Pediatrics and gut feelings

Several articles were published in high impact factor journals for the last 10 years about the role of GPs’ intuition managing children health.

  • A 2008 Danish article « “This is not normal … “–signs that make the GP question the child’s well-being  » (1) describes how the GP separates the healthy normal child’s developmental crises from children with problems that need special attention and treatment through a qualitative study with 28 GPs. All the GPs were recruited in the County of West Zealand in Denmark and four of them were interviewed individually after the first focus groups. The four informants were selected for divergent or surprising points of view.The data were collected between 2004 and 2006 according to the following steps : 2 focus group discussions, individual in-depth interviews and then two another focus group discussions. The study showed that GPs presented 89 case stories, mostly about children aged under six. Five categories of signs that make the GP question the child’s well being were described : child’s symptoms and problems, parents’ ability to handle their child’s health an well-beeing, child’s and parents’ communication and behaviour during the consultation, the parents’ use of the health care system and the doctor knowledge of the family members. When GPs in this study became aware of a child in need, it was frequently during clinical work as a feeling of « this is not normal ».In conclusion, GPs known as frontline workers may benefit from a systematic attention to the contextual issues. They need relevant supervision and a good dialogue with experts in order to recognise children in need.
  • The BMJ article « Clinician’s gut feeling about serious infections in children : observationnal study » (2) underlines the place that gut feelings (GF) have in detecting children serious infections. This 2004 observational study was based in Belgium Primary Care Settings and included 3390 children from 0 to 16 year old. A clinical impression (subjective observation that the disease is serious or not depending on the evolution of symptoms, observation and clinical exam) was asked and if GF suggest something more serious is happening. Here, GF are described as an intuitive feeling that something is wrong even if the physician doesn’t know why. Severe infections were described as hospital admissions in the next 24 hours or more beause of pneumonia, sepsis, viral or bacterial meningitis, kidney infection, cellulitis, osteomyelitis or bacterial gastro-enteritis. On 3890 children, 3369 were considered without any serious disease after a clinical exam ruling out red flags. Six children / 3369 (0.2%) did have a serious infection. GF were present in two of these 6 cases and 44 times for children who didnt have serious infection at the end. The positive Likehood-ratio was LR+ = 25.5 (IC 95% = 7.0 -82). The most important contextual factor were the parents or caregivers worrying about the difference between the actual picture and the child status before (OR=36.3, IC95%=12.3-107). Temperature didn’t influence GF. In conclusion GF is an intuitive response from the physician in front of the children and the parent’s worry. It should help to refer to the hospital or go further with other explorations.
  • The above mentioned study was commented by Wacogne (3) underlining the fact to stay objective in diagnostic management and not to over or underuse GF during consultations.
  • In the metanalysis « “Systematic review and validation of prediction rules for identifying children with serious infections in emergency departments and urgent-access primary care,” » (4) authors remind us a recurrent problem in these structures : not to diagnose a serious infection that could be potentially dangerous for the child versus the problem of ressources. The authors identified in the litterature 1939 articles using the following MESH terms : serious infections, children, clinical history and examination, laboratory tests and primary care settings. 35 articles were selected by two reviewers assessing quality of the studies using the quality assessment of diagnostic accuracy studies (QUADAS) and spectrum bias and validity of the reference standard as exclusion criteria. The best performing clinical prediction rule was a five-stage decision tree rule, consisting of the physician’s GF, dyspnoea, temperature > 40°C, diarrhoea and age. PCT and CRP had a better predictive value than blood full count. The authors remind the importance of red flags such as cyanosis, capillary refill time increase, polypnoea, meningitis signs, petechial rash, convulsions and consciousness alteration. The absence of red flags do not lower the risk of a serious infection and the diagnostic gap is currently filled by using clinical GF and diagnostic safety-netting.
  • A new study on this topic is actually running in France concerning the recognition of GF among paediatric emergency physicians all over the country with Delphi rounds aiming to formulate statements for proper definitions. For details contact the author of this review.

References:

1) Lykke K, Christensen P, Reventlow S. “This is not normal … “–signs that make the GP question the child’s well-being. FamPract. 2008;25(3):146-53

2) Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians’ gut feeling about serious infections in children: observational study. BMJ. 2012;345:e6144.

3) Ian Wacogne, Diagnosis: clinician’s gut feeling helps detect children with serious infection, Arch Dis Child Educ Pract Ed 2013;98:197

4) M Thompson, A Van den Bruel, J Verbakel, M Lakhanpaul, T Haj-Hassan, R Stevens, H Moll, F Buntinx, M Berger, B Aertgeerts, R Oostenbrink and D Mant, “Systematic review and validation of prediction rules for identifying children with serious infections in emergency departments and urgent-access primary care,” Health Technology Assessment 2012; Vol. 16: No. 15.

Author : Thomas Pernin, Department of General Practice, Paris Diderot University, France, docteur.pernin@gmail.com.