TUESDAY, March 9, 2004 (HealthDayNews) -- Pediatricians who use their good clinical judgment in deciding how to treat infants with fevers can effectively diagnose serious illness, even if they don't follow clinical guidelines to the letter.
That's the conclusion of a study appearing in the March 10 issue of the Journal of the American Medical Association.
The dilemma of how to treat a young infant with fever has existed for decades, with several sets of guidelines developed over the years, leaning toward the recommendation of hospitalization and many lab and blood tests, sometimes including a spinal tap. The fear has been that doctors who do less might miss a case of serious illness such as bacteria in the blood or bacterial meningitis, a potentially fatal infection of the membranes of the brain and spinal cord.
But the new study concludes experienced doctors in private practices and health maintenance organizations can rely on their know-how and choose not to follow the guidelines to the letter, without compromising their little patients' health. "If you are an experienced clinician, you can rely on your clinical judgment," says study author Dr. Robert H. Pantell, a professor of pediatrics at the University of California at San Francisco.
Pantell and his colleagues evaluated data from 3,066 infants aged 3 months or younger seen by 573 practitioners from 44 states, the District of Columbia and Puerto Rico. All had body temperatures of at least 100.4 degrees Fahrenheit. The researchers tracked what tests were ordered and whether the children were hospitalized.
"Had they followed the clinical guidelines they would not have done better in diagnosing the problem," Pantell says. "However, they would have hospitalized 40 percent more infants under [age] 30 days." Those hospitalizations would have cost much more, of course, than following the infants via regular office visits, Pantell says, not to mention the boost in stress for parents.
The physicians followed the current guidelines about hospitalization and testing 42 percent of the time, Pantell found. "Of the 3,066, 14 had bacterial meningitis diagnosed," Pantell says. "Of those, five also had bacteria in the blood and another 49 had bacteria, E. coli or group B strep in the blood. There were two cases they -- quote -- missed. But they were treated the next day and were fine."
Overall, the doctors hospitalized 36 percent of the infants, performed lab testing in 75 percent, and initially treated 57 percent with antibiotics. Most, 64 percent, were treated without hospitalizations.
The study results make sense to Dr. Kenneth B. Roberts, director of the pediatric teaching program at Moses Cone Healthy System in Greensboro, N.C., who wrote an editorial to accompany the report. Some of the previous guidelines, he says, were generated in inner-city emergency departments.
In those settings, he says, there is often no follow-up and the doctor who sees the patients does not see him or her regularly. In these cases, he adds, following the guidelines might make more sense. In the study reported by Pantell, however, the pediatricians were strong on follow-up. "Only in 4 percent [of cases] was it a one-time visit and that was the end of it," Roberts says.
Often, Roberts says, the situation and the setting of care have much to do with whether a doctor is wise to follow guidelines or to rely more on clinical judgment. "I had hoped to convey in the editorial that it's not that the data from one [set of guidelines] are wrong or that the way people are acting in one place [is] wrong. It's just that they are quite different settings," he says.
Parents should "recognize that fever in the first month of two or life is something they should bring to the attention of their physicians." Fever is defined, he adds, as a temperature of 100.4 degrees Fahrenheit or higher.
More information
For more information on children and fever, visit the American Academy of Family Physicians or the Nemours Foundation.
