Sick kids look sick.

Emergency physicians commonly evaluate children with fever and worry about how to best detect “occult” or “early” presentations of serious bacterial infections such as meningitis or sepsis. Laboratory testing is at times used to supplement clinical examination and physician judgment; however, the merits of such screening have long been debated and substantial practice variation remains. In this issue of Annals, there is a landmark study with important implications for the evaluation of the febrile child. Vaillancourt et al queried the aggregate health register for the province of Ontario, identifying 521 children, aged 30 days to 5 years, with confirmed sepsis or meningitis. Given that all province-wide emergency department (ED) visits are interlinked in this comprehensive database, they found that 22% of these children were discharged from an ED with a minor infectious diagnosis (eg, otitis media or upper respiratory tract infection) within 5 days preceding their lifethreatening illness. Thus, approximately 1 in 5 children apparently received a misdiagnosis and was sent home shortly—half of children in 24 hours or less and essentially all within 72 hours—before a repeated ED visit in which sepsis or meningitis was ultimately confirmed. Emergency physicians dread missing early presentations of sepsis or meningitis and would intuitively expect increased morbidity and mortality to result should these critical infections bemissed.However, Vaillancourt et al found that the children with delayed diagnoses had no relative increase inmortality, critical care use, or length of stay compared with those receiving a correct diagnosis on the first visit. Their administrative database lacked the capability to providemore detailed clinical information than these global measures. What should we make of this unexpected result? One interpretation posed by the authors is that of spectrum bias, ie, children receiving a correct diagnosis on the first visit might have had more aggressive disease, with an anticipated greater risk of harm in this group, offsetting the negative