Transcript Fever in Children

Fever in Children
Roger M. Barkin, MD
Measurement
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Definition of fever: 38 C or 100.4
Sites
– Rectal
– Tympanic membrane
– Oral
– Axillary
– Age dependent reliability (<6 mo old)
Causes of Fever
(<24 mo & >40oC)
Otitis Media
36.9%
Non-specific illness
25.5%
Pneumonia
15.5%
Recognizable viral syndrome 12.7%
(exanthem, encephalitis, gastroenteritis,
croup)
Recognizable bacterial synd. 9.4%
Antipyretic Therapy is
Imperative Early
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Acetaminophen
Ibuprofen
Tepid sponging
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Facilitates evaluation
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10-15 mg/kg
10 mg/kg
General Assessment
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Child looks and focuses on clinician,
spontaneously explores room
Child spontaneously makes sounds
or talks in a playful manner
Child plays, reaches for objects
Child smiles, interacts with parents
or practitioner
Child quiets easily when held by
parents
History
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Non-specific and by report
Exposure
Preexisting medical conditions
Prematurity
Physical Examination
Often non specific findings
Ancillary Data
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WBC
Urinalysis
Lumbar puncture
Cultures - blood, urine, CSF
Chest x-ray
Stool polys
Urine Evaluation
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Specimen
– Bag
63% contamination
– Catheter
9% contamination
– Suprapubic with ultrasound
Urine Evaluation
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Gram stain and dipstick analysis for
nitrite and leukocyte esterase are
similar in sensitivity and specificity
Both superior to microscopic analysis
for pyuria
Enhanced UA (microscopy + gram
stain)
– most sensitive but had 16% false +
– would have missed 4-6% positives
Urinalysis unremarkable in up to
80%
of newborns with UTI
Urine EvaluationCost Effectiveness
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Culture all infants
Rx if + LE or nitrite
Detected all infants with UTI
Chest X-ray
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Respiratory symptoms
– Tachypnea
>59 (<6 mo)
 >52 (6-11 mo)
 >42 (1-2 yr)
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– Coughing, wheezing, dyspnea,
retractions, grunting
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No focus
Key Questions
1. What is child’s risk of bacteremia?
- Does the history & clinical exam help?
2. Which diagnostic tests are helpful,
if any?
3. Should empiric antibiotics be
prescribed?
- If prescribed which one & by what
route?
4.What follow-up is appropriate?
Occult Bacteremia
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1-3% of febrile patients without a
defined focus
Etiology
– S. pneumoniae, H. influenzea type B,
N. meningitidis
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Risk Factors
– <24 months
– Temp > 39.4oC
– WBC > 15-20,000
Prevalence of Bacteremia
Pre-H.influenzae vaccine (n = 7899)
3.1%
Bacteremia
(n=244)
0.2%
SBI
(n=17)
0.1%
Meningitis
(n=7)
70-80% occult bacteremia resolve
spontaneously
Post H.influenzae vaccine(n = 9465)
1.6% Bacteremia
Risk of Developing SBI
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Incidence bacteremia
1.5%
– 90% strep pneumo
– 5% salmonella
– 1% n. meningitidis
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Likelihood of development SBI
0.1%
Cost Effective Analysis
Model
(Lee, 2001)
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CBC + selective BC and Rx
– WBC > 15,000
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If bacteremia rate dips to 0.5%
– clinical judgement may be most cost
effective
Infants Under 2 Months
of Age
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No laboratory, historical or physical examination factor can prospectively exclude
underlying bacterial infection
Clinical judgement alone is not consistently
useful in assessing the young febrile infant
Children under 3 mos. with temp >38.5oC have
a greater than 20-fold risk of having serious
infection than do older children with a similar
temperature
Rochester Criteria
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Well appearing infant - normal vital signs,
good hydration, perfusion
Healthy infant
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–
–
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Term (>37 week gestation)
No antibiotic therapy - antenatal or post natal
No underlying illness
No previous hospitalizations; discharged with
mother as newborn
Rochester Criteria
(continued)
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No focal infection (skin, soft tissue,
bone/joint)
Good social situation
Laboratory criteria
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WBC 5 - 15,000/mm3
Band form count <1500/mm3
Normal urinalysis (<5 WBC/HPF)
Normal stool (<5 WBC/HPF, if done)
Hyperpyrexia (Temp >41oC
[105.8oF])
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20% of children will have a seizure
10% of children < 2 yr will have
bacterial meningitis
53% of children will have serious
disease
– meningitis, bacterial pneumonia,
pericarditis, Kawasaki ‘s disease
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Temp >42oC often have non-infectious
etiology
Management
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Antibiotics
– IV, or
– Oral
Management
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0 - 30 days of life
30-60 days of life
Children under 3 years of age
Work-up and
Management
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CBC,UA/UC, blood culture; consider LP
Supportive care,antipyretics
<1 mo: assess, treat (ampicillin and
gentamicin/cefotaxime), admit
2-3 mo: assess, consider empirical
treatment,
reassess
Non-toxic Child >90 days,
T > 39oC
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Urine dip/Culture
– Males < 6 mos.
– Males 6-12 mos. If
uncircumcised
– Females < 12 mos.
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Urine dip/Hold
– Males 6-12 mos. If
circumcised
– Females 12-24 mos.
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Culture if positive
dip/gram stain
Non-toxic Child >90 days, T
> 39oC
Pneumococcal vaccine
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YES
– CXR if respiratory
findings and WBC
> 20,000
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NO
– if WBC > 15,000
 BC
 Ceftriaxone
 Recheck
Febrile Seizure
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Meningitis associated with seizure in
23% cases (115/503)
– 10 “relatively normal”
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Rate SBI in patient with first-time
febrile seizure same as those with
fever without seizure
Febrile Seizure
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Strongly recommend LP if < 12
months
Not routinely recommend LP if >18
months
Low threshold if on antibiotics
Fever evaluation
Immunocompromised
Children
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Chemotherapy
Asplenia - congenital, trauma
Sickle Cell disease
Fever and Petechiae
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15/90 had bacterial disease
– 13 - N. meningitidis
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Decreased risk if normal LP, WBC, ANC
and bands, and temp <40oC
DISCHARGE
INSTRUCTIONS AND
FOLLOW-UP IS
ESSENTIAL.
KEY POINTS
TO REMEMBER
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FEVER IS A COMMON COMPLAINT IN THE
ED
NEWBORN: GBS IS MOST COMMON
BACTERIAL PATHOGEN. ALSO E. COLI AND
LISTERIA MONOCYTOGENES
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APPROACH TO FEBRILE CHILD SOULD BE
AGE SPECIFIC
HISTORY AND PHYSICAL ARE OFTEN NONSPECIFIC
KEY POINTS
TO REMEMBER
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EXPECTANT MANAGEMENT IS OFTEN
APPROPRIATE
ANTIPYRETICS MAY ASSIST IN
ASSESSMENT BUT ARE NOT
PREDICTIVE OF THE ETIOLOGY