Dr Hennes wrote:
"The guidelines from the AAP and the ACEP are just guidelines and I hope to
God they will stop publishing them.
I'm just tired of these so called guidelines which may cause unnecessary
risks to kids and is a financial burden for some parents."
Mega ditto's Halim!!!
The other concern that I have with such promulagations is that they have
medicolegal implications for all of us who are practicing real world
medicine ( & not "ivory tower" recommendations); I do understand that they
are only guidelines that need not be followed in all cases and tend to be
conservative in their intent, but when one has a large national
organization representing children in our country, come out with a
consensus statement, it makes things very awkward indeed. More so, if faced
with an outcome that does not follow one's honest clinical judgement....
Emotions aside, where is the clinical data to support this age cut offf??.
It seems strange to me that in the "fever" guidelines clinical judgement
was recommended to decide need for an LP above the age of 2- 3 months but
the same judgement cannot be utilized for a febrile child with a seizure
who is 9 months old and is now alert and and blowing bubbles at me???
I have been following this thread with avid interest and would add the
following comments not mentioned:
1. The decision analytic model used by Joffe, Deangelis & Mcormick
published in AJDC 1983; 137(12) entitled "Which children with a FC need
LP?" is worth reading. They reviewed 300 odd patients presenting (in the
pre-Hib era) with fever and seizure. The results had a 100 % NPV for
meningitis if these 4 criteria are used (a) presenting with an active
seizure to the ED (b) Abnormal neuro exam (c) focal seizure (d) Seen PMD
within the last 48 hours.
2. There is enough data out there to suggest that, depending on whom you
read, 30 -60 % of these FC are caused by HHV 6 ( same one causing Roseola).
A smaller % are also caused by HHV 7, adenovirus etc.
3. Occult meningitis was an issue with febrile kids with HFlu bacteremia.
With its virtual elimination, having an age cut off like 12 months makes no
sense to me.
I would also rely on a careful history & good clinical examination in such
cases. Have I caught the wrong end of this burning stick ??
Jay Pershad, MD
"Every noble thought in your mind brings you closer to God"
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