"my question is: is there any newer literature to support the idea of narrowing the previous recommendations of 4-12 weeks to a smaller group?? i have done a pretty good search and can't find much. I'd be interested to know if any ED's have written policies on narrowing this second group and what literature you used to support your stance. "
I know you have scoured the literature thoroughly. Perhaps, there is really no evidence, hence the variability in practice.
Did your search include articles that were non-ED based? If so, you may have reviewed the JAMA article of 3000+ febrile infants < 12 weeks, published this year, by your neighbours in "No-Cal", that was part of AAP's PROS network? [Pantell, R et al. JAMA March 2004. "Management and Outcome of Fever in Young Infants."]
It represents a cross section of infants seen in offices around the nation. Their rates of bacteremia and meningitis were similar to most of our PED studies. Their miss rate for SBI was 2/63 (with no major M&M). It came as no surprise again that only a third of these infants received labs or for that matter received management consistent with the various guidelines that you mention!!
I reckon we should just abandon all these age and laboratory cutoffs for infants between 28-90 days and simply use our clinical "judgment" to decide which ones deserve a work up. For 30 + years the rest of the non-academic world has been doing precisely this, without an increase in febrile infant mortality or morbidity!!!
Given the infrequency of the disease, you and I could go through our PEM careers without ever missing a bacterial meningitis in this cohort of 1- 3 month olds. Truly, I am not being facetious. Sometimes, (these days more often than not), I believe, we in the PEM fraternity are living in isolation when it comes to management of these infants. There may be a collective wisdom from the non-academic world that is not getting it's due recognition in our arena.
What do ya'll think?
With best regards
Jay Pershad, M.D.
Division of Pediatric Emergency Medicine
Department of Pediatrics
University of TN Health Sciences Center
Le Bonheur Children's Medical Center
Pediatric Emergency Specialists, PC
Pediatric Sedation Specialists, PC
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