From the Guidelines
An ESR of 35 mm/hr in a 9-year-old child is elevated and warrants further investigation, as it indicates the presence of inflammation somewhere in the body, but is not specific to any particular condition. Normal ESR values for children this age typically range from 0-20 mm/hr. The child should be evaluated by a pediatrician for a complete history and physical examination, focusing on symptoms such as fever, joint pain, weight loss, fatigue, or recent infections, as suggested by the American College of Rheumatology clinical guidance for multisystem inflammatory syndrome in children associated with SARS-CoV-2 and hyperinflammation in pediatric COVID-19 1.
Additional laboratory tests should be ordered, including:
- Complete blood count
- C-reactive protein
- Tests specific to suspected conditions based on clinical presentation Common causes of elevated ESR in children include:
- Infections (streptococcal, viral, osteomyelitis)
- Inflammatory conditions (juvenile idiopathic arthritis, inflammatory bowel disease)
- Occasionally more serious conditions like malignancy The ESR is useful as a marker of inflammation and can help monitor disease activity and response to treatment once a diagnosis is established, as noted in the diagnosis, treatment, and long-term management of Kawasaki disease 1.
Key Considerations
- The child's symptoms and medical history should guide the diagnostic approach
- A tiered diagnostic approach, as recommended by the American College of Rheumatology, may be useful in evaluating patients with possible multisystem inflammatory syndrome in children (MIS-C) 1
- The ESR should be interpreted in conjunction with other laboratory results and clinical findings to determine the underlying cause of the elevation
- No specific medication is recommended based solely on an elevated ESR; treatment should target the underlying cause once identified, as emphasized in the EULAR/PReS recommendations for the diagnosis and management of Still's disease 1.
Next Steps
- The child should be closely monitored for any changes in symptoms or condition
- Periodic follow-up and additional testing may be necessary to determine the cause of the elevated ESR and to guide treatment
- A multidisciplinary approach, involving pediatricians, rheumatologists, and other specialists as needed, may be necessary to manage the child's condition effectively.
From the Research
ESR of 35 in a 9-year-old
- The erythrocyte sedimentation rate (ESR) is a marker of systemic illness, and its value can be influenced by various factors such as age, sex, and disease states 2.
- In pediatric patients, an ESR of 35 mm/hour may not be considered extremely elevated, as a study found that an ESR ≥ 100 mm/hour is usually associated with significant diseases 3.
- However, it is essential to consider the clinical context and other laboratory values when interpreting the ESR result, as a normal ESR can reassure that there is no active disease when clinical suspicion for infection or inflammation is low 2.
- The ESR can be used to screen for disease or disease complications, aid in disease diagnosis, or assess disease activity or response to therapy, in conjunction with physical findings and other laboratory values 2.
- It is also important to note that the ESR is not diagnostic, and clinical findings remain the cornerstones for the diagnosis of rheumatic disease 4.
Possible Causes and Considerations
- Infection is a common cause of elevated ESR in pediatric patients, and other possible causes include connective tissue diseases, malignancy, and renal diseases 3.
- The ESR result should be interpreted in the context of other laboratory values, such as hemoglobin and leukocyte counts, and clinical findings 3, 2.
- The presence of antinuclear antibodies (ANAs) may also be relevant in the diagnosis of rheumatic diseases, but the ANA test has minimal clinical significance in the absence of connective tissue disease symptoms 5, 6.