Pediatrician's Judgment Often Better Than Treatment Guidelines

March 09, 2004
News Office: Carol Hyman (415) 502-9553

Pediatricians frequently use individual judgment in treating infants with fever, and according to a new study, this judgment is often as good as or better than following the current clinical guidelines on how to manage these cases.

Dr. Robert Pantell, a pediatrician at UCSF Children's Hospital, is the lead investigator of "Management and Outcomes of Fever in Early Infancy," a study appearing in the March 10 issue of the Journal of the American Medical Association.

The researchers point out that infants who are running high fever often lack overt symptoms, thus making it difficult for the physician to know if the child has a serious bacterial illness such as bacteremia (bacteria in the blood) or bacterial meningitis. For children younger than one month, the guidelines state that the child should be hospitalized, and a whole battery of tests, including a spinal tap, be performed.

"These guidelines were developed following small studies at inner-city emergency departments," said Pantell, who also is a UCSF professor of pediatrics. "We wanted to see if these guidelines made sense for all children." The study team set out to discover what illnesses these children really have and what the doctors are doing to diagnose and treat them.

The researchers recruited 573 practitioners from the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics in 44 states, Washington, DC, and, and Puerto Rico. These physicians submitted data from 3,066 infants aged 3 months or younger with temperatures of at least 38 degrees Celsius (100.4 Fahrenheit).

The PROS clinicians hospitalized 36 percent of the infants, performed laboratory testing in 75 percent, and initially treated 57 percent with antibiotics, the researchers report. The majority (64 percent) were treated exclusively outside of the hospital. Bacteria in the blood was detected in 1.8 percent of infants (2.4 percent of those tested) and bacterial meningitis in 0.5 percent.

The researchers found that the doctors followed current guidelines in 42 percent of episodes. Had clinicians followed guidelines, all of the infants under one month of age would have been hospitalized, whereas clinicians in this study kept 40 percent of these infants out of the hospital and cared for them during regular office visits.

"This is important because while the physicians didn't follow the guidelines 42 percent of the time, fewer serious illnesses were missed," Pantell said. "One infant with bacteremia and one with bacterial meningitis were not treated with antibiotics by the physicians on day one, but they were treated on the next day, so every child got proper treatment and did well."

The researchers write in JAMA: "The findings suggest that if close follow-up care is attainable, the management of selected cases by experienced clinicians using clinical judgment may be more appropriate than strict adherence to published recommendations, with the potential benefit of reducing considerable costs and iatrogenic morbidity (unfavorable outcomes). While guidelines have an important role in ensuring the quality of care for many clinical issues, their performance in complex clinical situations, such as the management of febrile illnesses, should be analyzed to evaluate whether the guidelines actually optimize care."

"Guidelines are set up in good faith, and they work," Pantell continued, "but following them in the case of fever is very expensive as well as having other effects. It can be very upsetting for a family to have an infant hospitalized, and hospitalization opens up a child to additional risks, such as infection."

Pantell explained that guidelines continue to change, and this study will have an effect on those changes. "It will encourage us to look at guidelines and enforce the ones that are appropriate," he said. "We need to work hard on enforcing appropriate guidelines, and reevaluating ones that may not be as appropriate."

Co-investigators on the study are Dr. Thomas B. Newman, M.P.H.; Jane Bernzweig, Ph.D.; Mark Segal, Ph.D., and Dr. John Takayama, M.P.H., all of UCSF; Dr. David Bergman, Lucille Packard Children's Hospital at Stanford Medical Center; Stacia Finch, M.A., American Academy of Pediatrics; and Dr. Richard Wasserman, M.P.H., American Academy of Pediatrics and Vermont College of Medicine.

This study was supported by a grant from the Agency for Healthcare Research and Quality, with additional support from the Health Resources and Services Administration Maternal and Child Health Bureau.

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