Optimization of home treatment in haemophilia: effects of transmural support by a haemophilia nurse on adherence and quality of life.

BACKGROUND: Transmural support by a haemophilia nurse may improve treatment and may empower parents and patients. AIM: To measure the effect of structured home visits by a haemophilia nurse in (parents of) patient on aspects of prophylactic home treatment. METHODS: A multicentre intervention study in two paediatric haemophilia treatment centres was performed. Primary outcome measures were: adherence to prescribed treatment, health-related quality of life and behavioural scores. Secondary outcome measures were: total clotting factor consumption, self-efficacy and number of joint bleeds. RESULTS: Over a period of 22 months (median, IQR 21-23), four to seven home visits in 46 patients (mean age 9.4 ± 4.2 years) were made. No difference in adherence to prescribed treatment was seen after the home visits when compared to baseline measurements. Both the Child Health Questionnaire (CHQ) scales on 'Role functioning - Emotional/Behavioural' (P = 0.02, d = 0.53) and 'Parental Time Impact' (P = 0.04, d = 0.33) were reduced after intervention. The disease-specific Haemo-QoL questionnaire showed improvement in domains: 'Family' (P = 0.04, d = -0.14), 'Friends' (P = 0.03, d = -0.29) and 'Perceived support' (P = 0.03, d = -0.37). Significant improvement was observed with regard to domain 'Communication' of the VERITAS-Pro scale (P = 0.03, d = -0.28). CONCLUSIONS: After a period of transmural care by a haemophilia nurse, significant but small positive effects were demonstrated with regard to communication and increase of perceived support between parents and haemophilia treatment centre. No improvement was observed in other outcome measures.

Health-related quality of life in preschool children in five health conditions.

OBJECTIVE: To test the responsiveness of the Infant/Toddler Quality of Life Questionnaire (ITQOL) to five health conditions. In addition, to evaluate the impact of the child's age and gender on the ITQOL domain scores. METHODS: Observational study of 494 Dutch preschool-aged children with five clinical conditions and 410 healthy preschool children randomly sampled from the general population. The clinical conditions included neurofibromatosis type 1, wheezing illness, bronchiolitis, functional abdominal complaints, and burns. Health-related quality of life (HRQoL) was assessed by a mailed parent-completed ITQOL. Mean ITQOL scale scores for all conditions were compared with scores obtained from the reference sample. The effect of patient's age and gender on ITQOL scores was assessed using multi-variable regression analysis. RESULTS: In all health conditions, substantially lower scores were found for several ITQOL scales. The conditions had a variable effect on the type of ITQOL domains and a different magnitude of effect. Scores for 'physical functioning', 'bodily pain', and 'general health perceptions' showed the greatest range. Parental impact scales were equally affected by all conditions. In addition to disease type, the child's age and gender had an impact on HRQoL. CONCLUSIONS: The five health conditions (each with a distinct clinical profile) affected the ITQOL scales differently. These results indicate that the ITQOL is sensitive to specific characteristics and symptom expression of the childhood health conditions investigated. This insight into the sensitivity of the ITQOL to health conditions with different symptom expression may help in the interpretation of HRQoL results in future applications.

Recognition of child maltreatment in emergency departments in Europe: Should we do better?

OBJECTIVES: To evaluate the different policies to recognize child maltreatment in emergency departments (EDs) in Europe in order to define areas of improvement. METHODS: A survey was conducted on the recognition of child maltreatment in EDs in European countries with a focus on screening methods, parental risk factors, training and hospital policies. The survey was distributed through different key members from the EUSEM, REPEM and the EuSEN. A summary score based on the NICE guideline (4 questions on child characteristics, 4 questions on parental characteristics and 5 questions on hospital policy) was calculated. RESULTS: We analysed 185 completed surveys, representing 148 hospitals from 29 European countries. Of the respondents, 28.6% used a screening tool, and 31.8% had guidelines on parental risk factors. A total of 42.2% did not follow training based on child characteristics, and 57.6% did not follow training on parental characteristics. A total of 71.9% indicated that there was a need for training. 50.8% of the respondents reported a standardized policy for the detection of child maltreatment. Translating the survey results to NICE summary scores of the EDs in Europe, we found that 25.6% (34/133) met most, 22.6% (30/133) met some and 51.9% (69/133) met few of the NICE guideline recommendations. More specifically, with respect to hospital policies, 33.8% (45/133) met most, 15.0% (20/133) met some and 51.1% (68/133) met few of the NICE guideline recommendations. CONCLUSION: There is high variability regarding policies for child maltreatment detection and only a quarter of the EDs met most of the NICE guideline recommendations for child maltreatment. There is a need for the use of screening tools, training of ED staff and implementation of local hospital policies.

