do the following:In the Startlist, select After Previous. In the Fill Color list, click More Colors. In the Colors dialog box, on the Custom tab, enter values for Red: 130, Green: 153, Blue: 117. In the Speedlist, select Very Fast.On the slide, select the third text box. In the CustomAnimation task pane, do the following:Click Add Effect, point to Entrance and then click More Effects. In the Add Entrance Effect dialog box, under Subtle, clickFade. Select the eighth animation effect (fade effect for the third text box). Under Modify: Fade, do the following:In theStart list, selectWith Previous.In the Speed list, select Very Fast. On the slide, select the fourth oval. In the CustomAnimation task pane, do the following:Click AddEffect, point to Emphasis, and then click More Effects. In the Add Emphasis Effect dialog box, under Basic, click Change Fill Color. Select the ninth animation effect (change fill color effect for the fourth oval). Under Modify: Change Fill Color, do the following:In the Startlist, select After Previous. In the Fill Color list, click More Colors. In the Colors dialog box, on the Custom tab, enter values for Red: 130, Green: 153, Blue: 117. In the Speedlist, select Very Fast.On the slide, select the fourth text box. In the CustomAnimation task pane, do the following:Click Add Effect, point to Entrance,and then click More Effects. In the Add Entrance Effect dialog box, under Subtle, clickFade. Select the 10th animation effect (fade effect for the fourth text box). Under Modify: Fade, do the following:In theStart list, selectWith Previous.In the Speed list, select Very Fast.
  2. SmartArt custom animation effects: stretch and curve up(Intermediate)To reproduce the SmartArt effects on this slide, do the following:On the Home tab, in the Slides group, click Layout, and then click Blank.On the Insert tab, in the Illustrations group, click SmartArt. In the Choose a SmartArt Graphic dialog box, in the left pane, click List. In the List pane, click Vertical Block List (fourth row, third option from the left), and then click OK to insert the graphic into the slide.Select the graphic, and then click one of the arrows on the left border. In the Type your text here dialog box, enter text for each of the rectangles.Press and hold CTRL, and select each of the second-level rectangles on the slide. Drag the left sizing handle of one of the second-level rectangles to the left 0.5” to increase the width of the second-level rectangles. (Note: The first-level rectangles (rounded rectangles) will decrease in width at the same time.)Select the SmartArt graphic. Under SmartArtTools, on the Design tab, in the SmartArtStyles group, click SmartArtStyles, and under BestMatch for Document select IntenseEffect (fifth option from the left).Press and hold CTRL, and then select each of the first-level rectangles (rounded rectangles) in the SmartArt graphic.Under SmartArtTools, on the Format tab, in the WordArtStyles group, click the arrow to the right of TextFill, and under ThemeColors select White, Background 1, Darker 25%. (fourth row, first option from the left). Under SmartArtTools, on the Format tab, in the ShapeStyles group, click the arrow to the right of ShapeFill and under ThemeColors select White, Background 1 (first row, first option from the left). Select the top, second-level rectangle in the SmartArt graphic.Under SmartArtTools, on the Format tab, in the ShapeStyles group, click the arrow to the right of ShapeFill and under ThemeColors select Olive Green, Accent 3. (first row, seventh option from the left).Select the center, second-level rectangle in the SmartArt graphic.Under SmartArtTools, on the Format tab, in the ShapeStyles group, click the arrow to the right of ShapeFill and under ThemeColors select Olive Green, Accent 3, Lighter 40% (fourth row, seventh option from the left).Select bottom,second-level rectangle in the SmartArt graphic.Under SmartArtTools, on the Format tab, in the ShapeStyles group, click the arrow to the right of ShapeFill and under ThemeColors select Olive Green, Accent 3, Lighter 60% (third row, seventh option from the left).Press and hold CTRL, and select each of the second-level rectangles.On the Home tab, in the Font group, click Text Shadow, and then in the FontColor list, select White, Background 1 (first row, first option from the left). To reproduce the animation effects on this slide, do the following:On the Animation tab, in the Animation group, click CustomAnimation. Select the SmartArt graphic, and then in the CustomAnimation task pane, do the following:Click AddEffect, point to Entrance and select MoreEffects. In the AddEntranceEffect dialog box, under Exciting select Curve Up, and click OK. Click the arrow to the right of the curve up entrance effect (first effect) and select EffectOptions. In the CurveUp dialog box, do the following:On the Timing tab, in the Start list, select AfterPrevious.On the Timing tab, in the Speed list, select Fast.On the SmartArtAnimation tab, in the Groupgraphic list select One by one.Click the double arrow under the curve-up entrance effect (first effect) to expand the list of effects.Press and hold CTRL, and select the second, fourth, and sixth effects (curve-up entrance effects). Click Change, point to Entrance, and select MoreEffects. In the ChangeEntranceEffects dialog box, under Moderate, select Stretch.Press and hold CTRL, and select the second, fourth, and sixth effects. Under Modify: Stretch,do the following:In the Direction list, select FromTop.In the Speed list, select Fast. To reproduce the background effects on this slide, do the following:Right-click the slide background, and then click Format Background. In the Format Background dialog box, click Fill in the left pane, select Gradient fill in the Fill pane, and then do the following:In the Type list, select Radial.In the Direction list, click From Center (third option from the left).Under Gradient stops, click Add or Remove until two stops appear in the drop-down list.Also under Gradient stops, customize the gradient stops as follows:Select Stop 1 from the list, and then do the following:In the Stop position box, enter 33%.Click the button next to Color, and then under Theme Colors click White, Background 1 (first row, the first option from the left).Select Stop 2 from the list, and then do the following: In the Stop position box, enter 100%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 15% (third row, first option from the left).