By Stephan R. Paul, MD, JD, Attorney, White & Williams, LLP; Associate Professor, Department of Pediatrics, Temple University School of Medicine, Philadelphia.
Editor’s note: The evaluation of a febrile child is an extremely common scenario in most emergency departments (EDs). Although the majority of patients may have benign and self-limited diseases, some will have infections that can be life threatening or have serious sequelae. The source of infections is often obvious on physical examination; however, it is possible that younger infants only will have nonspecific signs that can be misdiagnosed easily. Emergency physicians (EPs) must decide which children require a work-up, the nature of that work-up, and the need for antibiotics with or without hospitalization. This process often is in the context of evaluating many febrile children, with only subtle clues as to which child truly may be ill. Unfortunately, it is common for inadvertent errors in judgment to end up in the courtroom as a subject of malpractice lawsuits.1 This month’s issue focuses on some of the risks and controversies in the evaluation of the febrile child.
Age is Important
Approximately 10% of otherwise well-appearing febrile infants have a serious bacterial infection, in contrast to 2% of older well-appearing febrile children.2,3 Coupled with the subtlety of signs in young infants, it is inherently obvious that young infants must be approached with maximal intensity. Due to this intensity, often patients younger than 2 to 3 months have full septic work-ups and are hospitalized with antibiotic therapy until the results of cultures are known.4 Multiple studies have attempted to define protocols to identify young children at risk for serious bacterial infections. One such protocol, the Rochester criteria, has achieved reasonably wide acceptance in the evaluation of infants older than 1 week.5 However, it has been shown subsequently that 3%-5% of infants identified as low risk by this protocol developed serious bacterial infections.6,7
The American College of Emergency Physicians (ACEP) has published a clinical policy statement regarding children younger than 3 years presenting to the ED with fever.8 Indeed, the ACEP recently addressed critical questions regarding these patients. The first question asked was: Are there useful age cutoffs for the different treatment strategies in febrile children? The ACEP policy noted that children in the first few months of life have decreased opsonin activity, macrophage function, and neutrophil activity.9 Because of this condition, the ACEP policy recommends that infants between 1 and 28 days old with a fever should be presumed to have a serious infection. In addition, the policy asks the question: Does a response to antipyretic medication indicate a lower likelihood of serious bacterial infection in a pediatric patient?10 The policy basically did not state that a response to an antipyretic medication changed the likelihood of a child having a serious bacterial infection. Other ACEP recommendations include: 1) the use of a chest radiograph in febrile children younger than 3 months with evidence of acute respiratory illness; and 2) urinalysis for females between 1 and 2 years presenting with a fever. In addition, the ACEP concluded that occult bacteremia among febrile children ages 3 to 36 months is 1.5%-2%, and that approximately 5%-20% of those patients will develop significant sequelae, including pneumonia, cellulitis, septic arthritis, osteomyelitis, meningitis and sepsis. As such, the ACEP recommends that antibiotic therapy is necessary for previously healthy, well-appearing children ages 3 to 36 months with a fever without a source and with a temperature greater than 39°C, when in association with a white blood cell count of 15,000 cells/mm3 or higher. In addition, it recommends that in cases where antibiotics are not prescribed in these patients, close follow-up must be ensured.
In spite of the recommendations of the ACEP, EPs are at risk for liability in cases involving fever in infants. Here, we will discuss the potential legal manifestations of this condition.
Unquestionably, meningitis is the most feared consequence of a delay in treatment of a serious bacterial infection. Despite the increasing number of childhood vaccines, meningitis continues to be a major cause or morbidity in children and also is a major cause of medical malpractice cases involving both pediatricians and EPs.
Meningitis is the inflammation of the two meningeal membranes — the arachnoid and the pia mater — that surround the brain and spinal cord. Inflammatory cells flow into the cerebral spinal fluid from the meninges producing an increased white blood cell count, which is the diagnostic hallmark of the disease. Classic symptoms of meningitis are headache, fever, and neck stiffness, although these symptoms may be less evident in younger patients.11 Inflammation of the meninges can spread to adjacent brain parenchyma, and the patient can develop encephalitis. Much of the damage to the central nervous system is not only from bacterial agents, but also from inflammation and secreted cytokines. Outside the neonatal period, the majority of bacteria that cause meningitis initially colonize in the nasopharynx and spread from there.12 Colonization in the nasopharynx occurs rarely in the neonate, and the infection is most often bloodborne with an initially unknown site.13 As the subarachnoid space is a region of impaired host defense, pathogens have an excellent chance of survival in the cerebrospinal fluid.14 A hallmark of meningitis is increased intracranial pressure, which can cause brain pathology through reduction of cerebral perfusion and cerebral ischemia, as well as the potential of herniation.15,16 Until recently, bacterial meningitis primarily was caused by Haemophilus influenzae. An epidemiologic study in 1986 revealed that H. influenzae was responsible for 45% of cases of bacterial meningitis and 70% in children between 1 month and 5 years of age.17 Since the advent of the H. influenzae vaccine however, it is clear that H. influenzae now is a relatively rare cause of bacterial meningitis in children in the United States.18 Currently, group B Streptococci, Escherichia coli, and Listeria monocytogenes remain the primary causes of meningitis in neonates in the United States.19
The sequelae for bacterial meningitis in young children are particularly severe, despite major improvements in infant intensive care, and neonatal meningitis remains a devastating disease. Survivors are at high risk for lifelong neurologic handicaps, and indeed, there is a significant mortality. Ironically, as the mortality has decreased and the cost of lifetime care has increased, malpractice litigation has become potentially even more expensive.