Functional abdominal complaints in pre-school children: parental reports of health-related quality of life.

PURPOSE: The aim of this study is to assess the influence of functional abdominal complaints (FAC) on health-related quality of life in a group of Dutch pre-school children. METHODS: Parents of children aged up to 6.0 visiting the outpatient pediatric department, Erasmus MC-Sophia, Rotterdam, The Netherlands in the period January 2005-December 2006 for functional abdominal complaints during at least 3 months were asked to complete the Infant/Toddler Quality of life Questionnaire (ITQOL), and questions of the abdominal pain index for use by parents to report pain symptoms in pre-school children. ITQOL scale scores of children with FAC were compared against with Dutch reference values. The abdominal pain index was tested for internal consistency and test-retest reliability. Correlations between ITQOL scale scores and abdominal pain index were assessed by Spearman's rank test. RESULTS: Results are based on 81 questionnaires completed by parents of children with FAC (response rate 61%). Children had a median age of 46 months (interquartile range 27-59), 48% girls. A significant impact was observed on most aspects of quality of life, particularly for physical functioning, general development, bodily pain, temperament and moods, general health perceptions and parental emotional impact. Parents of children with functional constipation tended to report lower scores than those of children with other FAC. The abdominal pain index appeared to be valid and was significantly correlated with ITQOL scales bodily pain and general health perceptions. CONCLUSIONS: A substantial lower health-related quality of life is reported in pre-school children with functional abdominal complaints, with effects on physical, emotional and parental domains. The 5-question severity index of abdominal pain appeared a valid tool and may be helpful to quickly assess the severity of abdominal pain in clinical practice.

Health-related quality of life in children with neurofibromatosis type 1: contribution of demographic factors, disease-related factors, and behavior.

OBJECTIVE: To investigate health-related quality of life (HR-QOL) in children with neurofibromatosis type 1 (NF1) with parental reports and children's self-reports, and to investigate the potential contribution of demographic factors, disease-specific factors, and problems in school performance or behavior. STUDY DESIGN: In a prospective observational study, parents of 58 children with NF1 (32 boys, 26 girls, age 12.2 +/- 2.5 years) visiting a university clinic, and their 43 children 10 years or older were assessed with the Child Health Questionnaire (CHQ). Potential determinants of domain scores were assessed in 3 explorative regression models. RESULTS: Parents reported a significant impact of NF1 on 9/13 CHQ scales, with moderate effect sizes on 8 (general health perceptions, physical functioning, general behavior, mental health, self esteem, family activities, role functioning emotional/behavioral, and parent emotional impact). Children report an impact on bodily pain, and an above average general behavior. Multiple CHQ scales were sensitive to demographic factors and behavioral problems, and 1 to NF1 severity. NF1 visibility and school problems did not influence HR-QOL. CONCLUSIONS: Parents, but not the children with NF1, report a profound impact of NF1 on physical, social, behavioral, and emotional aspects of HR-QOL. Multiple HR-QOL domains were most sensitive to behavioral problems, which points to an exciting potential opportunity to improve HR-QOL in children with NF1 by addressing these behavioral problems.

Update of a clinical prediction model for serious bacterial infections in preschool children by adding a host-protein-based assay: a diagnostic study.

