Evaluation of febrile children with petechial rashes: is there consensus among pediatricians?

Background. The evaluation of febrile children with petechial rashes evokes controversy. Although many of these children have viral infections, on occ asion such patients may be infected with Neisseria meningitidis, Objective. To investigate differences in practice trends for the evaluation and management of non-toxic-appearing febrile children with petechial rash es among pediatric specialty groups. Methods, We surveyed 833 pediatricians in 4 specialties [community (CGP) an d academic (AGP) general pediatrics, emergency medicine (EM) and infectious diseases] regarding 4 hypothetical non-toxic-appearing febrile children ag es 1, 2, 5 and 7 years. The patients differed with regard to clinical appea rance, distribution of petechiae and complete blood count results. We compa red specialty group responses, adjusting for practice setting, population s ize and years in practice using multiple logistic regression analysis, Results. The survey was completed and returned by 416 (50%) pediatricians. There was substantial variation in the evaluation of the 2 younger febrile children without clear sources for their petechiae, For the 1-year-old the overall blood culture (BCx) rate was 82%, with the EM group (91%) more ofte n requesting BCx than either the CGP (76%) or AGP (73%, P = 0.001) groups. The overall hospital admission rate was 31%, with CG;P less often requestin g admission than infectious disease pediatricians (22% vs. 40%, P = 0.007), In the regression analysis the only significant difference between groups was in BCx rate between the FM and AGP groups. For the 2-year-old the overa ll rate of BCx was 95%, lumbar puncture was 41% and admission was 44%, with no significant differences among groups. For the scenarios involving the 2 older febrile children with sources for their petechiae, the majority of r espondents chose neither lumbar puncture nor admission. There was disagreem ent regarding BCx, both within and between groups, although most of the bet ween group differences did not persist in the regression analysis. Conclusions. There are substantial differences among pediatricians in the e valuation of young non-toxic-appearing febrile children with petechial rash es. Although there are some differences between pediatric subspecialties, m ost of these differences do not persist after adjusting for practice settin g, population size and physician experience.