Physicians should pay attention to their "gut feeling" that something may be seriously wrong when assessing a child with an infectious disease -- even if the clinical appearance is reassuring -- an observational study suggested.
Among 3,369 children whose primary care evaluation did not suggest a serious illness, six (0.2%) ultimately were admitted to the hospital with a severe infection, according to Ann Van den Bruel, MD, PhD, of the Radcliffe Observatory Quarter in Oxford, England, and colleagues.
The clinician's gut feeling that the child was seriously ill considerably increased the chance that a severe infection was present, with a likelihood ratio of 25.5 (95% CI 7.9 to 82), and heeding the feeling might have prevented two cases from being overlooked (33%, 95% CI 0.95 to 1.75), the researchers reported online in BMJ.
Considerable research has focused on developing tools for clinical prediction in acutely ill children, including symptoms, vital signs, and laboratory tests, but primary care physicians often see children before the full clinical picture has developed -- and sometimes report relying on intuition that a potentially serious problem exists even though they're unsure why.
Moreover, a systematic review recently determined that such a gut feeling had considerable diagnostic significance.
To clarify the usefulness of physicians' intuitive feelings as an addition to clinical impressions, Van den Bruel and colleagues recruited 3,890 acutely ill children presenting to primary care in Flanders, Belgium.
For each child, the researchers reviewed the clinical features of the illness, including the physician's overall clinical impression of whether the illness was serious based on the physical examination, history, and observation.
They also asked treating physicians for their gut feeling as to whether they suspected the illness was serious based on the appearance of the child or the attitude and behavior of the parent.
Serious infections included pneumonia, sepsis, meningitis, pyelonephritis, cellulitis, osteomyelitis, and bacterial gastroenteritis requiring at least 1 day of hospitalization.
A total of 21 children were hospitalized, with most ultimately being diagnosed with pneumonia or pyelonephritis.
Among the children for whom the clinical impression was that the illness was nonserious, the two cases that weren't missed were accompanied by 44 "false alarms," giving a sensitivity of 33.3% and a specificity of 98.7% for the physicians' gut feelings.
The researchers then looked at the clinical features that most often led to gut feelings that ran counter to the evidence, and found the strongest association for the child having a history of convulsions (OR 80.5, 95% CI 6.2 to 1,051).
Parental impression that the illness was different from others also was very important (OR 26.93, 95% CI 9.02 to 80.41).
Other features that led to physicians' gut feelings of serious illness, although less so than convulsions and parental concern, included:
- Drowsiness, OR 3.49 (95% CI 1.04 to 11.75)
- Changes in pattern of breathing, OR 4.88 (95% CI 1.38 to 17.26)
- Weight loss, OR 16.83 (95% CI 3.29 to 85.96)
- Urinary symptoms, OR 11.64 (95% CI 3.19 to 42.45)
Temperature was not a significant factor, contrary to the expectations of the researchers. They noted that fever may have contributed to parental impressions of serious illness, however.
"Nevertheless, it is important that primary care clinicians recognize the diagnostic value of fever in their clinical assessment -- for every 20 children with a temperature of 40° C [104° F) or more in a primary setting, one will have a serious infection," they cautioned.
The presence of diarrhea also was not associated with gut feelings, which also concerned the researchers, who noted that diarrhea in a young child is not necessarily benign, because it can lead to dehydration and also could be an early symptom of sepsis.
Among the 21 children who were hospitalized, nine were not admitted initially -- yet in four of those nine, the physician reported having a gut feeling that something was seriously wrong with the child.
The researchers also considered the treating clinicians' years of experience, and found that the likelihood of their having gut feelings different from their clinical impression decreased by 5% each year.
"This is presumably because the holistic clinical features that trigger gut feeling are gradually assimilated into clinical assessment," Van den Bruel and colleagues observed.
They advised that medical training should emphasize the potential value of gut feelings, and suggested that any such feelings should warrant a "full and careful" examination, consulting with other more experienced clinicians or referral, and explanations to the parent of their need to observe the child diligently.
"The observed association between gut feeling and clinical markers of serious infection means that by reflecting on the genesis of their gut feeling, clinicians should be able to hone their clinical skills," they concluded.
The study was limited by its inclusion of only children in primary care, and a lack of power to analyze the specific details of clinicians' gut feelings.
The study was supported by the Research Foundation-Flanders, Eurogenerics, and the National Institute for Health Research.
The authors reported no financial conflicts.
- Reviewed by Dori F. Zaleznik, MD Associate Clinical Professor of Medicine, Harvard Medical School, Boston and Dorothy Caputo, MA, BSN, RN, Nurse Planner