Usefulness of ESR in children with nonspecific symptoms – erythrocyte sedimentation rate

Usefulness of ESR in children with nonspecific symptoms – erythrocyte sedimentation rate – Tips from Other Journals

Jeffrey T. Kirchner

Nonspecific symptoms such as fever, abdominal pain or limp are often benign and self-limited in children, but they may represent the onset of a potentially serious illness. Some studies indicate that the erythrocyte sedimentation rate (ESR) may be a useful screening test to help rule out serious illness in a child with nonspecific symptoms or nonspecific clinical findings on physical examination. Huttenlocher and Newman evaluated the usefulness of the ESR in children presenting with nonspecific symptoms, including a limp, fever or abdominal pain.

The authors used a computer database and chart review to identify children in whom the ESR was determined during a three-year period. All of the patients were younger than 18 years, and none had a discharge diagnosis that would elevate the ESR, such as cancer, inflammatory bowel disease, collagen vascular disease or acquired immunodeficiency syndrome.

The study group consisted of 299 patients. Eighty-nine had an ESR of less than 20 mm per hour, 109 had an ESR of 20 to 50 mm per hour, and 101 had an ESR of greater than 50 mm per hour. Of this last group, 27 percent had an ESR of greater than 100 mm per hour.

Significant illness was present in 56 percent of the patients with an ESR of greater than 50 mm per hour. In contrast, only 27 percent of those with an ESR of 20 to 50 mm per hour had significant illness. Of the group with an ESR of less than 20 mm per hour, only 8 percent had significant illness. In children with an ESR of greater than 100 mm per hour, 78 percent had a “significant” diagnosis. The most common serious illnesses in children with an ESR over 50 mm per hour were juvenile rheumatoid arthritis, osteomyelitis, pneumonia and pyelonephritis.

The study also included evaluation of the usefulness of the ESR on the basis of the presenting symptoms, including fever, a limp or abdominal pain. For each of these three symptoms, an increasing ESR was predictive of serious disease. This trend was especially true in children with a limp and an ESR of greater than 50 mm per hour. A serious illness was diagnosed in 77 percent of these children, which translates to an 8.2 likelihood ratio for serious illness. With abdominal pain as the presenting symptom, the likelihood ratio of a serious illness was 6.0 when the ESR was greater than 50 mm per hour. For fever, the likelihood ratio was 2.5 when the ESR was over 50 mm per hour. In children with a limp but an ESR lower than 20 mm per hour, the likelihood ratio of serious illness was only 0.27. In those with fever but an ESR of less than 20 mm per hour, the likelihood ratio of a serious illness was zero.

The authors conclude that the ESR provides helpful information in the evaluation of children with nonspecific symptoms. However, the interpretation of the ESR must also include consideration of the presenting complaint, the prior probability of illness and the absolute ESR value. The decision to obtain an ESR still depends on whether one believes the result will acutely change the management of the patient. The group of patients for whom the ESR may be most helpful are those in whom the clinician may be suspicious of a serious underlying illness but is uncertain whether further testing or treatment is indicated.–JEFFREY T. KIRCHNER, D.O.

Huttenlocher A, Newman TB. Evaluation of the erythrocyte sedimentation rate in children presenting with limp, fever, or abdominal pain. Clin Pediatr 1997;June:339-44.

COPYRIGHT 1997 American Academy of Family Physicians

COPYRIGHT 2004 Gale Group