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PED-EM-L  August 2004

PED-EM-L August 2004

Subject:

Re: Feb Neo

From:

Kevin Osterhoudt <[log in to unmask]>

Reply-To:

Kevin Osterhoudt <[log in to unmask]>

Date:

Tue, 10 Aug 2004 11:57:57 -0400

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (62 lines)

Jay,

This message was interesting food for thought.

You state that the non-academic world has been using judgement 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 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). 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.

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.

Just more to think about. Cheers!

Kevin Osterhoudt, MD
Philadelphia, PA




>>> "Jay Pershad" <[log in to unmask]> 08/09/04 08:56AM >>>
You wrote:
"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. "

Maureen

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

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