Recently, Dr. McAbee reviewed malpractice cases involving meningitis in the pediatric population20 from the Physicians Insurers Association of America (PIAA) in 2000. At that time, there were 724 pediatric and adult meningitis claims during a 15-year period ending in 1999. Forty-three percent of those cases were closed with indemnity payments; the average payment was more than $308,000. The median age of those patients was 2 years with a higher indemnity for the younger patient. The PIAA also noted that death occurred in 30% of the cases; and in 83% of the cases where death occurred, the patient was younger than 1 year. Noteworthy is that 7% of the defendants in those cases were EPs and that 30% of the initial contact with the patient was in the ED. Besides fever, presenting symptoms included nausea, vomiting, flu-like symptoms, and lethargy. Neck stiffness was noted in only 10% of the cases. Dr. McAbee concluded that there was no such thing as too high an index for suspicion for infants and toddlers for meningitis, and that a lumbar puncture is critical. There is an old adage in pediatrics: The proper time to perform a lumbar puncture is when it crosses your mind.
Case #1. Arvayo v. United States of America 21
On Jan. 30, 1979, Tina Arvayo brought her son, then 5 months old, to McConnell Air Force Base ED because of his crankiness and fever. Dr. Depoe diagnosed his condition as an upper respiratory tract infection and prescribed decongestants. The following day, his condition worsened, and he began having convulsions. His mother returned with him to the hospital where an EP recognized that the condition was critical and transferred him to a civilian hospital for more specialized care. Approximately seven hours later, the diagnosis of bacterial meningitis was confirmed by a lumbar puncture. Within the next eight months, it became clear that the child had suffered significant brain damage from the meningitis, and an administrative claim was filed. After this claim was denied, the Arvayos brought suit in federal district court alleging a failure to timely diagnose and treat the meningitis as a cause of the child’s retardation. The court ruled that Dr. Depoe (a U.S. government employee), was negligent in his failure to diagnose and timely treat the child’s disease as bacterial meningitis, and the United States was liable to the parents and natural guardians for $1.95 million under the Federal Tort Claims Act (FCA). The judgment was later reversed based on a statute of limitations claim in the FCA.
Case #2. Armand v. State of Louisiana 22
On Oct. 5, 1988, Derrick Armand became nauseous, disoriented, and developed a high fever. He was taken to the ED at the Earl K. Long Memorial Hospital in Baton Rouge, LA, for treatment of his condition. A diagnosis of viral gastroenteritis was made, and his mother was instructed to administer acetominophen to reduce the fever. Later that night, the child’s condition worsened and was noted to develop a petechiae of his trunk and back. Upon return to the hospital, he was diagnosed with meningococcemia and admitted. Ultimately, it was necessary to amputate both of his legs and two fingers on his right hand due to meningococcemia. Because the hospital had not functioned within its own medical policies and procedures by summoning the pediatrics on-call team, a reward of almost $5 million was made on the plaintiff’s behalf.
Meningitis clearly has the most significant complications that occur secondary to an undiagnosed fever. Note that the hallmarks of meningitis, such as meningismus, are not always present, and a high index of suspicion is necessary. The EP always should be aware of what the hospital’s policies are regarding the treatment and diagnosis of young children. A high false-negative rate of lumbar punctures is essential to providing good clinical care to these children.
Urinary Tract Infections
Pediatric urinary tract infections (UTIs) differ from adult UTIs in several clinically important ways.23 (See Table 1.)
Five percent of children who present with fever during infancy ultimately are diagnosed with a UTI.24 Risk factors include female gender and young age. Among children 1 to 2 years of age, 8.1% of girls have a UTI compared with 1.9% of boys.25 Recurrent UTIs and delays in treatment can be associated with an increased risk of renal scarring. Among the children with renal scars, up to 30% may develop hypertension.26 Renal failure is clearly the most significant consequence of undiagnosed UTI. There is a relatively small number of children who progress to end-stage renal failure from UTI, however, some studies estimate that 10% to 20% of children with end-stage renal disease had, at one point, a diagnosis of pyelonephritis with or without vesicureteral reflux.27
In infancy, it is difficult for children to express localizing signs such as dysuria, frequency, or suprapubic and/or back pain.28 Most often parents report nonspecific signs, such as fever, fussiness, vomiting, diarrhea, abdominal pain, or anorexia. Obviously, because of the occult presentation, clinicians, specifically EPs taking care of pediatric patients, must maintain a high index of suspicion for UTI in young children and infants.
Urinalysis is notoriously unreliable in the diagnosis of UTIs. A culture is almost essential. It often is necessary to perform transurethral catherization or suprapubic aspiration to perform a reliable culture.29 Reliable cultures cannot be obtained from specimens by a perineal bag collection.
The treatment of children with UTIs is variable. Some recommend that infants with fever and suspected UTI should be hospitalized and treated with intravenous antibiotics.30 The American Academy of Pediatrics (AAP) also recommends intravenous antibiotics in children who are toxic, dehydrated, or unable to tolerate oral medication. Generally, older children may tolerate oral antibiotics and can be treated empirically pending culture results.
The AAP generally recommends renal and bladder ultrasound for all children younger than 2 years for the first UTI to rule out hydronephrosis and evidence of obstruction.31 The AAP also strongly encourages evaluation for vesicureteral reflux with a voiding cystouretherogram or radionuclide-cystography in children up to the age of 2 years after the first UTI.
Case #3. McKechnie v. Stanke32
Sean McKechnie was seen during the course of eight years by multiple physicians and medical clinics. The child routinely was diagnosed with UTIs. Because of persistent problems, the plaintiff-parents took the child to another doctor and later to an urologist. An appropriate evaluation revealed a congenital defect in the urinary collection system. Plaintiffs alleged in a lawsuit that the delay in surgical repair of this congenital defect caused a number of complications to his renal system and a risk of renal failure.
