ObjectiveTo identify the best clinical decision rules (CDRs) for diagnosing group A streptococcal (GAS) pharyngitis in children. A combination of symptoms could help clinicians exclude GAS infection in children with pharyngitis.DesignSystematic review and meta-analysis of original articles involving CDRs in children. The Pubmed, OVID, Institute for Scientific and Technical Information and Cochrane databases from 1975 to 2010 were screened for articles that derived or validated a CDR on a paediatric population: 171 references were identified.SettingAny reference including primary care for children with pharyngitis.Data extractionThe methodological quality of the articles selected was analysed according to published quality standards. A meta-analysis was performed to assess the statistical performance of the CDRs and their variables for the diagnosis of GAS pharyngitis.Primary outcome measureThe main criterion was a false-negative rate in the whole population not any worse than that of a rapid diagnostic test strategy for all patients (high sensitivity and low negative likelihood ratio).Results4 derived and 12 validated CDRs for this diagnosis in children. These articles involved 10 523 children (mean age, 7 years; mean prevalence of GAS pharyngitis, 34%). No single variable was sufficient for diagnosis. Among the CDRs, that of Joachim et al had a negative likelihood ratio of 0.3 (95% CI 0.2 to 0.5), resulting in a post-test probability of 13%, which leads to 3.6% false-negative rate among low-risk patients and 10.8% overall, equivalent to rapid diagnostic tests in some studies.ConclusionsThe rule of Joachim et al could be useful for clinicians who do not use rapid diagnostic tests and should allow avoiding antibiotic treatment for the 35% of children identified by the rule as not having GAS pharyngitis. Owing to its poor specificity, such CDR should be used to focus rapid diagnostic tests to children with high risk of GAS pharyngitis to reduce the antibiotic consumption.

Objective To examine paediatric malpractice claims and identify common characteristics likely to result in malpractice in children in France. Design and materials First, the authors did a retrospective and descriptive analysis of all paediatric malpractice claims involving children aged 1 month to 18 years, in which the defendant was coded as paediatrician or general practitioner, reported to the Sou Médical-groupe MASCF insurance company during a 5-year period (2003)(2004)(2005)(2006)(2007). Then, a comparison of these results with those from the USA was performed. Results The average annual incidence of malpractice claims was 0.8/100 paediatricians. 228 malpractice claims were studied and were more frequent (41%) with more severe outcomes in children younger than 2 years of age (52% deaths or major injuries). Meningitis (n=14) and dehydration (n=13) were the leading causes of claims, with highest mortalities (93% and 92%, respectively). The most common alleged misadventures were diagnosis-related error (47%), and medication error (13%). Malignancy was the most common medical condition incorrectly diagnosed (14%). Conclusions Paediatric malpractice claims are less frequent in France than in the USA, but they share many similarities with those in the USA. These data would enhance the knowledge of high-risk areas in paediatric care that could be targeted to reduce the risk of medical malpractices and to improve patient safety.