Risk score enables GPs to spot serious child infections

By Christian Duffin

Reduced skin turgor, high temperature and severe hypoxia are among several red flags signs that UK researchers, who have developed a risk scoring tool for use by GPs, say can help diagnose serious bacterial illnesses, such as meningitis.

A study published online in the journal Archives of Diseases in Childhood outlines eight categories of symptoms that researchers say can guide GPs' decisions on how to treat and whether to refer children to A&E.

Researchers analysed clinical data on all children presenting at the emergency department of Queen's Medical Centre in Nottingham during two periods between September 2000 and March 2001, and September 2001 and March 2002.

Doctors at the hospital had carried out tests and made observations on the children's temperature, consciousness level, blood pressure, skin condition and other variables, and used them to compile a list of twelve symptoms for inclusion in the risk tool, assigning them all a score between one and four. The tally can then be converted into a percentage risk of serious bacterial illness.

The authors, including a GP in the department of primary care at the University of Oxford and researchers from Great Ormond Street Hospital and the Royal College of Paediatrics and Child Health, said the work is still in its early stages but said the score could be incorporated into electronic decision support and medical records.

The final analysis included 1,951 children aged one month to 15 years, although most were less than two years old. 74 had serious bacterial illnesses, mostly pneumonia or sepsis.

Clinical predictors of serious bacterial illness were analysed in multivariate logistic regression and a score derived with a ‘reasonable ability' to discriminate children with a suspected serious bacterial illnesses and stratify their risk.

The area under the curve for the score as a predictor of serious bacterial illness, a statistical measure of its discriminative capacity, was 0.77 – meaning the score was able to rule out illness in 77% of children in the dataset to whom the score was applied.

Lead researcher Dr Andrew Brent, a researcher in the Wellcome Trust research programme at the Royal College of Paediatrics and Child Health concluded: ‘The specificity of reduced activity or level of consciousness, prolonged capillary refill time and reduced skin turgor support the NICE clinical guidelines which use these clinical features as "red flags" to identify seriously ill children.

‘The presence of these features in a febrile child should prompt a careful clinical assessment and underlines the need to use such a clinical score as part of a broader algorithm to guide management decisions including additional investigations, plans for review or admission for observation.'

Research co-lead by Dr Monica Lakhanpaul, a senior lecturer in child health at the University of Leicester said: ‘In time we could use the scoring system as a way to give extra support for clinical judgement for GPs. It would help GPs to know whether they need to send patients to hospital or do more tests.'

Dr Chantal Simon, a GP in Bournemouth with an interest in child health, said it would be useful for GPs to have an effective scoring system on computer templates. ‘The current NICE traffic light system for identifying serious illness contains clinical pointers that some GPs dispute or consider overly simplified. For experienced GPs it's like being taught to suck eggs. If GPs had something computerised it would feel like taking a step forward.'

ADC Online First published on 24 January

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