Which symptoms and clinical features correctly identify serious respiratory infection in children attending a paediatric assessment unit?

Abstract

Objective: Parent-reported symptoms are frequently used to triage children, but little is known about which symptoms identify children with serious respiratory infections. The authors aimed to identify symptoms and triage findings predictive of serious respiratory infection, and to quantify agreement between parent and nurse assessment.

Design: Prospective diagnostic cohort study.

Setting: Paediatric Assessment Unit, University Hospitals Coventry and Warwickshire NHS Trust.

Patients: 535 children aged between 3 months and 12 years with suspected acute infection.

Methods: Parents completed a symptom questionnaire on arrival. Children were triaged by a nurse, who measured routine vital signs. The final diagnosis at discharge was used as the outcome. Symptoms and triage findings were analysed to identify features diagnostic of serious respiratory infection. Agreement between parent and triage nurse assessment was measured and kappa values calculated.

Results: Parent-reported symptoms were poor indicators of serious respiratory infection (positive likelihood ratio (LR+) 0.56-1.93) and agreed poorly with nurse assessment (kappa 0.22-0.56). The best predictor was clinical assessment of respiratory distress (LR+ 5.04). Oxygen saturations <94% were highly specific (specificity 95.1%) but had poor sensitivity (35.6%). Tachypnoea (defined by current Advanced Paediatric Life Support standards) offered little discriminatory value.

Conclusion: Parent-reported symptoms were unreliable discriminators of serious respiratory infection in children with suspected acute infection, and did not correlate well with nurse assessment. Using symptoms to identify higher risk children in this setting is unreliable. Nurse triage assessment of respiratory distress and some vital signs are important predictors.