OBJECTIVE: To determine whether updating a diagnostic prediction model by adding a combination assay (tumour necrosis factor-related apoptosis-inducing ligand, interferon γ induced protein-10 and C reactive protein (CRP)) can accurately identify children with pneumonia or other serious bacterial infections (SBIs). DESIGN: Observational double-blind diagnostic study. SETTING: Two hospitals in Israel and four hospitals in the Netherlands. PATIENTS: 591 children, aged 1-60 months, presenting with lower respiratory tract infections or fever without source. 96 of them had SBIs. The original Feverkidstool, a polytomous logistic regression model including clinical variables and CRP, was recalibrated and thereafter updated by using the assay. MAIN OUTCOME MEASURES: Pneumonia, other SBIs or no SBI. RESULTS: The recalibrated original Feverkidstool discriminated well between SBIs and viral infections, with a c-statistic for pneumonia of 0.84 (95% CI 0.77 to 0.92) and 0.82 (95% CI 0.77 to 0.86) for other SBIs. The discriminatory ability increased when CRP was replaced by the combination assay; c-statistic for pneumonia increased to 0.89 (95% CI 0.82 to 0.96) and for other SBIs to 0.91 (95% CI 0.87 to 0.94). This updated Feverkidstool improved diagnosis of SBIs mainly in children with low-moderate risk estimates of SBIs. CONCLUSION: We improved the diagnostic accuracy of the Feverkidstool by replacing CRP with a combination assay to predict pneumonia or other SBIs in febrile children. The updated Feverkidstool has the largest potential to rule out bacterial infections and thus to decrease unnecessary antibiotic prescription in children with low-to-moderate predicted risk of SBIs.

Autism Spectrum Disorder in an Unselected Cohort of Children with Neurofibromatosis Type 1 (NF1).

In a non-selected sample of children with Neurofibromatosis type 1 (NF1) the prevalence rate of autism spectrum disorder (ASD) and predictive value of an observational (ADOS)-and questionnaire-based screening instrument were assessed. Complete data was available for 128 children. The prevalence rate for clinical ASD was 10.9%, which is clearly higher than in the general population. This prevalence rate is presumably more accurate than in previous studies that examined children with NF1 with an ASD presumption or solely based on screening instruments. The combined observational- and screening based classifications demonstrated the highest positive predictive value for DSM-IV diagnosis, highlighting the importance of using both instruments in children with NF1.

Health-related quality of life of pre-school children with wheezing illness.

Pre-school children are frequently affected by wheezing illness, with substantial influences on their health-related quality of life (HRQL). The Infant/Toddler Quality of Life Questionnaire (ITQOL) is the only generic health status measure for children aged 2 months up to 5 years. In this present study we evaluated the impact of wheezing illness in pre-school children on the HRQL, using the ITQOL. A questionnaire including the ITQOL and ISAAC questions on frequency and severity of respiratory complaints were sent to parents of patients aged 6 months-5 years visiting the outpatient department with wheezing illness. Scale scores of ITQOL of the included children were compared with general population scores. Using multivariate analysis, the influence of general and clinical characteristics on ITQOL scale scores was evaluated. Results are based on 138 children, 59% male, mean age 34 months. Children with wheezing illness scored differently to the general population sample on 8 of the 11 ITQOL scales. Age, comorbidity and employment of the respondent affected scales on child's physical and emotional functioning and parental functioning. Severity of dyspnoea and wheezing, presence of cough, corticosteroid use, and number of GP visits negatively affected scales on the child's physical and emotional functioning. In conclusion, the HRQL as measured by the ITQOL was lower in a group of Dutch pre-school children with wheezing illness compared to a general population sample. The scale scores were sensitive to age, co morbidity, socio-economic situation, and disease severity.

[Fever of unknown origin in a young child: diagnosis and treatment]. / Het jonge kind met koorts zonder focus; diagnostiek en beleid.

