The statistical probability of a child with FWLS > 39 between 3-36
months developing SBI is not zero ( more like 1: 1000 to 2000). This is
not an exact science like most things in medicine. The real question is
how risk averse the provider is and more importantly is this relative
risk shared with the caretakers of the child and how risk averse they
are in the management approach.
For example, when a child with a new onset HA presents to you and your
evaluation strongly suggests possibility of migraine, you treat and
discuss the diagnosis. The question on the parents' mind is about the
possibility of a tumor and they expect a CT to rule it out. The usual
approach would be to counsel them on the low risk of a tumor at that
time and reaffirm need for close follow up. The risk of tumor is not
zero and nor is it zero with continued HA's with a normal initial scan.
I believe, & i fully agree with Jeff Avner + Al Sachetti, that decision
making should be an informed one with full participation of the
What about the larger soceital issue of "do nothing" versus "Vitamin R"
for kids with FWLS? Some might say, as the OB study group maintains,
that the risk of over treating 2000 kids to prevent one case of
meningitis ( approximately $200,000) is less than the impact on the
system of 1 missed bacterial meningitis. But what if you were the CDC
evaluating the impact of resistant pnemococci as cause of meningitis and
the risk of use of Vitamin R for all fevers? What if you were the CEO of
an MCO doing a cost benefit analyses on the practice management style
and economic profile of 2 PEM groups on various common pediatric
diagnoses like "fever" (which constitutes 30 % of all pediatric visits)?
The proof of the pudding is in the eating they say. In surveys done in
the Salt Lake area as well as th Baltimore area of pediatric
practitioners, less than half were actually following the guidelines!!
[Young et al Pediatrics 1995] Their outcome data was no different than
The issue of radiographs has been downplayed by the OB study group
because if you follow the guidelines and treat everybody with "vitamin
R" it does not matter if they have a pneumonia or not. You would have
still done the same thing!! Now, if they have persistent fever on follow
up then a radiograph is worth doing for missed partially treated
Lastly, is OB a monster created out of the Roche RND division?. I don't
remember it as part of the older lexicon!!!
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