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Acute infectious illnesses are common in children under age three. It is often difficult for parents to evaluate the illnesses and to decide whether to report these to the physician. Parents' clinical judgment was not well researched until recently. One study found that parents tended to have poor overall judgment of children's well-being, often overestimating the severity of illness. However, the use of the Acute Illness Observation Scales (AIOS) helped improve parental judgment. This article discusses a second aspect of this study, in which the influence of demographic factors on the reliability of parental judgment were assessed. At one site, of 317 parents were asked to participate, and 225 agreed to do so, while 172 of 219 parents at a second site participated. A final group of 369 mothers were studied; their average age was 22 years. Of these women, 183 used the AIOS. Mothers made one-to-three visits to clinics with their children, and their reliability was assessed for each visit. During the first two visits, mothers using the AIOS were fairly reliable, but this faded with the first visit. Maternal anxiety about the baby were strongly correlated with unreliably. Other variables such as previous child with serious illness, pregnancy complications, and location of clinic (inner city or suburban) had small-to-medium effects on reliability. Other important influences included maternal age and maternal worry about pregnancy. Reliability of maternal judgment decreased with an increase in the number of previous children, possibly due to lack of attentiveness in learning about illnesses. Marital status, level of education, and method of payment did not significantly affect the mother's medical judgment. The report suggests that worry, anxiety, and other unidentified maternal characteristics are more important than some demographic factors in influencing maternal judgement of children's illnesses. (Consumer Summary produced by Reliance Medical Information, Inc.)

Infants with fever who are younger than two months of age may still require full laboratory testing to determine if bacterial infection is present. One-month-old infants with fever may require hospitalization and antibiotics. Three recent research studies address the evaluation and care of infants with fevers. Before adopting the recommendations of these studies, several issues must be considered. The appearance of an infant cannot be used as a criterion for ruling out bacterial infection unless standardized by experienced professionals using objective measures. Diagnostic criteria used to evaluate infants with fever must be tested for applicability in various medical settings and as applied by different medical professionals. Both the negative predictive value and the sensitivity of the low-risk criteria must be assessed. The Pediatric Research in Office Settings network study will address the aforementioned issues and the results will guide the evaluation and management of infants with fevers.

