Written by Clay Smith
There is large practice variation in performance of a lumbar puncture (LP) in infants 29-60 days old, with overall LP rate of 69.5%, but a range across centers from 35-90%.
Why does this matter?
There have been attempts to standardize the approach to febrile infant workups. Rochester and Philadelphia criteria come to mind. The Step-by-Step approach and PECARN rule are also promising. I did a podcast treatise on infant fever with Rob Orman on ERcast that comes out July 7 that you may find helpful. This link saves you 25% on a subscription to ERcast and gives JournalFeed an Amazon gift card = win-win. There is wide variability in the approach to these babies. How much practice variation is there?
We need a standard approach
This was a planned secondary analysis of the PECARN study for infant fever that enrolled 4780 infants: 32%, 0-28 days; the rest, 29-60 days. LP is the elephant in the room. In infants 0-28 days, LP was done in 92.7%. If 29-60 days, it was done 69.5% of the time. CXR rates were about 36% for both age ranges. Viral testing was slightly more common in the true neonate cohort (66%) vs 29-60 day group (53%). Although overall rates of LP were lower in the 29-60 day group, it ranged from 35-90% across centers. Admission rate was 97.8% if ≤28 days; 64.4% if 29-60 days. What this tells us is that no one knows what to do in 29-60 day old infants with fever when it comes to LP. We know the risk of meningitis in these kids is low, a 1 in 500 chance. But it’s devastating if missed. For me, I do the LP if ≤28 days. I am increasingly likely to risk stratify infants 29-60 days old to determine if LP is performed or not.
Practice Variation in the Evaluation and Disposition of Febrile Infants ≤60 Days of Age. J Emerg Med. 2019 Apr 20. pii: S0736-4679(19)30129-5. doi: 10.1016/j.jemermed.2019.03.003. [Epub ahead of print]
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Reviewed by Thomas Davis