In children with fever without focus, evaluation should be aimed at recognition of children with an increased risk of bacteraemia or of major bacterial infections, while young children in particular will show few typical symptoms of bacterial infections. A child younger than 1 month with fever (> or = 38.0 degrees C) or hypothermia (< 36.0 degrees C) needs clinical evaluation and additional diagnostic investigations. In children aged from 1 to 36 months referral to hospital should be based on presence of age specific clinical characteristics, i.e. toxic appearance, high fever, diarrhoea, decreased urine production, tachypnoea, or bulging fontanelle. Presence of clinical characteristics as judged by a paediatrician or abnormal laboratory findings indicates hospitalisation and treatment with parenteral antibiotics. Absence of alarming clinical characteristics with normal laboratory values justifies outpatient follow-up without treatment or additional diagnostic procedures. Careful instructions to parents regarding observation, parents' ability to detect clinical changes and facilities for rapid medical re-evaluation are crucial.

[A diagnostic decision rule for managing children with signs of meningeal irritation]. / Een diagnostische beslisregel voor kinderen met tekenen van meningeale prikkeling.

OBJECTIVE: To develop a diagnostic decision rule based on clinical features to predict the risk of bacterial meningitis in children with signs of meningeal irritation. DESIGN: Retrospective and prospective. METHOD: Predictors for bacterial meningitis were identified by collecting clinical data from the records of 360 patients (aged 1 month to 15 years) who consulted the Casualty Department, Sophia Children's Hospital, Rotterdam, the Netherlands, with signs of meningeal irritation during the period 1988-1998. The diagnostic decision rule derived was prospectively validated on 226 similar children who consulted the casualty departments of four hospitals in the Netherlands during the period 1999-2001. RESULTS: Predictors for bacterial meningitis were the main complaint and vomiting (in the history) persisting for a long time, the presence of meningeal irritation, cyanosis, petechiae, disturbed consciousness (during physical examination), and a high serum concentration of C-reactive protein. Liquor analysis parameters with an added diagnostic value were the total polymorphonuclear cell count in the liquor and the liquor/blood glucose ratio. The use of these patient characteristics in a decision rule accurately predicted the chance of bacterial meningitis. The rule can also be used to refine the indication for lumbar puncture and empirical antibiotic treatment.

Derivation and validation of age and temperature specific reference values and centile charts to predict lower respiratory tract infection in children with fever: prospective observational study.

OBJECTIVES: To develop reference values and centile charts for respiratory rate based on age and body temperature, and to determine how well these reference values can predict the presence of lower respiratory tract infections (LRTI) in children with fever. DESIGN: Prospective observational study. PARTICIPANTS: Febrile children aged at least 1 month to just under 16 years (derivation population, n = 1555; validation population, n = 671) selected from patients attending paediatric emergency departments or assessment units in hospitals. SETTING: One hospital in the Netherlands in 2006 and 2008 (derivation population); one hospital in the Netherlands in 2003-05 and one hospital in the United Kingdom in 2005-06 (validation population). INTERVENTION: We used the derivation population to produce respiratory rate centile charts, and calculated 50th, 75th, 90th, and 97th centiles of respiratory rate at a specific body temperature. Multivariable regression analysis explored associations between respiratory rate, age, and temperature; results were validated in the validation population by calculating diagnostic performance measures, z scores, and corresponding centiles of children with diagnoses of pneumonic LRTI (as confirmed by chest radiograph), non-pneumonic LRTI, and non-LRTI. MAIN OUTCOME MEASURE: Age, respiratory rate (breaths/min) and body temperature (°C), presence of LRTI. RESULTS: Respiratory rate increased overall by 2.2 breaths/min per 1°C rise (standard error 0.2) after accounting for age and temperature in the model. We observed no interactions between age, temperature, and respiratory rates. Age and temperature dependent cut-off values at the 97th centile were more useful for ruling in LRTI (specificity 0.94 (95% confidence interval 0.92 to 0.96), positive likelihood ratio 3.66 (2.34 to 5.73)) than existing respiratory rate thresholds such as Advanced Pediatrics Life Support values (0.53 (0.48 to 0.57), 1.59 (1.41 to 1.80)). However, centile cut-offs could not discriminate between pneumonic LRTI and non-pneumonic LRTI. CONCLUSIONS: Age specific and temperature dependent centile charts describe new reference values for respiratory rate in children with fever. Cut-off values at the 97th centile were more useful in detecting the presence of LRTI than existing respiratory rate thresholds.

