(Continued) Table 2. Continued Baltimore et al Infective Endocarditis in Childhood: 2015 Update 1493 In 2008, the National Institute for Health and Clinical Excellence (NICE) guidelines in the United Kingdom con- cluded that the use of antibiotic prophylaxis before any invasive procedures should cease, unless requested by the patient.71 A subanalysis of data from a large, nationwide study in England72 comparing the incidence and mortality from IE in 373 chil- dren <18 years old, both before and after the NICE guidelines, reported no change in the incidence of IE.73 Although small in size, this subanalysis is the strongest study currently available concerning the efficacy of antibiotic prophylaxis for children, and it lends support to the position that antibiotic prophylaxis is ineffective and that it would be reasonable to shift the dis- proportionately large focus on antibiotic prophylaxis for dental procedures to oral hygiene and prevention of oral disease. Recommendation 1. It is reasonable to shift the disproportionately large focus on antibiotic prophylaxis to an emphasis on oral hygiene and prevention of oral disease (Class IIa; Level of Evidence B). Diagnosis Clinical Findings in Children and Adolescents The presentation generally is indolent, with prolonged low- grade fever and a variety of somatic complaints, including fatigue, weakness, arthralgias, myalgias, weight loss, rigors, and diaphoresis. Although these are nonspecific findings, the presence of this cluster of symptoms requires careful evalu- ation for IE in certain settings, such as in the patient with underlying heart disease. In contrast, on occasion, the presen- tation may be fulminant, with rapidly changing symptoms and high, spiking fevers. These children are acutely ill, and some require urgent intervention. In these children, infection caused by Streptococcus pneumoniae or S aureus is likely. 