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Clinicians’ gut feeling about serious infections in children: observational study

BMJ 2012; 345 doi: (Published 25 September 2012) Cite this as: BMJ 2012;345:e6144
  1. Ann Van den Bruel, clinical lecturer1,
  2. Matthew Thompson, director1,
  3. Frank Buntinx, professor2,
  4. David Mant, emeritus professor1
  1. 1Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK
  2. 2Department of General Practice, Catholic University of Leuven, Leuven, Belgium
  1. Correspondence to: A Van den Bruel ann.vandenbruel{at}
  • Accepted 24 August 2012


Objective To investigate the basis and added value of clinicians’ “gut feeling” that infections in children are more serious than suggested by clinical assessment.

Design Observational study.

Setting Primary care setting, Flanders, Belgium.

Participants Consecutive series of 3890 children and young people aged 0-16 years presenting in primary care.

Main outcome measures Presenting features, clinical assessment, doctors’ intuitive response at first contact with children in primary care, and any subsequent diagnosis of serious infection determined from hospital records.

Results Of the 3369 children and young people assessed clinically as having a non-severe illness, six (0.2%) were subsequently admitted to hospital with a serious infection. Intuition that something was wrong despite the clinical assessment of non-severe illness substantially increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and acting on this gut feeling had the potential to prevent two of the six cases being missed (33%, 95% confidence interval 4.0% to 100%) at a cost of 44 false alarms (1.3%, 95% confidence interval 0.95% to 1.75%). The clinical features most strongly associated with gut feeling were the children’s overall response (drowsiness, no laughing), abnormal breathing, weight loss, and convulsions. The strongest contextual factor was the parents’ concern that the illness was different from their previous experience (odds ratio 36.3, 95% confidence interval 12.3 to 107).

Conclusions A gut feeling about the seriousness of illness in children is an instinctive response by clinicians to the concerns of the parents and the appearance of the children. It should trigger action such as seeking a second opinion or further investigations. The observed association between intuition and clinical markers of serious infection means that by reflecting on the genesis of their gut feeling, clinicians should be able to hone their clinical skills.


  • We thank Rafael Perera for advising on the statistical analyses.

  • Contributors: AVdB conceived the study, did the main analyses, and contributed to the interpretation of the results and the drafting of the manuscript. She is guarantor of the study. MT contributed to the design and interpretation of the study and the drafting of the manuscript. FB conceived and designed the original study and contributed to the conception, design, and interpretation of the current analyses and the drafting of the manuscript. DM contributed to the conception and design of the current analyses, interpretation of the results, and drafting of the manuscript. All authors gave final approval of the version submitted.

  • Funding: The original study was funded by a grant of the Research Foundation-Flanders (FWO) and an unconditional grant from Eurogenerics. None of the funders had any role in the design or analysis of the original study nor of the current analyses. The present analyses were done as part of the MaDOx programme, which presents independent research commissioned by the National Institute for Health Research under its programme grants for applied research funding scheme (RP-PG-0407-10347). MT is funded by a career development fellowship supported by the National Institute for Health Research. The views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research, or the Department of Health.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare that they have received no support from any organisation for the submitted work; have no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and have no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the medical ethics committee of the Catholic University of Leuven.

  • Data sharing: No additional data available.

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