OBJECTIVE. Children with moderate to severe traumatic brain injury (TBI) show early neurobehavioral deficits that can persist several years after injury. Despite the negative impact that TBI can have on a child's physical, cognitive, and psychosocial well-being, only 1 study to date has documented the receipt of health care services after acute care and the needs of children after TBI. The purpose of this study was to document the health care use and needs of children after a TBI and to identify factors that are associated with unmet or unrecognized health care needs during the first year after injury. METHODS. The health care use and needs of children who sustained a TBI were obtained via telephone interview with a primary caregiver at 2 and 12 months after injury. Of the 330 who enrolled in the study, 302 (92%) completed the 3-month and 288 (87%) completed the 12-month follow-up interviews. The health care needs of each child were categorized as no need, met need, unmet need, or unrecognized need on the basis of the child's use of post-acute services, the caregiver's report of unmet need, and the caregiver's report of the child's functioning as measured by the Pediatric Quality of Life Inventory (PedsQL). Regardless of the use of services or level of function, children of caregivers who reported an unmet need for a health care service were defined as having unmet need. Children who were categorized as having no needs were defined as those who did not receive services; whose caregiver did not report unmet need for a service; and the whose physical, socioemotional, and cognitive functioning was reported to be normal by the caregiver. Children with met needs were those who used services in a particular domain and whose caregivers did not report need for additional services. Finally, children with unrecognized needs were those whose caregiver reported cognitive, physical, or socioemotional dysfunction; who were not receiving services to address the dysfunction; and whose caregiver did not report unmet need for services. Polytomous logistic regression was used to model unmet and unrecognized need at 3 and 12 months after injury as a function of child, family, and injury characteristics. RESULTS. At 3 months after injury, 62% of the study sample reported receiving at least 1 outpatient health care service. Most frequently, children visited a doctor (56%) or a physical therapist (27%); however, 37% of caregivers reported that their child did not see a physician at all during the first year after injury. At 3 and 12 months after injury, 26% and 31% of children, respectively, had unmet/unrecognized health care needs. The most frequent type of unmet or unrecognized need was for cognitive services. The top 3 reasons for unmet need at 3 and 12 months were (1) not recommended by doctor (34% and 31%); (2) not recommended/provided by school (16% and 17%); and (3) cost too much (16% and 16%). Factors that were associated with unmet or unrecognized need changed over time. At 3 months after injury, the caregivers of children with a preexisting psychosocial condition were 3 times more likely to report unmet need compared with children who did not have one. Also, female caregivers were significantly more likely to report unmet need compared with male caregivers. Finally, the caregivers of children with Medicaid were almost 2 times more likely to report unmet need compared with children who were covered by commercial insurance. The only factor that was associated with unrecognized need at 3 months after injury was abnormal family functioning. At 12 months after injury, although TBI severity was not significant, children who sustained a major associated injury were 2 times more likely to report unmet need compared with children who did not. Consistent with the 3-month results, the caregivers of children with Medicaid were significantly more likely to report unmet needs at 1 year after injury. In addition to poor family functioning's being associated with unrecognized need, nonwhite children were significantly more likely to have unrecognized needs at 1 year compared with white children. CONCLUSIONS. A substantial proportion of children with TBI had unmet or unrecognized health care needs during the first year after injury. It is recommended that pediatricians be involved in the post-acute care follow-up of children with TBI to ensure that the injured child's needs are being addressed in a timely and appropriate manner. One of the recommendations that trauma center providers should make on hospital discharge is that the parent/primary caregiver schedule a visit with the child's pediatrician regardless of the post-acute services that the child may be receiving. Because unmet and unrecognized need was highest for cognitive services, it is important to screen for cognitive dysfunction in the primary care setting. Finally, because the health care needs of children with TBI change over time, it is important for pediatricians to monitor their recovery to ensure that children with TBI receive the services that they need to restore their health after injury. KEY WORDS. health service utilization, traumatic brain injury.

One of us attended a recent meeting at which it was proposed that the generalist pediatrician should become a consultant and that primary care--which, according to the discussant, involved such [...]

Abstract. In order to study the occurrence and positive predictive value of history and physical examination findings suggestive of serious illness in ill-appearing and well-appearing febrile children, 103 consecutive children aged is less than or equal to 24 months with fever is greater than or equal to 38.3 Celsius were evaluated from July 1, 1982 to Nov 24, 1982. Patients were initially classified by an attending physician (A) as to whether they appeared ill (Yale Observation Scale score >10) or well (scale score is less than or equal to 10). The history was then taken by two attending physicians (A and B) and a resident; the physical examination was performed by attending physician B and the same resident. As history and physical examination findings were elicited, they were scored as to whether they did or did not suggest a serious illness. Serious illness was defined as the presence of a positive laboratory test. Ill-appearing patients had a significantly greater (P < .001, Fisher's exact test) occurrence of physical examination findings suggesting serious illness (14 of 22, 64%) than well-appearing children (12 of 81, 15%). The positive predictive values of abnormal physical examination findings for serious illness in ill-appearing (11 of 14, 79%) and well-appearing children (3 of 12, 25%) were significantly different (P = .02 by Fisher's exact test). The trends for abnormal history findings in ill-appearing and well-appearing children were similar to those for abnormal physical examination findings but did not achieve statistical significance. The results, indicating an important interaction between a febrile child's appearance and physical examination findings, are discussed in terms of probability reasoning in clinical decision making. [ABSTRACT FROM AUTHOR]

