Published online April 3, 2006
PEDIATRICS Vol. 117 No. 4 April 2006, pp. 1067-1076 (doi:10.1542/peds.2005-1865)
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The Role of Parental Preferences in the Management of Fever Without Source Among 3- to 36-Month-Old Children: A Decision Analysis

Kristine A. Madsen, MD, MPHa, Jonathan E. Bennett, MDb and Stephen M. Downs, MD, MSc

a Department of Pediatrics, University of California, San Francisco, San Francisco, California
b Division of Emergency Medicine, A.I. duPont Hospital for Children, Wilmington, Delaware
c Department of Children's Health Services Research, Indiana University School of Medicine, Indianapolis, Indiana

OBJECTIVES. Recent analyses assessing the impact of the conjugate pneumococcal vaccine on the care of febrile children do not reflect the role parental preferences play in physicians' decisions. The objective of this study was to identify the management strategy that would best suit parents, on the basis of their values for possible outcomes of fever of ≥39°C without source among well-appearing, 3- to 36-month-old children.

METHODS. A decision analysis was performed to compare the benefits and outcomes of 3 management options (treat: blood culture and antibiotics for all children; test: blood culture and complete blood count for all children, with antibiotics for selected children; observe: no immediate intervention). A hypothetical cohort of 100000 children with fever of ≥39°C with no obvious source of infection was modeled for each strategy. Using this model, we identified the treatment option that would best suit each parent's preferences, on the basis of parental utilities (from a prior study) for various interventions and outcomes at vaccine efficacies of 0% (ie, no vaccine) and 95%. In addition, we performed survival analyses to assess the morbidity and mortality rates associated with each treatment strategy at various vaccine efficacies.

RESULTS. At a vaccine efficacy of 0%, the majority of parents' preferences suggested the treat option, the strategy with the lowest mortality rate. At a vaccine efficacy of 95%, mortality rates were similar for all 3 management options (~1 in 100000), but parental preferences were still aligned with different options; 50% suggested observe, 42% suggested test, and 8% suggested treat.

CONCLUSIONS. Like physicians, parents have different approaches to risk. With the conjugate pneumococcal vaccine, risks of complications from fever without source are low regardless of treatment strategy. Rather than having a "one size fits all" approach, it is reasonable to incorporate parental preferences into the treatment decision.

Key Words: child • decision-making • fever of unknown origin • parental attitudes • patient-doctor communication

Abbreviations: WBC—white blood cell

Accepted Sep 26, 2005.




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B. W. Trautner, C. G. Macias, and A. C. Caviness
High Fever: In Reply.
Pediatrics, December 1, 2006; 118(6): 2604a - 2605.
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