Do You LP Febrile Neonates with Bronchiolitis?

April 10, 2019

Written by Clay Smith

Spoon Feed
In this survey of physicians from Canada and UK/Ireland, the strongest predictors of performing a LP in neonates with a clinical diagnosis of bronchiolitis were: practice location in Canada, <10 years in practice, and less comfort diagnosing bronchiolitis.

Why does this matter?
Many perform LP on any febrile neonate, whether bronchiolitis is present or not; some don’t. In a meta-analysis of 11 studies, 1,749 febrile infants <60-90 days with bronchiolitis, there were exactly zero cases of meningitis. The AAP Clinical Practice Guideline (CPG) on bronchiolitis says, “Studies have shown that febrile infants without an identifiable source of fever have a risk of bacteremia that may be as high as 7%. However, a child with a distinct viral syndrome, such as bronchiolitis, has a lower risk (much less than 1%) of bacterial infection of the cerebrospinal fluid or blood.” There are too many studies to list that say exactly the same thing – risk of serious bacterial infection (SBI) in neonates with clinical evidence of bronchiolitis is extremely low, <1%. And yet, I must confess that I am apt to do an LP on any febrile neonate regardless. What about you?

To LP or not to LP?
This was a survey of doctors out of residency in the Pediatric Emergency Research Canada (PERC) network and Pediatric Emergency Research Network UK/Ireland (PERUKI) who were presented a case of a 21 day old with low grade (but true) fever and bronchiolitis. See clinical vignette in box below. Only 20% of each network had rapid RSV testing available ≥75% of the time. Physicians in Canada were far more likely report that they would do a full sepsis workup, including LP, on the majority of these neonates. They found that practice in Canada, less experience (<10 years in practice), and a lower comfort level diagnosing bronchiolitis were the strongest predictors of responding that they would perform a LP. Having availability of a rapid RSV test with positive result would have decreased reported utilization of LP across the entire cohort of both networks from 35.4% to 20.2%. This study only informs us that there are huge practice variations depending upon where physicians practice, among other variables. My personal practice is to do a full sepsis workup in febrile neonates, even if they have apparent clinical or lab-confirmed bronchiolitis. But I am starting to wonder, as the overwhelming evidence suggests this is not necessary.

Source
Canadian and UK/Ireland practice patterns in lumbar puncture performance in febrile neonates with bronchiolitis. Emerg Med J. 2019 Mar;36(3):148-153. doi: 10.1136/emermed-2018-208000. Epub 2019 Feb 6.

Open in Read by QxMD