Ув. Женя! Посмотрите этот эдиториал. Здесь как говорится в общем и целом. Я думаю это немного придаст Вам уверенности.
Management of the Young Child with Fever
JERRY KRUSE, M.D., M.S.P.H.
Quincy Family Practice Residency Program
The proper evaluation and management of the febrile child with no obvious source of fever has long been a difficult proposition. During the past two decades, there has been a burgeoning growth in the body of literature that addresses the care of such children. Early in this period, the essential importance of observational assessment was recognized.1-5 Observational assessment was demonstrated to be useful in distinguishing children at higher risk for serious bacterial infection (i.e., children who appear toxic) from those at much lower risk (i.e., children who appear well).
In the landmark study that was the first study to systematically quantify an observational scale, McCarthy and colleagues1 wrote: «Observation, as the initial hypothesis-generating maneuver in evaluating febrile children, establishes the prior probability of disease and allows the pediatrician to interpret further clinical and laboratory data in light of that probability.» Many subsequent studies have produced information that has helped clarify the age-specific epidemiology of febrile illness in young children and has underscored the importance of clinical observation and examination of the febrile child.6-9
In this issue of the American Family Physician, Daaleman summarizes the recommendations for the management of the febrile child.10 This article highlights the unmistakable importance of astute clinical observation in the evaluation and management of febrile children. The widely publicized recommendations that are summarized by Daaleman were written by a seven-member panel of physicians in academic medicine with specialties in pediatric emergency medicine or pediatric infectious diseases. The work of the panel, sponsored by grants from the Agency for Health Care Policy and Research and from Roche Laboratories, resulted in the publication of «Practice Guideline for the Management of Infants and Children 0 to 36 Months of Age With Fever Without Source.»11,12 The strengths and shortcomings of this practice guideline have been articulated in the literature.13
The article by Daaleman includes useful tables and algorithms. One table (Table 3, page 2505) summarizes the characteristics of the child who appears toxic and another table (Table 1, page 2504) provides information on the Rochester criteria for evaluating febrile infants. The Rochester criteria specify clinical and laboratory characteristics of febrile children who are unlikely to have a serious bacterial infection.
The Rochester criteria have been the basis for studies that have provided significant information about the age-specific epidemiology of disease in febrile children. Fifteen years ago it was standard practice in academic institutions to admit all febrile infants aged 90 days or less and perform a complete septic evaluation and administer parenteral antibiotics, even if they appeared well and had no laboratory abnormalities.14 Over time, less aggressive plans of evaluation and treatment have proven safe and efficacious for infants aged 28 to 90 days. More recently, the Rochester criteria have been applied to define the risk status of infants under 28 days of age. As the panel reported in the guideline, a study by the Febrile Infant Collaborative Group6 revealed that only one of 227 infants under 28 days of age and categorized as low risk by the Rochester criteria had a serious bacterial infection (a urinary tract infection caused by Escherichia coli).
It is now evident that infants aged up to 90 days are not the homogeneous group that they were once thought to be. Physicians who are experienced in caring for young infants and who are thoroughly familiar with the child’s social situation may, after appropriate clinical and laboratory evaluation, elect to manage febrile infants aged 28 to 90 days without hospitalization or antibiotics. Such management may even be appropriate for infants 28 days of age or younger.
Despite observations that low-risk infants younger than one month of age may not require hospitalization, the members of the expert panel recommended that «all febrile infants less than 28 days of age, including those in the low-risk group, should have a sepsis evaluation and be hospitalized for parenteral antimicrobial therapy pending culture results.»11,12
To understand this recommendation, the factors that underlie the development of clinical practice guidelines must be considered. The rationale for such guidelines generally fall into three categories: (1) guidelines based on solid scientific evidence, (2) guidelines based on «safe» practice or the prevailing standard of care and (3) guidelines based on economic issues. Most of the information summarized by Daaleman falls into the first categoryÄ recommendations based on reasonably solid clinical evidence. The recommendation regarding the management of the febrile child less than 28 days old, however, falls into the second category. Though no reason for this recommendation is given in the text, it is apparent that the panel did not believe that evidence from one large study was enough to allow a recommendation to abandon the prevailing standard of care. This opinion is likely based again on the importance of observational assessment.
The most important elements of observational assessment of the young febrile child are responsiveness and playfulness.3,5 These characteristics, particularly the child’s reaction to eye contact, cannot be counted on in the first few weeks of life, since the social smile is usually not present in the first month.15 The ambiguities involved in establishing a clinical state of wellness in a very young infant make it difficult for the current practice standard to be abandoned until an abundance of evidence is available.
The most recent information regarding the management of the febrile child reaffirms much of what was previously known, provides new information of value and demands some words of caution. The following are some implications for clinicians:
Daaleman correctly indicates that the recommendations of the panel are guidelines, not standards, and are not intended to be applied universally. However, widely publicized clinical practice guidelines tend to quickly become standards of care. Clinicians need to clearly understand the composition and mission of the bodies that make clinical recommendations and the evidence on which the recommendations are made. Clinicians should question why evidence regarding less aggressive treatment of infants younger than 28 days was rejected and why only one specific antibiotic was mentioned in the guidelines.
The Rochester criteria for low risk in a febrile infant give clinicians a powerful tool for risk stratification. When utilizing the Rochester criteria, it is most important to first distinguish children who appear well from those who do not. Children who appear toxic should be managed aggressively with hospitalization, sepsis evaluation and parenteral antibiotics. The remainder of the criteria may then be applied to the children who appear well.
After proper assessment, less aggressive evaluation and treatment and care at home are indicated for many children who previously would have received a more aggressive evaluation and treatment. This approach will minimize the pain of intervention, the risks of intervention (e.g., nosocomial infections, side effects of medication, infiltration of infusions) and the monetary costs of intervention.
Current guidelines make little reference to the beliefs and feelings of parents of febrile children. The management of the febrile child is often more difficult because the expectations and the health beliefs of the parents differ significantly from those of the physician. There is evidence that parents are more willing than physicians to risk rare but severe morbidity to avoid short-term adverse effects of testing.16 This interaction requires further study.
Serious bacterial infections are not confined to children with fever. Many of the principles outlined in the recommendations for management of the febrile child apply also to children who are afebrile but have other signs of illness. It is also important to remember that after a decision is made to treat a child empirically with antibiotics, there is still the need for careful observation, whether that be in the hospital or by frequent outpatient contacts with the physician.
Careful observational assessment and risk stratification, though not infallible, are very valuable tools that allow the family physician to accept varying degrees of uncertainty in clinical situations. The clinician’s response to uncertainty is part of the philosophy and art of family practice and allows the clinician to instill confidence as the therapeutic process proceeds.
Clinicians are eagerly awaiting further studies that more precisely define criteria for accurately assessing the risk of serious infection in the febrile child. For now, clinical observation and examination remain our most powerful tools.
У малыша 3,5 месяцев уже неделю держится температура 37.4-37.1. Опускается периодически до 36.9.В носике небольшые соплюшки, но сопли не текут. Если закапать физ. Р-ром , то на турундочке есть слизистые прозрачные выделения. Кашля нет. Доктор приходила на 5й день- в легких чисто. Ребенок немного капризный, не такой активный как всегда, но и не вялый. Пьет много водички и чая из ромашки. Я переживаю- нормально ли ,что так долго температура держится? Или это иммунитет так работает? Из лекарств ничего не даю- только обильное питье, влажный воздух. Помогите, пожалуйста.