Sunday, February 16, 2014

Well child, Sick child

Who doesn't get a little bit nervous in a pediatric clinic waiting room? Even in an office that divides “sick” from “well” waiting areas, kids tend to move pretty freely, and of course the pathogens contained in respiratory droplets move even more freely. I always assumed that the risk from these exposures (of the “well-children” to the “sick-children” in ambulatory clinics) was fairly small, at least compared with the usual community exposures kids have at home, at day care, at the children’s museum, etc.

Our colleague Phil Polgreen and his group analyzed some “Big Data” (the Medical Expenditure Panel Survey) to try to determine if well-child visits are indeed a risk factor for subsequent influenza-like illness (ILI). Their findings are published in this month’s issue of Infection Control and Hospital Epidemiology, and confirm the suspicion that the ambulatory pediatric clinic is likely to contribute to viral respiratory pathogen transmission. The odds ratio for ILI after a well-child visit (within prior 2 weeks) was 1.54 (95% CI, 1.43-1.66), which seems pretty large, though the absolute risk was modest (~3% increased risk). However, if you consider the total number of such visits annually, the number (~800K) and cost ($500 million) of excess ILI cases is substantial.

Lisa Saiman has an excellent editorial discussing the implications of these findings, the main message being that we need to pay more attention to infection prevention in ambulatory settings. My only additional suggestion (which, admittedly, may be unrealistic for many clinics): forget about separate waiting rooms, instead have physically or temporally separate clinics for well-child versus sick-child visits (with clear signage to direct kids who happen to be sick during a well-child visit to the “sick-child” clinic).


  1. Wonder how much the lack of hand hygiene between patient care contributes to this problem. My son's posh pediatric clinic is an example. Each pediatrician (and his assistant) has a central station with 4 exam rooms. While I wait with my son to be seen I can clearly see the doctor going in and out exam rooms with his stethoscope around his neck, his otoscope, and of course his hands without any hand hygiene or equipment disinfection in between cases.Same for his assistant. Zero hand hygiene. One day I finally said something about it…of course it only worked temporarily.
    Now that I am venting on this topic, let me say that the same thing happens at dentists offices. I brought it up one time to the dentist assistant who quickly looked at me as if I had 4 heads and told me that hand hygiene was not necessary if gloves were used. That was the end of that dentist office…the only problem is that the other offices have the same behaviors. Sounds like there is a need of guidelines in these settings.

  2. Interestingly, I have had the opposite experience at my dental practice: everyone is in scrubs and bare below the elbows, everyone wears eye protection and surgical masks, and hand hygiene is 100% compliant. I have been with that practice for many years and often marvel at their infection control.

  3. I'm just about to submit a manuscript which presents findings from environmental screening for viruses in this type of area! Watch this space!