Tamping down “guidelines” for management of infants with unexplained fever

Abstract

In this issue of The Journal, Jhaveri et al provide a good summation of data that would lead logical readers to tamp down enthusiasm for the application of previous “guidelines” for management of febrile infants and children without a focus of infection. In fact, if one applied such “guidelines” for management of febrile infants in the past, continued application in 2011 would be indefensible. Use of the term “guidelines” in the 1993 publication that started the ball rolling was accurate, literally (Ann Emerg Med 1993;22:1198-210); however, use of the term since then has been restricted to represent the outcome/consensus of a multi-pronged formal process, with engagement from conception and then endorsement of experts, professional associations, and other stakeholders. “Guidelines” on the management of febrile infants and children were embraced (and endorsed post facto) by Emergency Medicine physicians but not by the American Academy of Pediatrics, which is comprised of most pediatricians in practice and many experts in pediatric infectious diseases.It is difficult to rescind a non-policy. Although the authors of this Medical Progress article do not have the prerogative to make their own guidelines, they have raised the critical questions, exposed the facts, and provided the reader with risk assessments that should lead him or her to integrate the findings of the individual case into the context of what is already known to make a careful clinical decision on management — no algorithm, usually no tests, and no empiric outpatient antibiotic therapy. It seems the primary reason that one needs “rules” in medicine is when clinical judgment of wellness cannot be relied upon to conclude lack of risk of a disease or disorder. Thus, it seems prudent to have some “rules” (personal reminders of clinical inadequacy) for the infant <30 days of age with fever and no apparent focus of infection.For those who take validation from practicing under the tutelage of respected opinion leaders, Jhaveri et al are good ones. They have done a service by bringing new evidence to those who still might be following this non-policy.Article page 181▶ In this issue of The Journal, Jhaveri et al provide a good summation of data that would lead logical readers to tamp down enthusiasm for the application of previous “guidelines” for management of febrile infants and children without a focus of infection. In fact, if one applied such “guidelines” for management of febrile infants in the past, continued application in 2011 would be indefensible. Use of the term “guidelines” in the 1993 publication that started the ball rolling was accurate, literally (Ann Emerg Med 1993;22:1198-210); however, use of the term since then has been restricted to represent the outcome/consensus of a multi-pronged formal process, with engagement from conception and then endorsement of experts, professional associations, and other stakeholders. “Guidelines” on the management of febrile infants and children were embraced (and endorsed post facto) by Emergency Medicine physicians but not by the American Academy of Pediatrics, which is comprised of most pediatricians in practice and many experts in pediatric infectious diseases. It is difficult to rescind a non-policy. Although the authors of this Medical Progress article do not have the prerogative to make their own guidelines, they have raised the critical questions, exposed the facts, and provided the reader with risk assessments that should lead him or her to integrate the findings of the individual case into the context of what is already known to make a careful clinical decision on management — no algorithm, usually no tests, and no empiric outpatient antibiotic therapy. It seems the primary reason that one needs “rules” in medicine is when clinical judgment of wellness cannot be relied upon to conclude lack of risk of a disease or disorder. Thus, it seems prudent to have some “rules” (personal reminders of clinical inadequacy) for the infant <30 days of age with fever and no apparent focus of infection. For those who take validation from practicing under the tutelage of respected opinion leaders, Jhaveri et al are good ones. They have done a service by bringing new evidence to those who still might be following this non-policy. Article page 181▶ Management of the Non–Toxic-Appearing Acutely Febrile Child: A 21st Century ApproachThe Journal of PediatricsVol. 159Issue 2PreviewAlthough most febrile children aged <36 months have a self-limited viral infection that will resolve without treatment, a small proportion who are not obviously toxic will develop a serious bacterial infection (SBI), including bacteremia, meningitis, and urinary tract infection (UTI). How to best assess and manage such children has long been a matter of debate.1-5 Identifying non–toxic-appearing febrile children with an SBI is a persistent challenge for pediatric practitioners. Management of febrile children is further complicated by the fact that parents and physicians value the risks and costs differently. Full-Text PDF