Abstract. The pediatrician makes a judgment of the degree of illness (toxicity) of a febrile child based on observation prior to history and physical examination. In order to define valid and reliable observation data for that judgment, data from two previous studies were used to construct three-point scales of 14 observation items correlated with serious illness in those reports. Between Nov 1, 1980 and March 1, 1981, these 14 scaled items were scored simultaneously by attending physicians, residents, and nurses prior to history and physical examination on 312 febrile children aged less than or equal to 24 months seen consecutively in our Primary Care Center-Emergency Room and in one private practice. Of these 312 children, 37 had serious illness. Multiple regression analysis based on patients seen by at least one attending physician in the Primary Care Center revealed six items (quality of cry, reaction to parents, state variation, color, state of hydration, and response to social overtures) that were significant and independent predictors of serious illness (multiple R = 0.63). The observed agreement for scoring these six items between two attending physicians who saw one third of the patients ranged from 88% to 97%. The chance corrected agreement levels (Kw) for these six items were, with one exception, clinically significant (Kw = .47 to .73). A discriminant function analysis revealed that these six items when used together had a specificity of 88% and a sensitivity of 77% for serious illness. Individual scores for each of the six key items were added to yield a total score for each patient. Only 2.7% of patients with a score less than or equal to 10 had a serious... [ABSTRACT FROM AUTHOR]

Abstract. The experienced clinician makes a judgment (hereafter called overall assessment [OA]) about the degree of illness of a febrile child prior to physical examination. In order to define the history and observation variables on which OA is based, 262 febrile children less than or equal to less than or equal to 24 months of age were evaluated simultaneously by multiple observers including attending pediatricians, practicing pediatricians, pediatric house officers, and nurses. The observer listed history and observation variables he/she thought most important in making an OA on a blank, lined form and then scored those variables and OA as normal, or mildly, moderately, or severely impaired. Scoring for observation rather than history variables was better correlated with scoring for OA and serious illness. The observation variables most frequently mentioned by all observers were the child's "looking at the observer" and "looking around the room." There were 20 observation variables frequently mentioned, the scoring of which significantly correlated with scoring for OA; four of these 20 variables related to eye function. The child's response to a stimulus was noted in 105/186 different observation variables listed; both the attending pediatrician and the house officer scored these stimulus-response variables significantly different in children with, vs those without, serious illnesses. For attending pediatricians, house officers, and nurses, serious illness was five to seven times as likely if an OA of moderate or severe impairment was made than if it were not made. OA is a key skill in evaluating febrile children; these data identify... [ABSTRACT FROM AUTHOR]

Abstract. Attending pediatricians listed five history and eight observation variables on which they base their "instinctive" judgment (prior to performing a physical examination) of overall degree of illness of febrile children. Attending pediatricians and house staff observer pairs independently scored these variables in an overall assessment on 219 young, febrile children. The observation variable playfulness had the strongest correlation with overall assessment. Observer agreement in scoring the variables and overall assessment, while statistically significant, was only fair. When an attending pediatrician judged a child as moderately or severely ill on overall assessment, serious illnesses were four times as likely as when such a judgment was not made. When a house officer judged a child as moderately or severely ill, serious illnesses were less than twice as likely as when such a judgment was not made. However, only 57% of children with serious illnesses were judged by the attending pediatrician as moderately or severely ill on overall assessment. These data demonstrate the importance and limitations of "instinctive" clinical judgments about young, febrile children; the association between observation of complex behavioral patterns, especially playfulness, and overall assessment; and the need for further study of these complex behavioral patterns in order to define a reliable clinical approach to febrile children. Pediatrics 65:1090-1095, 1980; clinical judgment, fever, observer variability, screening. [ABSTRACT FROM AUTHOR]

Summarizes studies concerning fever in children under two years of age. Frequency and epidemiology; Differential diagnosis; Follow-up care indicated for the less than 2-year old child with fever.

