I would LP.
I've seen the discussion of the last few days about this topic, and I thought I would weigh in on some of the points raised.
1. I agree that Evidence Based Medicine (EBM) should not be our sole source of guidance. While I try to practice EBM, and I teach EBM to my residents and medical students, EBM to the exclusion of common sense and judgement makes the doctor nothing more than a trained monkey, albeit a well informed one.
2. I order lab tests to answer critical questions and to gather information that will be used to decide on the further management of a patient. Residents and students who work with me learn quickly that they had better have some justification for ordering a lab test on a child. Knee-jerk lab tests are another characteristic of a well-trained monkey.
3. I believe there is strong justification for doing an LP in the situation described below. Why do we do full sepsis workups in infants at this age who have fever without a source? Because they don't localize infections well, their immune system is immature, they tend to decompensate quickly, and occult bacteremia (with potential meningitic spread) is impossible to detect on the basis of history and physical exam alone.
4. Is pneumonia a good explanation for fever in a 7 week infant? Of course it is. This is not "fever without a source", and so guidelines developed to detect occult bacteremia do not apply. However, the points in #3 above still must be addressed. If this child has "a clear RLL infiltrate", my concern for a bacterial infection increases markedly. What is the likelihood of bacteremia in the presence of a bacterial pneumonia? The literature is all over the map on this question, partly because many of the studies looking at rates of bacteremia in pneumonia include children with any X-ray abnormality, including findings consistent with a viral pneumonia. Based on the literature and on common sense, I would argue that the likelihood is at least as high as it is for occult bacteremia in fever without a source. I believe there is justification for doing an LP on a febrile 7 week infant who has no source, so I certainly believe the same in a child with a "clear infiltrate".
5. If this child has meningitis, there is no way I'm sending him home. Oral therapy is not appropriate for any form of bacterial meningitis in a 7 week infant. In fact, I would admit this child for his pneumonia alone. Why? See #3 above. I would also point out that this child has been ill for only two days, and already has a "clear infiltrate". This constitutes rapid progression.
6. What is the argument against doing the LP in this situation? The fact that this debate is happening indicates that this is not just another unnecessary test. It would provide useful information, possibly critical information. In the hands of an experienced physician the procedure takes 5 minutes or less. In my 18 years as a pediatrician I have yet to see a significant complication from an LP.
I hope the child did well. Merry Christmas and Happy Holidays to all my colleagues out there in the ether.
Jim Wilde MD
James A Wilde MD, FAAP
Assistant Professor of Emergency Medicine and Pediatrics
Director of Pediatric Education
Department Research Director
International Fellowship Director
Department of Emergency Medicine
Medical College of Georgia
Augusta GA
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Phone: (706) 721-3258
Fax: (706) 721-7718

>>> <[log in to unmask]> 12/23/02 01:38PM >>>
Would you think an LP would be necessary in the evaluation of a previously
healthy, non preme, 7 week old boy with a two day history of cough and one
day of fever (102.1 rectal in er) who looks well and is feeding (bottle)
whose xray shows a clear RLL infitrate.   His sats are above 95 and he is not
tachypneic.   His WBC is normal and is c-reactive protein is 5 .   The
pediatrician wants to send him home after a shot of rocephin.   I was
thinking that he'd be more likely to have meningitis with the infiltrate than
less likely.   I would appreciate any feedback.

don zweig md

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