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
Director of Pediatric Education
International Fellowship Director
Department of Emergency
Medical College of Georgia
Augusta GA[log in to unmask]
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
healthy, non preme, 7 week old boy with a two day history of cough
day of fever (102.1 rectal in er) who looks well and is feeding
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
For more information, send
mail to [log in to unmask]
with the message: info PED-EM-L
for the PED-EM-L Web Page is: http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html