Systematic review and validation of prediction rules for identifying children with serious infections in emergency departments and urgent-access primary care.

BACKGROUND: Although the vast majority of children with acute infections are managed at home, this is one of the most common problems encountered in children attending emergency departments (EDs) and primary care. Distinguishing children with serious infection from those with minor or self-limiting infection is difficult. This can result in misdiagnosis of children with serious infections, which results in a poorer health outcome, or a tendency to refer or admit children as a precaution; thus, inappropriately utilising secondary-care resources. OBJECTIVES: We systematically identified clinical features and laboratory tests which identify serious infection in children attending the ED and primary care. We also identified clinical prediction rules and validated those using existing data sets. DATA SOURCES: We searched MEDLINE, Medion, EMBASE, Cumulative Index to Nursing and Allied Health Literature and Database of Abstracts of Reviews of Effects in October 2008, with an update in June 2009, using search terms that included terms related to five components: serious infections, children, clinical history and examination, laboratory tests and ambulatory care settings. We also searched references of included studies, clinical content experts, and relevant National Institute for Health and Clinical Excellence guidelines to identify relevant studies. There were no language restrictions. Studies were eligible for inclusion if they were based in ambulatory settings in economically developed countries. REVIEW METHODS: Literature searching, selection and data extraction were carried out by two reviewers. We assessed quality using the quality assessment of diagnostic accuracy studies (QUADAS) instrument, and used spectrum bias and validity of the reference standard as exclusion criteria. We calculated the positive likelihood ratio (LR+) and negative likelihood ratio (LR-) of each feature along with the pre- and post-test probabilities of the outcome. Meta-analysis was performed using the bivariate method when appropriate. We externally validated clinical prediction rules identified from the systematic review using existing data from children attending ED or primary care. RESULTS: We identified 1939 articles, of which 35 were selected for inclusion in the review. There was only a single study from primary care; all others were performed in the ED. The quality of the included studies was modest. We also identified seven data sets (11,045 children) to use for external validation. The most useful clinical features for ruling in serious infection was parental or clinician overall concern that the illness was different from previous illnesses or that something was wrong. In low- or intermediate-prevalence settings, the presence of fever had some diagnostic value. Additional red flag features included cyanosis, poor peripheral circulation, rapid breathing, crackles on auscultation, diminished breath sounds, meningeal irritation, petechial rash, decreased consciousness and seizures. Procalcitonin (LR+ 1.75-2.96, LR- 0.08-0.35) and C-reactive protein (LR+ 2.53-3.79, LR- 0.25-0.61) were superior to white cell counts. The best performing clinical prediction rule was a five-stage decision tree rule, consisting of the physician's gut feeling, dyspnoea, temperature ≥ 40 °C, diarrhoea and age. It was able to decrease the likelihood of serious infections substantially, but on validation it provided good ruling out value only in low-to-intermediate-prevalence settings (LR- 0.11-0.28). We also identified and validated the Yale Observation Scale and prediction rules for pneumonia, meningitis and gastroenteritis. LIMITATIONS: Only a single study was identified from primary-care settings, therefore results may lack generalisability. CONCLUSIONS: Several clinical features are useful to increase or decrease the probability that a child has a serious infection. None is sufficient on its own to substantially raise or lower the risk of serious infection. Some are highly specific ('red flags'), so when present should prompt a more thorough or repeated assessment. C-reactive protein and procalcitonin demonstrate similar diagnostic characteristics and are both superior to white cell counts. However, even in children with a serious infection, red flags will occur infrequently, and their absence does not lower the risk. The diagnostic gap is currently filled by using clinical 'gut feeling' and diagnostic safety-netting, which are still not well defined. Although two prediction rules for serious infection and one for meningitis provided some diagnostic value, we do not recommend widespread implementation at this time. Future research is needed to identify predictors of serious infection in children in primary-care settings, to validate prediction rules more widely, and determine the added value of blood tests in primary-care settings. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Impact of von Willebrand disease on health-related quality of life in a pediatric population.

