Should we promote the tumbler test?

David Mant, Ann Van den Bruel petechiae (eg, as a purple rash, pin-prick bruising, spots of blood under the skin) or demonstrating blanching (eg, by simply pressing on the skin) make more sense to parents. It is also possible that it may be better to play to parents’ strengths and focus on helping them assess severity of illness, perhaps by teaching them to apply Brogan’s ILL criteria (irritability, lethargy and low capillary refi ll).7 If research suggests that we should persist with the tumbler test, then we should also disseminate to parents the fact that vomiting alone can cause petechiae and that a child who appears well and whose non-blanching rash is restricted to above the nipple-line is very unlikely to have meningococcal disease (three children in all reported series).11 What we do know without further research is that when parents bring children with meningococcal disease to general practice or A&E departments in the UK, half are missed and sent home.5 12 In some cases this refl ects poor clinical practice but in others, probably the majority, it is simply too early in the illness to make the diagnosis. For this reason, effective safetynetting is the key issue we need to get right in empowering parents.13 Teaching parents about the tumbler test may play a role in this, but the key issues are: (1) communicating diagnostic uncertainty to the parent; (2) reinforcing the parent’s role as key carer and expert by being precise about what to look out for (and on what time scale); (3) making it very easy for the parent to re-consult by giving clear practical instructions on how to go about it. Making sure all general practitioners and junior hospital staff can safety-net effectively will be much more empowering for parents, and have a much greater impact on avoidable deaths from bacterial sepsis, than any public information campaign on recognising petechiae.