Initially, the case was decided on a summary judgment for the physicians based upon an argument about the statute of limitations. Ultimately, it was remanded to the trial court, however, and the plaintiffs were allowed to move forward in their case.
This case involves a persistent failure to appropriately evaluate a child with multiple urinary tract infections leading to significant damages. It is contingent upon the EP to be aware of the entire history of the patient and to not only diagnose the immediate problem, but to recognize the need for a potential work-up for more chronic underlying anomalies. Failure to do so may result in the EP finding himself in a courtroom such as in McKechnie. In our current litigious climate, when multiple defendants are named in almost every case, the proactive EP and nurse can manage the risk by good communication skills with both the pediatrician and the parents, documentation of the communication, and personal follow-up as needed.
Children with cancer, especially those undergoing cytotoxic chemotherapy, are at special risk for overwhelming sepsis.33,34 These children should be evaluated promptly and treated with prophylactic antibiotics after the submission of blood cultures. Generally, the clinical condition of the child will determine whether a urinalysis, spinal tap, or x-ray of the chest is clinically indicated. Because of the risk of overwhelming bactericidal in the presence of neutropenia, an EP should not perform a rectal examination in these patients.
In addition to neutropenia, other important disturbances of cellular and humoral immune mechanisms usually coexist and act synergistically, rendering the host more vulnerable to a variety of infections.35,36 Daunorubicin, methotrexate, and vincristine in particular also can inhibit phagocytosis and granulocyte bactericidal activity.37 Infection prophylaxis with oral antimicrobials may disturb normal flora, although the frequent readmissions to the hospital provide opportunities for colonization with nosocomial pathogens — nowadays often multiresistant to antibiotics — rendering subsequent infections difficult to treat. Close medical surveillance is essential for this category of patients, and empirical antimicrobial therapy should be administered within an hour of the first signs and symptoms of infection.38 Fever often is the sole sign of infection in neutropenic patients because they often are unable to mount a full inflammatory response. In a prospective study of 1,001 cancer patients with fever of unknown origin, Pizzo reported that only 45% of those with documented bacteremia exhibited signs of infections other than fever.39
In patients with prolonged neutropenia, mycotic infections also must be considered. The diagnosis of invasive fungal infections is difficult even today. Blood cultures become positive in less than 50% of deep-seated Candida infections and in 50%-60% of Fusarium and Trichosporon infections, whereas positive cultures from other sites, with the exception of those derived from a sterile organ, body cavity, or fluid, usually represent colonization.40
Vascular access is an important adjunct in modern oncologic care. Centrally placed, indwelling vascular catheters ensure reliable, often long-term vascular access for the administration of antineoplastic agents and supportive therapy, such as parenteral nutrition, antibiotics, fluids, and blood products.41 Unfortunately, these catheters can be the source of colonized organisms. Therefore, a child with suspected sepsis and an indwelling catheter should be treated with antistaphylococcal antibiotics also.42 Even a non-neutropenic child with an indwelling catheter and fever should be treated to save the line.
Case #4. Marshall v. Luce43
In June 1986, 17-year-old Guyron E. Marshall was diagnosed with osteosarcoma in his right knee. He underwent surgery and chemotherapy, which was completed July 1987. The cancer reappeared in his right lung in 1992, and chemotherapy was resumed. Surgery was performed, and chemotherapy was reinitiated. He was admitted to a hospital in Texas on Dec. 21, 1992, for chemotherapy. At the time, he had a temperature of 101.4°F, which ultimately rose to 103°F. Antibiotics were not initiated at his first temperature, and a blood culture later revealed four different bacterial organisms and one fungal organism. His chemotherapy was resumed three days later, and he subsequently died of renal failure.
Plaintiffs claimed that the physicians did not accurately assess the patient’s physical condition upon his admission to the hospital and inappropriately administered the second chemotherapy. In addition, it was alleged that there was a failure to timely diagnose and treat a systemic infection within the patient’s body. The trial court initially granted the physicians’ motion for summary judgment, however, the appeal was reversed, and the case went to trial.
This child had an indwelling catheter as well as the risk for infection secondary to severe neutropenia. It was very clear that it was inappropriate to initiate chemotherapy and delay treatment of this infection.
EPs should treat patients who are known to be neutropenic or are at risk very carefully with oncologic support, appropriate cultures, and appropriate antibiotic therapy.
Febrile seizures are the most common convulsive disorder of childhood. Febrile seizures will occur in approximately 3%-5% of children before their fifth birthday with a peak onset in the second year of life.44,45 Febrile seizures must be distinguished from children with an intracranial infection or a known seizure disorder. Eighty percent of these patients have simple seizures lasting fewer than 15 minutes and occurring only once in a 24-hour period. Children with seizures that have focal features that last more than 15 minutes or occur more than once in a 24-hour period are classified as having complex febrile seizures.46 There appears to be no increase in the risk of bacteremia in patients with simple febrile seizures as compared with that of patients with other febrile illnesses.47
The most common infectious illnesses associated with febrile seizures are otitis media (34%), upper respiratory tract infection (12%), viral syndrome (6%), pneumonia (6%), urinary tract infection (3%), gastroenteritis (2%), varicella (2%), and bronchiolitis (2%).48
It is critical to distinguish between febrile seizures and other potential causes of neurologic dysfunction. Children who were pretreated with antibiotics or who have focal seizures should be evaluated carefully. In addition, patients whose level of consciousness has not returned to baseline, or children who are lethargic or irritable should be evaluated for meningitis. Also, children younger than 6 months of age also should be evaluated and potentially treated because these patients fail the age criteria for febrile seizure. Note that anti-pyretics have not been shown to be effective in preventing the occurrence of febrile seizures.49
Many patients with febrile seizure will have a recurrence. Those who have their first febrile seizure at an age younger than 18 months or have a family history of febrile seizures have an increased risk of occurrence.50
Perhaps the most critical role of the EP is to distinguish between the patient with a simple febrile seizure and the patient with potential meningitis. Patients who are of the age at which febrile seizures normally occur, often can manifest other signs of meningitis, including meningismus or lethargy. Again, in a situation where the use of a lumbar puncture for diagnostic purposes is considered, that lumbar puncture should be performed.
