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The management of fever and petechiae: collaborative studies are needed
  1. Royal Victoria Infirmary
  2. Newcastle, UK
  3. Newcastle General Hospital
  4. Newcastle, UK
  5. Leighton Hospital
  6. Crewe, UK
  7. Birmingham Heartlands Hospital
  8. Birmingham, UK
  1. F Andrew, I Riordan, Consultant Paediatrician, Birmingham Heartlands Hospital, UK (a.riordan{at}

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Editor,—We were interested to read Brogan and Raffles' audit of the management of fever and petechiae.1This is an important audit for many general paediatricians in the UK. In Newcastle 36% of children with petechiae were treated with antibiotics, and only 10% had meningococcal disease (MCD). Brogan and Raffles correctly state that more studies are required to validate their proposed guideline. We offer two such studies:

(1) The ILL criteria (irritability, lethargy, low capillary refill) were applied retrospectively to a cohort of children presenting with petechiae who were part of a multicentre prospective study of MCD from Merseyside, UK.2 The ILL criteria would have identified all except two of 66 children with MCD and petechiae. Both those not identified presented with seizures, one had meningism, the other a maculopapular rash. However, the ILL criteria were also present in 62 of 65 children with petechiae initially thought to have MCD, whose final diagnosis was a viral illness. In this cohort the features that suggested MCD were tachypnoea or signs of meningitis or septicaemia.3 The ILL criteria are therefore of limited use in children already suspected of having MCD.

Local paediatricians in training asked for an algorithm to help assess children with fever and petechiae. We therefore designed an algorithm which includes risk factors from previous studies (recently reviewed),4 the ILL criteria, the criteria from the above Merseyside study, and a period of observation. We introduced this algorithm into routine use in our hospitals this year. We are prospectively validating its use.

(2) During the first three months, 49 children presented with petechiae. Only one child had meningococcal disease. The algorithm was correctly followed in 34 (68%) children; this included prompt treatment for the child with MCD. For 15 children the algorithm was not followed; 7 …

Dr Mukherjee. Samudra.Surangama{at}

Malcolm Jones, Department of Community Child Health, St George's Hospital, Blackshaw Road, London SW17 0QT. malcolmjones{at}

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