Further definition of history and observation variables in assessing febrile children

The experienced clinician makes a judgment (hereafter called overall assessment [OA]) about the degree of illness of a febrile child prior to physical examination. In order to define the history and observation variables on which OA is based, 262 febrile children less than or equal to 24 months of age were evaluated simultaneously by multiple observers including attending pediatricians, practicing pediatricians, pediatric house officers, and nurses. The observer listed history and observation variables he/she thought most important in making an OA on a blank, lined form and then scored those variables and OA as normal, or mildly, moderately, or severely impaired. Scoring for observation rather than history variables was better correlated with scoring for OA and serious illness. The observation variables most frequently mentioned by all observers were the child's "looking at the observer" and "looking around the room." There were 20 observation variables frequently mentioned, the scoring of which significantly correlated with scoring for OA; four of these 20 variables related to eye function. The child's response to a stimulus was noted in 105/186 different observation variables listed; both the attending pediatrician and the house officer scored these stimulus-response variables significantly different in children with, vs those without, serious illnesses. For attending pediatricians, house officers, and nurses, serious illness was five to seven times as likely if an OA of moderate or severe impairment was made than if it were not made. OA is a key skill in evaluating febrile children; these data identify variables on which OA is based, document the importance of assessing eye function in young, febrile children, and demonstrate that eye function is one key type of stimulus-response behavior on which the pediatrician as clinician and developmentalist relies to make judgments about febrile children.