BACKGROUND: Von Willebrand disease (VWD) is the most frequent inherited bleeding disorder. Whether VWD is associated with health-related quality of life (HR-QoL) in children is unknown. OBJECTIVES: This nationwide cross-sectional study measured HR-QoL in children with moderate or severe VWD. Our primary aim was to compare HR-QoL of VWD patients with that of reference populations. Additionally, we studied the impact of bleeding phenotype and VWD type on HR-QoL. METHODS: HR-QoL was assessed with the Infant/Toddler QoL Questionnaire (0-5 years) and Child Health Questionnaire (6-15 years), and compared with reference population scores. Multivariate analysis was used to evaluate the influence of type of VWD and bleeding phenotype on HR-QoL scores. RESULTS: Preschool children (0-5 years, n = 46) with VWD had lower HR-QoL scores for general health perceptions and parental time than reference populations. School children (6-15 years, n = 87) with VWD had lower scores for physical functioning, role functioning - emotional/behavioral, general health perceptions, and physical summary. Type of VWD was associated with HR-QoL in school children for bodily pain, general health perceptions, parental emotion, family activities, and physical summary. Scores of children with type 3 VWD were, on average, 15 points lower than those of the reference population on the above-mentioned scales. A more severe bleeding phenotype was associated with a lower score on 11/15 physical, emotional and social scales. CONCLUSION: HR-QoL is lower in VWD children than in reference populations, in particular in school children. The negative impact of VWD is sensitive to type of VWD and bleeding phenotype; as well as physical scales, emotional and social scales are affected.

Prediction of vesico-ureteric reflux in childhood urinary tract infection: a multivariate approach.

UNLABELLED: In this study, independent predictors obtained from patient history, physical examination and laboratory results for vesico-ureteric reflux (VUR) in children of 0-5 y with a first urinary tract infection (UTI) were assessed and the added value of renal ultrasound (US) investigated. Information was collected from children visiting the paediatric outpatient department with a first proven UTI, defined as a urine monoculture with > or = 10(5) organism/ml, with clinical symptoms and possible white cell count > or = 20 per high-power field of spun fresh urine. Children with neurologic bladder dysfunction were excluded. VUR was determined by voiding cystourethrography (VCUG) and graded from I to V. The diagnostic value of predictors was judged using multivariate logistic modelling with the area under the receiver operating characteristic (ROC area). A risk score was derived based on the regression coefficients of the independent predictors in the logistic model. In 140 children (51 boys and 89 girls) VUR was diagnosed in 37. Independent predictors for VUR were male gender, age, family history for uropathology, serum C-reactive protein level (CRP) and dilatation of the urinary tract on US. The ROC area of this model was 0.78 (95% CI: 0.69-0.87). This prediction model identified 12% (95% CI: 7-18) of the patients without VUR without missing one case of VUR. If we used VUR > or = grade 3 as a threshold, the model assessed VUR to be absent in 34% (95% CI: 26-42). CONCLUSION: A prediction rule based on age, gender, family history, CRP and US results is useful in assessing the probability of VUR in the individual child with a first UTI and may help the physician to make decisions about performing additional imaging techniques. Prospective validation of the model in future patients, however, will be necessary before applying the rule in practice.

Prediction of bacterial meningitis in children with meningeal signs: reduction of lumbar punctures.