Febrile seizures can occur secondary to a fever following immunization. In this case, if there are persistent medical problems, the patient might be eligible for compensation under the National Childhood Vaccine Injury Act of 1986. This is a vaccine safety and compensation system that 1) created a no-fault compensation alternative to suing vaccine manufacturers and providers on behalf of citizens injured or killed by vaccines; 2) helps prevent future vaccine injuries through education and an adverse reaction reporting system; and 3) creates incentives for the production of safer vaccines.
Case #5. Earls v. Sec. of Health & Human Resources51
Vance Earls presented to the ED at Washington Hospital in Fremont, CA, at the age of 4½ months with a temperature of 102°F and a seizure. He had received his first dose of diphtheria pertussis and tetanus (DPT) vaccine at the office of his pediatrician earlier that day. He was discharged with a final diagnosis of febrile seizure and DPT reaction. He had multiple seizures during the next year and was admitted at the age of 2 years with a fever of 104°F and increased seizure activity. An electroencephalogram was performed; the results were considered borderline, and he was discharged again with a diagnosis of febrile seizures. He subsequently developed a series of nonfebrile seizures in moderate-to-mild mental retardation. The parents asked for compensation under the National Vaccine Injury Compensation Program, and it was awarded.52
Besides meningitis as mentioned above, febrile seizures with persistent problems can occur secondary to vaccinations, specifically DPT. Under the National Vaccine Compensation Act many patients who manifest seizure following the fever associated with a vaccination may ask for compensation. It is contingent upon the EP to evaluate the history of the patient carefully and determine whether recent immunizations may have led to the febrile seizure seen in the ED.
Pneumonia occurs in 30-45 of every 1,000 children younger than 5 years. It is less common in 5- to 9-year-olds and older children.53,54 Respiratory infection, including pneumonia and bronchitis, accounts for 24% of all hospital stays in the 1- to 4-year-old age group, and pneumonia is responsible for 8% of all hospital stays in the 5- to 9-year-old group.55 Approximately 62% of pneumonia cases have a viral etiology that is more common in patients younger than 5 years. A bacterial etiology composes approximately half of the causes of pneumonia for children between the ages of 2 and 5 years.56 Immunization with H. influenzae and S. pneumoniae vaccines has reduced the incidence of bacterial pneumonia.57
Every EP and pediatrician recognizes that the etiology of pneumonia also is dependent upon the season with a more common incidence of respiratory syncytial virus and para-influenza in the late fall and winter and influenza virus in the late winter and early spring.
Classically, the child arrives at the ED with sudden onset of fever, chills, tachypnea, and cough.58 Bacterial pneumonia often has a more rapid onset than viral pneumonia and often is accompanied by a low-grade fever. Mycoplasma also is an etiology of pneumonia and often is seen with clinical signs of wheezing.59 Physical examination manifested by careful auscultation is critical in determining which patients require chest x-rays for diagnosis.60,61 The respiratory rate is somewhat variable according to age with higher respiratory rates in the early-age group.62
Chest x-rays long have been considered the gold standard for patients for the diagnosis of pneumonia in children. However, chest x-rays do not replace a good physical examination.63 Blood cultures have been found to be positive in less than 3% of pediatric outpatients with pneumonia who have normal immunity.64 Blood cultures usually are recommended for patients with more severe cases of pneumonia and for infants younger than 3 months of age. Sputum samples, which are routinely used in adults, are often difficult to obtain in younger children.65
Supportive care through respiratory support is critical for patients who have a significant increase in the work of breathing or a respiratory rate greater than 25% of normal or an oxygen requirement. The presence of chronic disease, such as cystic fibrosis or sickle cell disease, may predispose the patient to more severe illnesses and should lead to hospital admission. Individual treatment with antibiotics is determined based upon the severity of the disease, the likelihood of bacterial pneumonia, and the age of the patient. The EP often must decide whether to use an antibiotic for a patient based upon whether there is more likely a viral vs. bacterial etiology of the disease. Regardless of whether the patient is admitted or treated with antibiotics, careful follow-up is critical in those patients.66
Often times, the diagnosis of pneumonia necessitates careful clinical assessment, including the ascertainment of the risk of serious disease and selective studies to determine the best management.67
Case #6. Barcia v. Society of New York Hospital68
At the time of her death, Maria Barcia was a 2-year-old who had been brought by her parents to the ED with presumptive pneumonia. The child presented with a temperature of approximately 104.2°F, a pulse of 120 bpm, and respiratory rate of 48. Her tonsils were noted to be enlarged and mildly inflamed, and the child had coryza and mild respiratory distress. A chest x-ray was performed indicating a posterior infiltrate in the right lower lobe. The EP, Dr. Baum, ordered several tests, including a throat culture. Allegedly, Dr. Baum stated that the infant wasn’t ill enough to be hospitalized and recommended that she return to her home for follow-up with her local family physician. The child went home, and her condition grew progressively worse. The following day, the child was brought back to the hospital and admitted. Unfortunately, in spite of heroic efforts, she succumbed to her illness, thought to be staphylococcal pneumonia. The minor-plaintiff estate’s administrator filed an action against defendant hospital for damages for the wrongful death of the child. The court entered judgment in favor of the administrator, and the defendants lost their appeal.
