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PED-EM-L  August 2004

PED-EM-L August 2004

Subject:

Re: Feb Neo

From:

Jay Pershad <[log in to unmask]>

Reply-To:

Jay Pershad <[log in to unmask]>

Date:

Tue, 10 Aug 2004 23:04:34 -0500

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (124 lines)

Hi Kevin:
Good to hear from you and always appreciate your comments. We are actually
in agreement on several issues you raise. See below.


-----Original Message-----


Jay,

This message was interesting food for thought.

You state that the non-academic world has been using judgment to work-up
neonatal fever without morbidity; however, when you speak to most senior
pediatricians, family practitioners, and ED physicians they can relate
personal stories of the well-appearing febrile baby who was later noted to
have meningitis or sepsis. Often, these physicians can sadly relate stories
of horrific outcomes. These cases, for obvious reasons, don't typically get
published as case reports and haven't been subjected to rigorous study. I
don't think anyone can be quite sure what to make of these anecdotes.

I couldn't agree more. Although anecdotal cases do add to the "collective
wisdom" and contribute to our individual practice variations, one is hard
pressed to make any meaningful inferences from such personal stories.

I am an academic PEM physician who typically follows the "sepsis evaluation"
strategy for all febrile babies under 56 days (a point at which I believe
the decreased risk of bacterial infection is met by the developmental
acquisition of a social smile and other interaction skills).

You are actually reinforcing my point about utilizing individual practioner
judgment. I commend you for deviating from the published guidelines, that
Dr. McCullough was alluding to, that typically extend this age cut-off to 90
days.

What I am concerned about is your seemingly dogmatic position about this "56
day rule" As an academic physician, you may not realize it but, you have
tremendous clout in changing the face of our field. You have the unique
ability to influence trainees at all levels (GEMS, PEMS & PEDS). When you
encourage these "rules" and diminish the weight of published evidence from
the real world, I fear that with it you are diminishing that intangible
called the "art of medicine" [a la practioner's judgment]

Besides, I am sure many on this esteemed list, including yourself, have seen
a social smile in infants as young as 42 days!





Of potential interest to the group...one day, with a particularly
well-appearing and "URI-looking" 52-day-old with good parents, I recommended
to do watchful waiting. The physician mother, presented with all the
information, decided later that any risk was too great for her baby and
asked me to do a sepsis evaluation. The baby had CSF pleiocytosis and grew
S. pneumonia in the CSF within 24 hours. Sometimes it is better to be lucky
than good.

Humbling case indeed. This is again a  good example of your astute acumen in
being willing to go against your initial desire to defer a workup (i.e.
"follow the guidelines") and "listen" to the mother. I am also willing to
bet that this family had a primary care pediatrician (a la "real world" doc)
whom they perhaps established contact with prior to presenting to your
"academic" ED. Many such visits are screened by generalists who have
established that the infant was relatively "ill" and referred the child to
you. These cases pose a clinical dilemma because they often look "well" upon
arrival to our arena, the ED.

In the JAMA study, they missed 1 /3067 infant screened in the age group of
28-90 days. The case was very similar to your 52 day old. This was a 42 day
old that was sent home without a workup and returned the next day with
increasing irritability. The eventual diagnosis was pneumococcal meningitis.
At one year follow up the child had no residual neurodevelopmental issues.

Let me cite a case from my personal diary. I was involved in the care of a
"well" appearing febrile 11 month old whom I discharged as a presumed viral
illness that returned to the ED with  meningococcemia 12 hours later.

It is my humble belief that "someone else" was calling the shots in these
cases!!

One question that the research on neonatal fever (and occult bacteremia)
seems to avoid is the question that begs to be answered before the studies
are performed:

What incidence of occult bacterial meningitis would warrant performing an LP
on all febrile neonates...1 in 10?..1 in 100?..1 in 1,000?..1 in 10,000? It
is interesting to compare the numbers in the JAMA article you cite with the
risk aversion currently practiced in regard to occult bacteremia, CT
scanning after minor head injury, CTscanning for abdominal pain, etc.

I know that if you told my wife that my youngest son had a 1 in 1000 chance
of having meningitis which could kill him or leave him with permanent
disability, she would want the procedure done.

How about if the probability was 1 in 3067 with a 25 % chance of residual
morbidity and a 1: 10000 chance of an epidural hematoma or abscess from an
LP :-) ....just kidding!! This is a million dollar question that requires
practioner judgment and parental involvement in the decision making process.

Best wishes

Jay


Jay Pershad, M.D.
Pediatric Emergency Specialists, PC
Pediatric Sedation Specialists, PC
&
Associate Professor
Division of Pediatric Emergency Medicine
Department of Pediatrics
University of TN Health Sciences Center
Le Bonheur Children's Medical Center
Memphis, TN
&
Affiliate Faculty, Department of Anesthesia
St. Jude Children's Research Center
Memphis, TN

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

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