An Ounce of Anticipatory Guidance Is Worth a Pound of Testing

An ex-full-term, healthy, without birth complications, 6-week-old girl was brought to her pediatrician for a well-child visit and given the following vaccines: diphtheria-tetanus–acellular pertussis, Haemophilus influenzae type b (Hib)–inactivated poliovirus, hepatitis B, and rotavirus. Most vaccine schedules begin at 2 months of age, but they can be given as early as 6 weeks.¹ Later that day, the patient developed a fever, and her concerned parents brought her to the emergency department (ED). She was well-appearing, with no other symptoms, and feeding well. In the ED she had a temperature of 38.7°C, initiating a serious bacterial infection (SBI) evaluation. Vital signs were otherwise normal, including normal respiratory rate, and complete physical examination was normal. Studies were performed, including urinalysis, urine culture, complete blood count, blood culture, lumbar puncture with cerebrospinal fluid studies and culture, chest radiograph, and molecular respiratory viral panel.

The white blood cell (WBC) count was elevated at 18 000 cells/mm³, with 55% neutrophils and no bands. Urinalysis was negative, cerebrospinal fluid studies showed 3 nucleated cells/mm³, 1 red blood cell/mm³, 53 mg/dL protein, and 56 mg/dL glucose. Based on the elevated WBC count, this patient was excluded from the low-risk category, admitted to the pediatric wards, and started empirically on intravenous ceftriaxone. At 22 hours, the patient’s blood culture resulted positive with Gram-positive cocci suggestive of Staphylococcus. A repeat blood culture was drawn, the patient was continued on antibiotics and hospitalized another night. The final blood culture reported coagulase-negative Staphylococcus spp, clinically determined to be contamination rather than bacteremia. The patient continued to be well-appearing, the repeat blood culture as well as all other tests ultimately resulted negative. The fever was attributed to her recent vaccinations and she was discharged from the hospital with her parents after 60 hours.

This case illustrates how a routine well-visit with vaccinations can easily turn into a 3-day-long predicament for a healthy, well-appearing child and her parents. The sequence of events led from an expected reaction to routine vaccinations, to multiple unnecessary interventions, with results from that testing leading to further unnecessary interventions. This all culminated in stress and significant harm to the family. At multiple stages throughout this patient’s care, there were opportunities to reevaluate the workup and consider stopping additional interventions to avoid further harms.

Anticipatory guidance provided on many topics has been shown to improve health outcomes.² The value of anticipatory guidance on vaccines is not only to educate parents, but also to reassure them about common side effects. Fever after vaccinations is an expected event, for which anticipatory guidance should be given. A study assessing acetaminophen use after vaccinations found that 75.4% of infants (including 2-month-olds) developed fever >38°C within 4 days after receiving diphtheria-tetanus–acellular pertussis, Hib–inactivated poliovirus, and hepatitis B vaccines.³ Although expected, parents often develop “fever phobia,” where they become concerned about fever itself and may seek immediate medical care, especially if they have not received proper guidance on postvaccine fever. Anticipatory guidance about the frequency and safety of fevers after vaccinations might have led these parents to treat with antipyretics at home, unless the child was ill-appearing. Some parents feel uncomfortable treating a fever at home because of cultural concerns that fevers may be harmful to a child’s health. A discussion about attitudes surrounding fevers can improve parents’ understanding and decrease fever phobia. If parents continue to have fever phobia, it may be worthwhile to wait until 2 months of age to give vaccinations, where after that age, providers are less likely to perform a complete SBI evaluation in a well-appearing febrile infant.⁴

Another point where the clinical course for this patient may have changed was when the parents immediately sought care in the ED, rather than from their pediatrician. Having a primary care medical home has been shown to decrease ED visits as well as hospitalizations.⁵ A study by Pantell et al⁶ characterized the management and outcomes of febrile infants treated by pediatricians in office settings in a large network of practitioners throughout the country. The authors found that office practitioners deviated in management from the current clinical guidelines for febrile infants, performing less testing and hospitalizing fewer patients than studies suggest. Using their clinical judgment to determine the management course of febrile infants, they had the same sensitivity in identifying and treating patients with bacteremia and meningitis, but were able to spare many infants the extensive workup that is called for by the current clinical guidelines. Had these parents used the pediatrician’s office or on-call service, they might have avoided the extensive workup, hospitalization, and associated harms.

When a febrile infant presents to the ED, the most concerning diagnosis that needs to be ruled out is SBI, but this does not mean a full laboratory workup needs to be completed. Criteria for managing febrile infants in the ED help determine which patients are low risk for SBI based on examination and laboratory results.^7–9 However, these criteria do not need to be applied to every single febrile infant, if they are well-appearing and have a known reason for developing a fever (such as recent vaccinations). These criteria determine which patients are low risk for SBI, but patients who do not fit into the low-risk category are not necessarily at high risk. Even patients in the high-risk category in these studies had low rates of SBI, especially patients who were >28 days old.^7,8 Much has changed since these studies were done, including routine intrapartum group B streptococcus prophylaxis and more widespread infant Hib and pneumococcal vaccinations, that makes SBI less likely in infants overall.^10–12 A well-appearing infant who just received vaccinations is low risk for SBI by history and physical examination alone, and laboratory evaluation is unlikely to be revealing.

When laboratory studies are performed with low pretest probabilities, false-positive results can be even more likely than true positives. This patient’s initial blood culture grew a contaminant, which resulted in additional testing and a prolonged hospitalization. Many studies show that blood cultures have a high false-positive rate, ranging from 3% to 9%.^13,14 A recent study showed that 69% of positive blood cultures drawn from infants were not treated as pathogenic and deemed to be contaminants.¹⁵ When tests result with an elevated WBC count or a positive culture, it is difficult for clinicians to ignore these results, even when the pretest probability was low. These positive results often guide us down a path of further interventions that are led by laboratory results rather than the clinical picture.

Although we constantly worry about the harm caused by missing and not treating an infant with SBI, we often underestimate the harm that can result from our interventions. This patient suffered through procedures including blood draws, intravenous line placement, repeated blood cultures, urine catheterization, and lumbar puncture (likely each with multiple attempts). She was hospitalized for 60 hours, with the risk of being exposed to hospital-acquired infections and medical errors. She was treated with an unnecessary antibiotic, with risks of short-term side effects of ceftriaxone (diarrhea, biliary sludging) as well as the potential for long-term side effects of early antibiotic exposure (asthma, celiac disease, obesity).^16–18 These parents lost work days and had expenses because of the hospitalization. In addition, there are harms that are much more difficult to measure. These parents went through the stress of having their child in the hospital for 2.5 days, and were made to believe that their child had a serious illness. There is a potential lasting effect that these parents will always worry whether their child will be healthy in the future, or have any long-term effects from this “illness” she suffered as an infant. This “vulnerable child syndrome” can lead to disturbances in psychosocial development and parent-child relationships.¹⁹

A few minutes of anticipatory guidance in this case could have completely changed the course of this patient’s care, and saved this family from the harms they endured. If the parents had expected a fever to occur as the natural course after receiving vaccines, or if their first response was to call their pediatrician, they might have been spared a visit to the ED. If the ED team focused on the history and physical exam of this well-appearing infant, this could have avoided unnecessary tests, which led to further unnecessary tests and hospitalization, resulting in significant harms to the family and utilization of unneeded health care resources. The value of a simple conversation with a family is often overlooked when we focus too intently on vaccine guidelines and sepsis criteria and the fear of missing a patient with SBI, rather than focusing on the overall health and well-being of a patient and her family and the harms we cause when “doing too much.”

• Copyright © 2015 by the American Academy of Pediatrics