ABSTRACT. We compared WBC count is greater than or equal to 15,000/cu mm (high WBC count), Wintrobe ESR is greater than or equal to 30 mm/hr (high ESR), temperatttre is greater than or equal to 40 Celsius and positive slide tests for C-reactive protein (CRP) at a serum dilution of 1:50 in febrile, ambulatory children. The CRP test was performed with and without heat inactivation of serum. An excellent correlation was found between noninactivated and inactivated CRP test remits. Since the noninactivated CRP test can be done quickly, its results would be readily available in an outpatient setting. High ESR demonstrated the best balance of specificity and sensitivity for bacteremia, pneumonia, and other possible or proved bacterial illnesses. A positive CRP test was highly specific for these diagnoses but less sensitive than an ERS is greater than or equal to 30 mm/hr. Three combinations of acute-phase reactants, high WBC count and/or high ESR, high ESR and/or positive CRP test, and high WBC count and/or high ESR and/or positive CRP test performed as well as high ESR alone. Each was less specific but more sensitive than high ESR for possible or proved bacterial illnesses. The evaluation of an ambulatory, febrile child with acute-phase reactants should include at least determination of ESR. [ABSTRACT FROM AUTHOR]

Comments on several studies on pediatrics which appeared in the `Pediatrics' journal. Opinion on the statistical analyses used in the study on fever and diagnostic expenses in children; Quality of over-the-counter drugs in Spain; Study on the pneumococcal septicemia and meningitis in the neonate.

Abstract. In a prospective study, 330 consecutive children less than 24 months old coining to the emergency room of Yale-New Haven Hospital with a temperature is greater than or equal to 40 C were evaluated. Nearly all patients had a white blood cell (WBC) count, crythrocyte sedimentation rate (ESR) (Wintrobe), blood culture, and chest roentgenogram. Eighty-eight percent Were evaluated 24 to 48 hours later. The mean WBC count and ESR were significantly elevated in children with positive blood cultures or pneumonia. The risk of bacteremia was increased threefold and the risk of pneumonia was increased twofold in children with a WBC count is greater than or equal to 15,000/ cu mm or an ESR is greater than or equal to 30 mm/hr compared to children without leukocytosis or elevated ESR. Sixty-one percent of children with bacteremia or pneumonia, 63% of children in whom these diagnoses were not apparent on physical examination, arid 86% of children with otitis media complicated by pneumonia or bacteremia had either a WBC count is greater than or equal to 15,000/cu mm or an ESR is greater than or equal to 30 mm/hr. A WBC count is greater than or equal to 15,000/cu mm and an ESR is greater than or equal to 30 mm/hr were more effective than a polymorphonuclear leukocyte count is greater than or equal to 10,000/cu mm and/or a band count is greater than or equal to 500/cu mm in screening young children with high fever for bacteremia, pneumonia, or complicated otitis media. [ABSTRACT FROM AUTHOR]

Abstract. In a 20-month period, 1,783 children seen in the pediatric outpatient department had blood cultures performed and 117 (6.5%) of these children had bacteremia. Two thirds of the isolates were Diplococcus pneumoniae and Hemophilus influenzae b. Ninety-three percent of children with H. influenzae b bacteremia and 20% of children with pneumococcal bacteremia had soft tissue involvement at the initial visit. Most children with positive blood cultures (102) were previously well and beyond the newborn period and many (46) had seemingly trivial illnesses initially: upper respiratory tract infection, fever of unknown origin, otitis media, and diarrhea. In the absence of soft tissue infection, the latter three diagnoses correlated best with bloodstream invasion. Nineteen children had persistent bacteremia and five developed soft tissue complications not noted initially. Two factors, age between 7 and 24 months and temperature between 39.4 and 40.6 C, showed increased specificity for bacteremia but were sensitive only for pneumococcal disease. A temperature of Is greater than or equal to 40.5 C showed more specificity for bacteremia than lesser fevers. A white blood cell count > 20,000/cu mm was poorly sensitive, and pulmonary infiltrates were neither specific nor sensitive for positive blood cultures. Five bacteremic children had aseptic lymphocytosis in the cerebrospinal fluid. Two days of intravenous antibiotic therapy and eight days of oral therapy were adequate for pneumococcal bacteremia without soft tissue involvement. This therapy may not be ideal, however, since other routes and duration of therapy were not evaluated. Pediatrics, 57:861-869, 1976, BACTEREMIA, FEVER, INFECTION, LEUKOCYTOSIS. [ABSTRACT FROM AUTHOR]