As with most pediatric diseases involving fever, it is critical that a high index of suspicion for serious disease be considered. Careful auscultation and chest x-ray often can be used to diagnose the possibility of pneumonia. Initial clinical signs often are indistinguishable from an upper respiratory tract infection, which is certainly the most common complaint of most parents. In addition, very careful follow-up after evaluation of oxygenation is critical to avoid medical errors regarding the diagnosis of pneumonia. Pulse oximetry reading to evaluate the oxygenation of the child is an essential element of the vital signs and is inexpensive and noninvasive.
The risk of bacteremia in febrile young children in the ED has changed significantly since the advent of H. influenzae type B vaccination.69 One major study showed that in a major urban ED, occult bacteremia was seen in 1.57% of blood cultures drawn in children considered to be at risk. Results of this study also indicated that a white blood cell count of 15,000 cells/mm3 would be the most accurate predictor of occult pneumococcal bacteremia.70 The study also indicated that in the post-Haemophilus influenzae vaccine era, pneumococcal bacteremia was fairly consistent from the age of 6 months to 3 years and rare in children younger than 6 months. Results from another study indicated that clinical improvement with defervescence with antipyretic therapy was not a reliable indicator for the presence of occult bacteremia. The study, however, did show that a lack of clinical improvement with defervescence was a reliable indicator for the presence of meningitis.71 Occult bacteremia occurs in approximately 3% of children younger than 3 years of age in patients with fever without source and a temperature of 39°C or higher.72 Other studies have shown that a temperature of 39°C and white counts of 15,000 cells/mm3 or greater are excellent indicators of potential bacteremia.73 Results of two studies showed that patients with S. pneumoniae who were not treated with antibiotics at the time of the initial evaluation had a potential of developing complications including cellulitis, pneumonia, sepsis (10%-25%), and meningitis (3%-6%).74,75
Serious complications of occult bacterial infection include bacterial meningitis, sepsis, bacteremia, pneumonia, urinary tract infections, bacterial gastroenteritis, osteomyelitis, and pyelonephritis.76
The evaluation of children with fever without source in the ED is controversial, and a need to evaluate these patients is extraordinarily common. Most visits to the ED for a fever will involve viral illnesses. Evaluation of the rates of bacterial illness within the subset of patients with fever is difficult because of inconsistent use of blood and other bacterial cultures.
In one study, 182 patients younger than 3 months of age with fever were evaluated prospectively.77 All evaluated patients had blood urine and CSF bacterial and viral cultures, as well as nasal pharyngeal viral cultures and acute and convalescent viral titers. Viral pathogens outnumbered the bacterial pathogens by almost 3-to-1 with aseptic meningitis as the most common diagnosis in 30% of the infants. UTI was the most common bacterial infection, found in 11%. In another large retrospective study of ED presentation of children with fever, 23% of febrile children were at risk for bacteremia; however, bacteremia was only present in 1.6% of those children.78 No laboratory test was singularly predictive as to which febrile child has bacteremia. An abnormal total white blood cell count greater than 15,000 cells/mm3 or fewer than 5,000 cells/mm3 was insensitive and nonspecific, but as good as any other test available. The presence of bands or shifts to the left is likewise nonpredictive.79 Modified Rochester criteria had been used to determine which patients were at a greater risk. These criteria hold that generally an infant is considered low risk if he or she appears generally well, had been previously healthy, has no evidence of skin, soft-tissue, bone joint or ear infection, has a white blood cell count between 5,000 cells/mm3 and 15,000 cells/mm3, has an absolute band count of fewer than 1,500 cells/ mm3, has fewer than 10 white blood cells per high-power field in urine, and if diarrheic, has fewer than 25 white blood cells per high-power field in a stool sample.80,81
Unfortunately, it is difficult to predict which children are at risk, and, as many EPs know, the hospitalization of a child for routine antibiotic therapy in all cases has a significant risk of iatrogenic complications, as well as significant costs.82 As a result, there are no hard-and-fast rules in making the determination as to which child requires empiric antibiotics and hospitalization. Clearly, at the very least, all children should be followed after the determination of the risk of lost follow-up. Often a pediatrician or an EP will develop a sixth sense by looking at a child as to how sick he or she may be. Unfortunately, mistakes have the potential of leading to litigation.
Case #7. Gartner v. Hemmer 83
On the evening of April 15, 1995, 5-month-old Haley Gartner was evaluated in an ED. At the time, Haley had a history of emesis and high fever and in the ED showed vomiting, lethargy, irritability, crying, and a fever of 103.5° F. The child was examined; an x-ray, a urinalysis, blood count, and blood culture were performed. The white blood cell count was 16,400 cells/mm3 with a left shift. The blood culture was submitted prior to the discharge from the ED. The child was given acetominaphen, which reduced her temperature by two degrees, and she became less irritable. Based upon her improvement, as well as the seasonality of the evaluation, the child was sent home with a presumptive diagnosis of viral disease. No antibiotics were prescribed. The child ultimately developed meningitis and had pneumococcal bacteremia. The Garners brought a medical malpractice action against multiple care providers, claiming that Hayley’s presentation at the ED indicated that she had an infection, and that if antibiotics had been administered at that time, it would have likely prevented the development of meningitis. Initially, the plaintiff’s expert was disqualified but on appeal was allowed. The appellate court reversed the trial court’s holding in favor of the defendants and remanded the matter for a new trial.
