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2. Tugwell BD, Lee LE, Gillette H, Lorber EM, Hedberg K, Cieslak PR.Chickenpox outbreak in a highly vaccinated school population. Pediatrics2004;113:455-9.3. Galil K, Lee B, Strine T, Carraher C, Baughman AL, Eaton M, et al.Outbreak of varicella at a day-care center despite vaccination. N Engl J Med2002;347:1909-15.

Management and outcomes of care of fever inearly infancy

PANTELL RH, NEWMAN TB, BERNZWEIG J, BERGMAN DA, TAKAYAMA JI,

SEGAL M, ET AL. JAMA 2004;291:1203-12

Context Fever in infants challenges clinicians to distinguish

between serious conditions, such as bacteremia or bacterial

meningitis, and minor illnesses. To date, the practice patterns

of office-based pediatricians in treating febrile infants and the

clinical outcomes resulting from their care have not been

systematically studied.

Objectives To characterize the management and clinical

outcomes of fever in infants, develop a clinical prediction

model for the identification of bacteremia/bacterial meningitis,

and compare the accuracy of various strategies.Design Prospective cohort study.

Setting Offices of 573 practitioners from the Pediatric

Research in Office Settings (PROS) network of the American

Academy of Pediatrics in 44 states, the District of Columbia,

and Puerto Rico.

Participants Consecutive sample of 3066 infants aged 3

months or younger with temperatures of at least 388C seen

by PROS practitioners from February 28, 1995, through April

25, 1998.

Main outcome measures Management strategies, illness

frequency, and rates and accuracy of treating bacteremia/

bacterial meningitis.

Results The PROS clinicians hospitalized 36% of the infants,

performed laboratory testing in 75% (74% with complete blood

cell count or blood culture; 54% with urine testing; 33% with

lumbar punctures), and initially treated 57% with antibiotics.

The majority (64%) were treated exclusively outside of the

hospital. Bacteremia was detected in 1.8% of infants (2.4% of

those tested) and bacterial meningitis in 0.5%. Well-appearing

infants aged 25 days or older with fever of

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Objectives To review the data on diagnostic and supportive

testing in the management of bronchiolitis and to assess the

utility of such testing.

Design Systematic review of studies addressing diagnostic

and supportive testing for bronchiolitis.

Main outcome measures Sensitivity and specificity of

various diagnostic tests, and impact of these tests on clinical

outcome.

Study identification In conjunction with an expert panel, the

authors derived relevant terms to search the literature

published from 1980 to November 2002 in MEDLINE and the

Cochrane Collaboration Database of Controlled Clinical Trials.

Studies reviewed Of the 797 abstracts identified, 82 trials

met the authors inclusion criteria (17 are primary articles on

diagnosis of bronchiolitis and 65 are reports of treatment or

prevention trials).

Results Numerous studies demonstrate that rapid RSV tests

have acceptable sensitivity and specificity, but no data show

that RSV testing affects clinical outcomes in typical cases of the

disease. Seventeen studies presented chest radiographic film

data. Abnormalities on chest radiographs ranged from 20% to

96%. Insufficient data exist to show that chest radiographs

reliably distinguish between viral and bacterial disease or

predict severity of disease. Ten studies included complete

blood cell counts, but most did not present specific results. In

one study, white blood cell counts correlated with radiologi-

cally defined disease categories of bronchiolitis.

Conclusions A large number of studies include diagnostic and

supportive testing data. However, these studies do not define

clear indications for such testing or the impact of testing on

relevant patient outcomes. Given the high prevalence of

bronchiolitis, prospective studies of the utility of such testing

are needed and feasible.

Comment Bronchiolitis is one of the most common child-

hood diseases and has been variably diagnosed over decades

with differing sobriquets such as infectious asthma, wheezy

bronchitis, and infectious bronchitis. Nevertheless, no gold

standard exists for its diagnosis. With our current technologic

advances, the diagnosis of this clinical entity has become

increasingly laboratory-based, but not evidence-based, accord-

ing to Bordley et al.

Over 12 years only 82 trials met the inclusion criteria for their

review, and presumably there would have been fewer if they

had limited the age to that usually applied to the diagnosis ofbronchiolitisthe first two years of life. Of these studies,

diagnosis was the primary focus of only 17, and none evaluated

the usefulness of supportive testing in diagnosing bronchiolitis.

The other 65 studies were primarily on treatment and

prevention but contained some data on diagnosis and testing.

The included populations, however, had differing or poorly

defined inclusion criteria. Most required an etiologic diagnosis,

but none asked or answered whether knowing RSV to be the

cause affected the clinical outcome. Most focused on disease

severity assessed by clinical scales, the reliability of which may

be more dependent on the assessor than what is assessed.

Bordley et al, recognizing these differences and deficits,

concluded that the studies did not define clear indications

for such testing or for the impact of testing on relevant patient

outcomes. This may be interpreted, though incorrectly in my

opinion, as evidence against the use of supportive diagnostic

testing. One may conclude that specific or supportive testing in

managing bronchiolitis seems unlikely to be beneficial for most

children, but may be warranted in individual circumstances,

which currently are not able to be defined. Second, the bestdiagnostic method currently available is the test of time,

performed by an experienced clinician. Third, this analysis

substantiates the authors suggestion that prospective trials of

the value of such testing are needed. However, although they

state that such studies are feasible, they do not define how todo

them. The design, implementation, and funding of such a trial

will I hope bethe subject of a futurepublication fromthisgroup.

Caroline Breese Hall, MDDepartments of Pediatrics and Medicine, Infectious Diseases

University of Rochester, School of Medicine and DentistryRochester, NY 14642

Otitis media and speech and language:A meta-analysis of prospective studies

ROBERTS JE, ROSENFELD RM, ZEISEL SA. PEDIATRICS 2004;113:e238-48

Context Considerable controversy surrounds whether a his-

tory of otitis media with effusion (OME) in early childhood

causes later speech and language problems.

Objectives Todetermine(1) whether a historyof OMEin early

childhood is related to receptive language, expressive language,

vocabulary, syntax, or speech development in children 1 to 5

years of age; and (2)whether hearing loss causedby otitis media

in early childhood is related to childrens receptive language or

expressive language through 2 years of age.

Design Systematic review of prospective studies examining

how OME in early childhood relates to later speech and

language skills.

Main outcome measures Speech and language outcomes in

children tested between 1 and 5 years of age.

Study identification The authors searched online databases

and bibliographies of OME studies and reviews for prospective

or randomized clinical trials published between January 1966

and October 2002 that examined the relationship of OME or

OME-associated hearing loss in early childhood to childrens

later speech and language development.

Studies reviewed Of the 38 studies identified, 14 had data

suitable for calculating a pooled correlation coefficient

(correlational studies) or standard difference between parallel

groups (group studies).

Results There were no significant findings for the analyses of

OME during early childhood versus receptive or expressive

language during the preschool years in the correlation studies.

Similarly, there were no significant findings for OME versus

vocabulary, syntax, or speech during the preschool years.

Conversely, there was a significant negative association

between OME and preschoolers receptive and expressive

language (lower language, 0.24 and 0.25 standard difference,

respectively) in the group studies. In addition, hearing was also

418 Clinical Research Abstracts for Pediatricians The Journal of Pediatrics September 2004