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Shivering has little diagnostic value in diagnosing serious bacterial infection in children: a systematic review and meta-analysis

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Abstract

Early diagnosis of serious bacterial infections (SBI) is important for improving outcome of morbidity and mortality in children. A systematic review was conducted to examine if shivering had any value in diagnosing serious bacterial infection. We split our population (0–18 years old) into two categories depending on the presence of a known malignancy. The databases of Medline, Embase, Cinahl, and Web of Science were searched from inception until July 2019. The quality was assessed with the QUADAS-2 tool. Two by two tables were created, extracting the number of true positive (TP), true negative (TN), false positive (FP), and false negative (FN) regarding shivering and SBI, by 2 authors independently. Sensitivity, specificity, likelihood ratios, and their 95% confidence intervals were calculated using the MetaDATA Shiny app. In a population with known malignancy, we found a +LR of 3.47 (95% CI 2.58–4.36) for a serious bacterial infection when shivering was present, implying an increase of 25–30% possibility for a serious bacterial infection. In children without malignancy, diagnostic accuracy of shivering was poor.

Conclusion: Shivering is of limited use to diagnose serious bacterial infection in children without malignancy. Nevertheless, in children with known malignancy, it can be useful as an alarm signal.

What is Known:

• In the NICE guidelines for febrile illness in children, “shivering” is considered as an intermediate risk factor (“amber” sign) for a serious illness.

• A systematic literature search conducted in 2007 investigating the correlation between shivering in a febrile child and the presence of a serious bacterial infection could include only one study.

What is New:

• Based on the results of this systematic review, shivering has little diagnostic value in children without malignancy but can be useful as an alarm sign of serious bacterial infection in children with known malignancy.

• In case of absence of shivering, serious bacterial infection cannot be ruled out.

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Abbreviations

AB:

Antibiotics

CI:

Confidence interval

CVC:

Central venous catheter

ED::

Emergency department

FN:

False negative

FN:

Febrile neutropenia

FP:

False positive

HC:

Hemoculture

HiB:

Haemophilus influenzae type b

IMD:

Immunodeficiency

LR:

Likelihood ratio

MeSH:

Medical subject headings

nfs:

Not further specified

NICE:

National Institute for Health and Care Excellence

NIHR:

National Institute for Health Research

QUADAS-2:

Quality Assessment of Diagnostic Accuracy Studies 2

RT:

Radiotherapy

SBI:

Serious bacterial infection

STC:

Stem cell transplant

TN:

True negative

TP:

True positive

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Authors and Affiliations

  1. KU Leuven, Leuven, Belgium

    Maud Vandenberk & Kasper De Bondt

  2. Department of Development and Regeneration, KU Leuven, Leuven, Belgium

    Emma Nuyts

  3. Department of Pediatrics, Division of Woman and Child, UZ Leuven, Leuven, Belgium

    Jaan Toelen

  4. Department of Development and Regeneration, KU Leuven, Leuven, Belgium

    Jaan Toelen

  5. EPI-Centre, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium

    Jan Y Verbakel

  6. Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK

    Jan Y Verbakel

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  4. Jaan Toelen
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  5. Jan Y Verbakel
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Contributions

All authors (MV, KDB, EN, JT, JV) contributed to the study conception and design. Material preparation, data collection, and analysis were performed by MV, KDB, and JV. The first draft of the manuscript was written by MV, KDB, and JV, and all authors (MV, KDB, EN, JT, JV) commented on the previous versions of the manuscript. All authors (MV, KDB, EN, JT, JV) read and approved the final manuscript.

Corresponding author

Correspondence to Jan Y Verbakel.

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Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

This study does not require ethical approval because this is a systematic review of published articles. This article does not contain any studies with human participants or animals performed by any of the authors.

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Informed consent is not necessary for this study because this is a systematic review of published articles.

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Communicated by Gregorio Paolo Milani

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Maud Vandenberk and Kasper De Bondt share first authorship.

Jaan Toelen and Jan Y Verbakel share last authorship.

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Vandenberk, M., De Bondt, K., Nuyts, E. et al. Shivering has little diagnostic value in diagnosing serious bacterial infection in children: a systematic review and meta-analysis. Eur J Pediatr 180, 1033–1042 (2021). https://doi.org/10.1007/s00431-020-03870-7

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  • DOI: https://doi.org/10.1007/s00431-020-03870-7

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