Acute otitis media is probably the most common diagnosis made by pediatricians and EPs in situations where a child has fever. The prevalence of this condition is overwhelming, and there are data to suggest that there actually has been an increase in the incidence of otitis media in the United States.84 The medical costs for the management of otitis media in children younger than 5 years totaled more than $5 billion per year, which does not include indirect costs associated with parental absenteeism from work.85 Certain studies suggest, that as of 1990, otitis media was the most frequent diagnosis for children younger than 15 years of age.86 The most common bacterial pathogens associated with otitis media are S. pneumoniae, H. influenzae, and Moraxella catarrhalis.87,88 Many cases also may have a viral etiology.89 The most common diagnosis is made through direct otoscopy. Otoscopy can be difficult, especially in the presence of obstructing cerumen. The EP should become efficient at curettage, irrigation, or suction to remove cerumen.90,91 Tympanocentesis formerly was a standard for the diagnosis of acute otitis media. However, it is not used frequently, except in patients who are unresponsive to antibiotic therapy.92
Review of the antibiotic therapy of otitis media is beyond the scope of this report; however, it has been reviewed extensively in the literature.93 Because the mortality associated with otitis media is low and serious complications are rare, there is a tendency to regard this condition with complacency. However, it is very important that one be sure of the diagnosis and that concomitant infections of a more serious nature also are ruled out.
Case #8. Deberry v. Sherman Hospital Assoc.94
Shaunita DeBerry, age 8 months, was brought to the hospital’s ED suffering from a fever, rash, and a stiff neck. The EP considered the possibility of meningitis, but ultimately rejected that diagnosis based upon obvious otitis media symptoms. The child was sent home with antibiotics, but, was readmitted two days later with meningitis.
The family sued for medical malpractice in state court, as well as on a theory based on the EMTALA anti-dumping statute in federal court. The court granted the hospital’s motion for summary judgment and dismissed the child’s anti-dumping act claim. The court also dismissed the child’s pendant state law malpractice claim with leave to reinstate in state court.
There is a tendency to attempt to explain all clinical signs based upon a single diagnosis. This is often the most satisfying, but it is sometimes inaccurate and can lead to a misdiagnosis of a serious illness in the case of a diagnosis of otitis media. Children can look quite ill from otitis media, and this diagnosis often can explain fairly severe signs.
It is important, however, to be aware that otitis media can mask meningitis or other serious infections, when making this diagnosis and discharging the patient from the ED.
Fever in children poses a common diagnostic and therapeutic challenge to the EP. Although the majority of cases are relatively minor and nonspecific, complications of catastrophic illness can lead to disastrous consequences if not detected early. ED personnel should be proficient in the examination of the child with fever and use the appropriate consultations during this evaluation.
EPs must recognize which laboratory and diagnostic tests are important in pursuing more serious illnesses that can be manifested by fever. It is important to be sensitive to the needs of the child and the family and cognizant of the limitations in acquiring an adequate history and performing an appropriate physical examination. For this reason, it is important to use appropriate consultations, admission when necessary, and, at the very least, assuredness of follow-up. The EP and pediatrician often develop the ability to recognize subtle differences in a child who is significantly ill vs. a child with a simple viral syndrome.
1. Karcz A, Korn R, Burke MC, et al. Malpractice claims against emergency physicians in Massachusetts: 1975-1993. Am J Emerg Med 1996;14:341-345.
2. Luszczak M. Evaluation and Management of Infants and Young Children with Fever. Am Fam Physician 2001; 64:1219-1226.
3. Alpern ER, Allessandrini EA, Bell LM, et al. Occult bacteremia from a pediatric emergency department: Current prevalence, time to detection, and outcome. Pediatrics 2000;106:505-511.
4. Lynn RR, Wiebe RA. Initial approach to the infant younger than two months who presents with fever. Semin Pediatr Infect Dis 1995;6:212-217.
5. Jaskiewicz JA, McCarthy CA, Richardson AC, et al. Febrile Infants at low risk for serious bacterial infection: An appraisal of the Rochester criteria and implications for management. Febrile Infant Collaborative Study Group. Pediatrics 1994; 94:390-396.
6. Kadish HA, Loveridge B, Tobey J, et al. Applying outpatient protocols in febrile infants 1-28 days of age: Can the threshold be lowered? Clin Pediatr 2000;39:81-88.
7. Baker MD, Bell LM. Unpredictability of serious bacterial illness in febrile infants from birth to one month of age. Arch Pediatr Adolesc Med 1999;153:508-511.
8. ACEP Clinical Policies Committee. Clinical policies committee on pediatric fever. Ann Emerg Med 2003;42:530-545.
9. Baker MD. Evaluation and management of infants with fever. Pediatr Clin North Am 1999;46:1061-1072.
10. McCarthy PL. Infants with fever. N Engl J Med 1993;399: 1493-1494.
11. Bonthius DJ, Karacay B. Meningitis and encephalitis in children: An update. Neurol Clin 2002;20:1013-1038.
12. Quagliarello VJ, Scheld WM. Treatment of bacterial meningitis. N Engl J Med 1997;336:708-716.
13. Bonthius, supra note 11, 1013.
14. Simberkoff MS, Moldover NH, Rahal J. Absence of detectible bacteria opsonic activities in normal and infected human cerebral spinal fluids: A regional host deficiency. J Lab Clin Med 1980;95:362-372.
15. Dodge PR. Neurologic sequelae of acute bacterial meningitis. Pediatr Ann 1994;23:101-106.
16. Lindvall P, Ahlm C, Ericsson M, et al. Reducing intracranial pressure may increase survival among patients with bacterial meningitis. Clin Inf Dis 2004;38:384-390.
