History and observation variables in assessing febrile children

Attending pediatricians listed five history and eight observation variables on which they base their "instinctive" judgment (prior to performing a physical examination) of overall degree of illness of febrile children. Attending pediatricians and house staff observer pairs independently scored these variables in an overall assessment on 219 young, febrile children. The observation variable playfulness had the strongest correlation with overall assessment. Observer agreement in scoring the variables and overall assessment, while statistically significant, was only fair. When an attending pediatrician judged a child as moderately or severely ill on overall assessment, serious illnesses were four times as likely as when such a judgment was not made. When a house officer judged a child as moderately or severely ill, serious illnesses were less than twice as likely as when such a judgment was not made. However, only 57% of children with serious illnesses were judged by the attending pediatrician as moderately or severely ill on overall assessment. These data demonstrate the importance and limitations of "instinctive" clinical judgments about young, febrile children; the association between observation of complex behavioral patterns, especially playfulness, and overall assessment; and the need for further study of these complex behavioral patterns in order to define a reliable clinical approach to febrile children.