Development of the New AAP Febrile Infant Clinical Practice Guideline.

Back in 1974, in an effort to engage residents in research, senior residents were asked to identify the clinical activity they found most frustrating. They responded, “Having to do complete sepsis work-ups on young infants just because they are febrile. Practitioners don’t do that, and we can tell when infants are septic or not.” This prompted a study to determine how well the clinical judgment of senior residents, supplemented by complete blood cell counts and cerebrospinal fluid (CSF) analyses, performed in the evaluation of febrile infants 0 to 8 weeks of age. It was the heyday of group B streptococcal infections, as reflected in the bacteremia rate of 14.8% in the 62 consecutively enrolled infants studied.1 Infants classified as “ill” or “can’t tell” had rates of 18.5% and 18.8%, respectively, whereas the rate in infants classified as “well” was 5.6%, 1 of 18 infants. The study was small, to be sure, but that was not the major impediment to publication. Journal peer reviewers could not understand why such a study was performed because it was common knowledge that clinical judgment did not apply to very young febrile infants. Other similar studies followed2,3 along with the recognition of iatrogenic complications associated with hospitalizing these infants.4 By the mid-1980s, there was sufficient confirmation that, although well-appearing febrile infants had a lower rate of bacteremia than those who were ill-appearing, the rate was not 0, and infants with bacteremia could not be distinguished with complete certainty from those without bacteremia. Then Keith Powell and his colleagues at Rochester proposed an alternative strategy: instead of focusing on who had bacteremia, focus on those who did not and create criteria for a low-risk category that could permit infants to avoid unnecessary (over)treatment. Thus, the Rochester criteria were born,5 followed …