17. Wenger JD, Hightower AW, Facklam RR, et al. Bacterial meningitis in the United States, 1986: Report of a multi-state surveillance study, The Bacterial Meningitis Study Group. J Infect Dis 1990;162:1316-1323.
18. Frohna JG, Park SM, Gopal S. Diagnosing bacterial meningitis after the Haemophilus Influenzae vaccine. Arch Pediatr Adolesc Med 2001;155:1307-1310.
19. Smith AL, Haas J. Neonatal bacterial meningitis. In: Scheld WM, Whitley RJ, Durack DT, eds. Infections of the Central Nervous System. New York City: Raven Press; 1991, pp. 313-333.
20. McAbee GN. Lessons can be learned from malpractice cases involving meningitis. Amer Acad Pediatr News, 2004:180-182.
21. Arvayo v. United States of America, 580 F. Supp. 753, U.S. District Court for the District of Kansas (1984); rv’d 766 F.2d 1416 (10th Cir. 1985).
22. Armand v. State of Louisiana, 729 So. 2nd 1085 (1999).
23. Layton K. Diagnosis and management of pediatric urinary tract infections. Clin Fam Prac 2003;5:367.
25. American Academy of Pediatrics Practice Parameter. The diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics Committee on Quality Improvement, Sub-Committee on Urinary Tract Infection. Pediatrics 1999;103:843-852.
26. Chon CH. Pediatric urinary tract infection. Pediatr Clin N Amer 2001;48:1441-1459.
27. Jodal U, Hansson S. Urinary tract infections. In: Holiday MA, Barratt MB. Avner YA, eds. Pediatric Nephrology. Baltimore: Williams & Wilkins; 1994, pp. 950-962.
28. Linder T, Shortliffelm KA. Evaluation and management of repeat urinary tract infections. Urol Clin N Amer 1999;26:719-728.
29. Udal U. Suprapubic aspiration in the diagnosis of urinary tract infections in infants. Acta Paediatr 2002;91:497-498.
30. Baraff LJ, Bass JW, Fleisher GR, et al. Practice guidelines for the management of infants and children 0-36 months of age with fever without source. Pediatrics 1993;92:1-12.
31. Academy of Pediatrics. Practice Parameter: The Diagnosis, Treatment and Evaluation of the Initial Urinary Tract Infection in Febrile Infants and Young Children. American Academy of Pediatrics, Committee on Quality Improvements, Sub-Committee on Urinary Tract Infection. Pediatrics 1999;103:843-852.
32. McKechnie v. Stanke, 124 Ore.App. 405 (Ore. App. 1993).
33. Langley J, Gold R. Septic and febrile neurtopenic children with cancer sepsis in febrile neutropenic children with cancer. Pediatr Infect Dis J 1988;1:34-37.
34. Chanock SJ, Pizzo PA. Fever in the neutropenic host. Infect Dis Clin N Amer 1996;10:777-796.
35. Giamarellou H. Empiric therapy for infections in the febrile neutropenic compromised host. Med Clin North Amer 1995; 79:59-80.
36. Giamarellou H, Antoniadou A. Infectious complications of febrile leukopenia. Infect Dis Clin North Am 2001;15(2):457-82.
37. Giamarellou H. Infection in febrile neutropenia. In: Cunha BA, ed. Infectious Diseases in Critical Care Medicine. New York City: Marcel Dekker; 1998, p. 563.
38. Klastersky J. Empirical treatment of sepsis in neutropenic patients. Hospital Med 2001;62:101-103.
39. Pizzo PA. Current concepts: Fever in immunocompromised patients. N Engl J Med 1999;341:893-900.
40. De Marie S. New developments in the diagnosis and management of invasive fungal infections. Haematologica 2000;85:88-93.
41. Wiener ES, Albanese CT. Venous access in pediatric patients. J Intraven Nurs 1998;21:S122-33.
42. Pizzo, supra note 38.
43. Marshall v. Luce, 1998 Tex. APP. LEXIS 1428 (Tex. App., 1998).
44. Freedman SB, Powell EC. Pediatric seizures and their management in the emergency department. Clin Pediatr Emerg Med 2003;4:195.
45. Gray C, Davies F, Molyneux E. Apparent life-threatening events presenting to a pediatric emergency department. Pediatr Emerg Care 1999;15:195-199.
46. Verity C, Golding J. Risk of Epilepsy after febrile seizures: A national cohort study. BMJ 1991;303:1373-1376.
47. Trainor JL.Children with simple first-time febrile seizures are at low risk of serious bacterial illness. Acad Emerg Med 2001;8:781-787.
49. Baumann RJ. Prevention and management of febrile seizures. Paediatr Drugs 2001;3:585-592.
50. Berg AT, Shinnar S, Hauser WA, et al. A perspective study of recurrent febrile seizures. N Engl J Med 1992; 327:1122-1127.
51. Earls v. Secretary of Health and Human Resources, 1991 U.S. Cl.Ct. LEXIS 105 (1991).
53. Laupland KB, Davies HD. Pneumonia and Bronchiolitis. In: Feldman W, ed. Evidence-Based Pediatrics. Hamilton [Ontario], St. Louis, B.C.: Decker; 2000, p. 155.
54. Mahabee-Gittens EM. Pediatric pneumonia. Clin Pediatr Emerg Med 2002;3:200.
55. McCormick MC. Annual report on access to and utilization of healthcare for children and youth in the United States, 2000. Ambul Pediatr 2001;1:3-15.
56. Juven T, Metsola J, Waris M, et al. Etiology of community-acquired pneumonia in 254 hospitalized children. Pediatr Infect Dis J 2000;19:293-298.
