Müller comments with regard to the examination technique that children should always be completely undressed for a physical exam and that signs of meningismus should be actively excluded in every child. Undressing completely is an important prerequisite for the physical exam, in order to rule out heat accumulation as the cause of the raised temperature and to detect findings in sites that are difficult to access, for example petechiae on the buttocks in meningitis. Unfortunately the meningismus signs are often not very reliable, and their investigation is not helpful especially in younger children.
Schneider points out exsiccosis (thirst fever) with regard to differential diagnoses in febrile children, and hypohidrotic forms of ectodermal dysplasia (ED). His working group has contributed to the elucidation of ED in crucial ways (see the reference list of his letter to the editor). Infants with ED are subject to high mortality, and it is possible that there is a certain unknown number of ED that remain undiagnosed. In infancy, the stigmata of ED may not yet be recognizable, for example, conical teeth; thin/sparse hair/eyebrows, reduced lacrimal secretion.
With regard to laboratory tests, Müller pointed out that urine tests should always be conducted in febrile children. We cannot emphasize enough the importance of urinalysis. However, situations are common in which the cause of the fever can be identified without urine testing (for example, otitis, tonsillitis, gastroenteritis). In such obvious cases, rational diagnostic evaluation is indicated. In my view, initially leaving out urine tests is justified in the sense of putting less stress on the child and saving costs.
Pohlandt points out that it should be a learning objective that physical examination alone is not enough to base a decision on regarding outpatient treatment or admission to a pediatric hospital, and that, with regard to laboratory diagnostic evaluation, the guideline on bacterial infections in neonates (AWMF 24–008, set out in June 1997) and the therapeutic approach to be concluded from this guideline should be a learning objective. The guideline was last updated 8 years ago, is not listed in the AWMF register, and is thus not appropriate as an up-to-date recommendation. Clearly, physical examination alone is not sufficient in premature babies and neonates. The history is of crucial importance in this context ( Box). Complementary laboratory tests (especially IL-6) are certainly required, especially in preterm infants and neonates. Their significance, however, is overestimated since all markers (CRP, procalcitonin, IL-6) are raised as a matter of course, in the context of the physiological acute-phase reaction up to 36 hours post partum. In recent years, many scientific proofs have been identified for the limited study data regarding the significance of laboratory tests as predictors of severe bacterial infections (2, 3).
Aliani points out that outpatient laboratory testing in the context of EBM reimbursement is not justifiable in terms of economicalness. As a consequence, all children will have to be admitted as inpatients for the purpose of laboratory tests. We intentionally did not further define the term “children without any other signs of severe illness.” The suspicion that a child has abnormal symptoms leads to laboratory investigations in day to day practice. Specialist doctors in private practice order laboratory investigations and interpret them on a daily basis and in a competent manner. Laboratory tests are, however, only one of the pieces of the puzzle in deciding the pros and cons of a hospital admission or administration of antibiotics. In my experience, the significance of laboratory tests for assessing febrile children is overestimated, while the history and physical examination are underestimated. A rational approach to taking blood spares the children and our resources.
Staus (glucose solution) and Röhnelt (indication for and selection of antipyretic drug) wrote regarding the treatment of febrile children. In text books and guidelines the term “glucose solution” is used in isolation, without mentioning any added electrolyte. Obviously, children (and adults) must never be given free glucose solution, as this may cause severe harm to the patient.
Röhnelt writes that the degree of fever in infants is never a measure for the severity of disease. This contradicts a meta-analysis of 30 studies, in which a body temperature >40 °C is regarded as a red flag symptom of s serious bacterial infection ( Box). Standard references and textbooks recommend using antipyretics in very high temperatures >40 °C, because the hope is for an improvement in the child’s conditions (4, 5). Röhnelt mentions tests from his own clinical practice of many years (for example, lowering a fever, but lacking clinical response to antipyretics as a sign of pneumonia). In my opinion, using antipyretics ex juvantibus is questionable, since studies or long term observations are lacking. Röhnelt’s experience of the innocuousness of metamizole in treating febrile children from the 3rd month of life is not shared by some (6). Metamizole still accounts for the majority of medication induced cases of the extremely rare, but potentially life-threatening, agranulocytosis (7). The safety profile of ibuprofen or paracetamol/acetaminophen is far more favorable, either of those two drugs is preferred in febrile children (4, 5).
Prof. Dr. med. Tim Niehues
HELIOS Klinkum Krefeld
Zentrum für Kinder- und Jugendmedizin
Conflict of interest statement
Prof. Niehues has served as a paid consultant for Wyeth. He has also received reimbursement of scientific meeting participation fees and of travel and accommodation costs and lecture honoraria from Abbott, Baxter, Novartis, Pfizer, Bristol Myers Squibb, ZLB Behring, Octapharma, and Glaxo SmithKline. He has received financial support from Glaxo SmithKline for a research project that he initiated.
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