UNLABELLED: Physicians often have to perform a lumbar puncture to ascertain the diagnosis in patients with meningeal signs, because of the serious consequences of missing bacterial meningitis. The aim of this study was to derive and validate a clinical rule to predict bacterial meningitis in children with meningeal signs, to guide decisions on the performance of lumbar punctures. Information was collected from records of patients (aged 1 mo to 15 y) consulting the emergency department of the Sophia Children's Hospital between 1988 and 1998 with meningeal signs. Bacterial meningitis was defined as cerebrospinal fluid (CSF) leucocyte count >5 cells microl(-1) with a positive bacterial culture of CSF or blood. The diagnostic value of predictors was judged using multivariate logistic modelling and area under the receiver operating characteristic curves (ROC area). In the derivation set (286 patients, years 1988-1995) the duration of the main complaint, vomiting, meningeal irritation, cyanosis, petechiae and disturbed consciousness were independent clinical predictors of bacterial meningitis. The ROC area of this model was 0.92. The only independent predictor from subsequent laboratory tests was the serum C-reactive protein concentration, increasing the ROC area to 0.95. Without missing a single case, this final model identified 99 patients (35%) without bacterial meningitis. Validation on 74 consecutive patients in 3 subsequent years (1996-1998) yielded similar results. CONCLUSION: This prediction rule identifies about 35% of the patients with meningeal signs in whom a lumbar puncture can be withheld without missing a single case of bacterial meningitis. For the individual patient this prediction rule is valuable in deciding whether or not to perform a lumbar puncture.

Early prediction of neurological sequelae or death after bacterial meningitis.

UNLABELLED: This study determined independent predictors of the occurrence of permanent neurological sequelae or death after childhood bacterial meningitis. Data were used from a large study on children (aged 1 mo to 15 y) initially presenting with meningeal irritation. A nested case-control study was performed on children with (n = 23) and without (n = 70) permanent neurological sequelae (hearing impairment, locomotor dysfunction, mental retardation or epilepsy) or death after bacterial meningitis. Predictors obtained from clinical evaluation and laboratory tests at presentation and during the clinical course were identified by multivariate logistic regression and receiver operating characteristic (ROC) curve analyses. The study population comprised 23 cases and 70 controls (52% boys, median age 2.8 y). Independent predictors for an adverse outcome after bacterial meningitis were male gender, atypical convulsions in history, low body temperature at admission and the pathogen Streptococcus pneumoniae. The area under the ROC curve of this prediction rule was 0.87 (95% confidence interval: 0.78-0.96), which was not improved by adding other characteristics. A score including these independent predictors could classify patients into categories with increasing risk for an adverse outcome. CONCLUSION: Clinical characteristics available early in the clinical course, such as gender, atypical convulsions in history, low body temperature at admission and the pathogen, are predictive for the occurrence of permanent neurological sequelae or death after bacterial meningitis in childhood. The pathogen type, in particular, is the main prognostic determinant of childhood bacterial meningitis.

Signs of meningeal irritation at the emergency department: how often bacterial meningitis?

OBJECTIVE: Although signs of meningeal irritation are highly indicative of meningitis, they are not pathognomonic. In this study, we described the final diagnoses in children with signs of meningeal irritation, and we assessed the frequency of bacterial meningitis related to specific signs of meningeal irritation. METHODS: Information was collected from records of 326 patients (aged 1 month to 15 years) who visited the emergency department of the Sophia Children's Hospital between 1988 and 1998 with signs of meningeal irritation, assessed by either the general practitioner or the pediatrician. RESULTS: Bacterial meningitis was diagnosed in 99 patients (30%), viral or aseptic meningitis in 43 (13%). Other diagnoses were pneumonia (8%), other serious bacterial infections (2%), and upper respiratory tract infections or other self-limiting diseases (46 %). Presence of one of the signs of meningeal irritation assessed by the pediatrician was related to bacterial meningitis in 39%. Specific tests eliciting meningeal irritation, such as Brudzinski's and Kernig's signs, were not related to a higher frequency of bacterial meningitis than neck stiffness and the tripod phenomenon. In children < or =1 year, bacterial meningitis is more frequently related to presence of irritability and a bulging fontanel. CONCLUSION: Bacterial meningitis is present in 30% of children with signs of meningeal irritation. Presence of meningeal irritation as assessed by the pediatrician is related to bacterial meningitis in 39%. A better prediction of bacterial meningitis was not achieved by using more specific tests for signs of meningeal irritation.