57. McCracken GH. Diagnosis and management of pneumonia in children. Pediatr Infect Dis J 2000;19:924-928.
58. Margolis P, Gadomski A. Does this infant have pneumonia? JAMA 1998;279:308-313.
59. Ruuskanen O, Mertsola J. Childhood community-acquired pneumonia. Semin Respir Infect 1999;14:163-172.
60. Levinthal JM. Clinical predictors of pneumonia as a guide to ordering chest roentgenograms. Clin Pediatr 1982;21:730-734.
61. Zukin D, Hoffman J, Cleveland R, et al. Correlation of pulmonary signs and symptoms with chest radiographs in the pediatric age group. Ann Emerg Med 1986;15:792-796.
62. World Health Organization. The Management of Acute Respiratory Infections in Children. Practical Guidelines for Outpatient Care. Geneva; 1999.
63. Crain E, Bulis D, Bijur P, et al. Is the chest radiograph necessary for the evaluation of every febrile infant less than eight weeks of age? Pediatrics 1991;88:821-824.
64. Hickey RW, Bowman MJ, Smith GA. Utility of blood cultures in pediatric patients found to have pneumonia in the emergency department. Ann Emerg Med 1996;27:721-725.
65. Bartlett JG. Management of Respiratory Tract Infections. 2nd ed. Philadelphia: Lippincott, Williams & Wilkins; 1999.
66. Children’s Hospital Medical Center. CHMC: Evidence-Based Clinical Practice Guideline of Community Acquired Pneumonia in Children Sixty Days to Seventeen Years of Age. Cincinnati; 2000, pp. 1-11.
67. Hickey, supra note 63.
68. Barcia v. Society of New York Hospital, 39 Misc. 2nd 526, 241 NYS 2nd 373 (1963).
69. Lee GM, Harper MB. Risk of bacteremia for febrile young children in the post-Hemophilus influenza type B era. Arch Pediatr Adolesc Med 1998;152:624-628.
71. Baker MD. Evaluation and management of infants with fever. Pediatr Clin N Am 1999;46:1061-72.
72. Baraff LJ, Bass JW, Fleisher GR, et al. Practical guidelines for the management of infants and children 0-36 months of age with fever without a source. Pediatrics 1993;92:1-12.
73. Jaffe DM, Tanz RR, Davis AT, et al. Antibiotic administration to treat possible occult bacteremia in febrile children. N Engl J Med 1997;317:1175-1180.
74. Kuppermann N. Occult bacteremia in young febrile children. Ped Clin N Am 1999;46:1073-1109.
75. Avner JR, Baker MD. Management of fever in infants and children. Emerg Med Clin N Am 2002;20:49-67.
76. Bleeker SE, Moons KG, Derksen-Lubsen G, et al. Predicting serious bacterial infection in young children with fever without apparent source. Acta Paediatr 2001;90:1226-1232.
77. Krober MS, Bass JS, Powell, JM. Bacterial and viral pathogens causing fever in infants less than 3 months old. Am J Dis Child 1985;139:889-892.
78. Mazur LJ, Kozinetz CA. Diagnostic tests for occult bacteremia: Temperature response to acetaminophen versus WBC count. Am J Emerg Med 1994;4:403-406.
79. Jaffe DM, Fleisher GR. Temperature and total white blood cell count as indicators of bacteremia. Pediatrics 1991;87(5): 670-674.
80. Dagan R, Powell KR, Hall CB, et al. Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis. J Pediatr 1985;107:855-860.
81. Dagan R, Sofer S, Philip M., et al. Ambulatory care of febrile infants younger than 2 months of age classified as being low risk for serious bacterial infections. J Pediatr 1988;112:355-360.
82. DeAngelis C, Jaffe A, Wilson M, et al. Iatrogenic risks and financial costs of hospitalizing febrile infants. Am J Dis Child 1983;137:1146-1149.
83. Gartner v. Hemmer, 2002 Ohio 2040, 2002 Ohio App., LEXIS 1976 (Ohio App. 2002).
84. Lanphear BP, Byrd RS, Auinger P, et al. Increasing prevalence of recurrent otitis media among children in the United States. Pediatrics 1997;99:E1-E7.
85. Bondy J, Berman S, Glazner J, et al. Direct expenditures related to otitis media diagnosis: Extrapolations from a pediatric Medicaid cohort. Pediatrics 2000;105:E72.
86. Shappert SM. Office Visits for Otitis Media, United States, 1975-1990. Advance Data from Vital and Health Statistics, No. 214. Hyattsville, MD: National Center for Health Statistics; 1992.
87. Barnett ED, Klein JO. The problem of resistant bacteria for the management of acute otitis media. Pediatr Clin N Am 1995;42:509-517.
88. Jacobs MR. Increasing importance of antibiotic-resistant Streptoccocus pneumoniae in acute otitis media. Pediatr Infect Dis J 1996;15:940-943.
89. Heikkinen T, Thint M, Chonmaitree T. Prevalence of various respiratory viruses in the middle ear during acute otitis media. N Engl J Med 1999;340:260-264.
90. Pichero ME. Acute otitis media, 1: Improving diagnostic accuracy. Am Fam Physician 2000;61:2051-2056.
91. Hoberman A, Paradise J. Acute otitis media, diagnosis and management in the year 2000. Pediatr Ann 2000;29:609-620.
92. Berman S. Otitis media in children. N Engl J Med 1995;332: 1560-1565.
93. McCracken GH. Diagnosis and management of acute otitis media in the urgent care setting. Ann Emerg Med 2002;39: 413-421.
94. Deberry v. Sherman Hospital Assoc., 769 F. Supp. 1030; 1991, U.S. Dist. LEXIS. 10476 (U.S.D.C. — N.D. Illinois, Eastern Div., 1991).