Febrile child
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Febrile Child. Ping-Wei Chen PGY-1 Emergency Medicine Dr. Lorraine Mabon. Objectives. Definition of Fever Measuring Fever Approach to Managing Febrile Patient <30 days old 1-3 months old >3 months old. What is a fever?. Pathophysiology Increased hypothalamic set point Pyrogens

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Febrile Child

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Febrile child

Febrile Child

Ping-Wei Chen

PGY-1 Emergency Medicine

Dr. Lorraine Mabon


Objectives

Objectives

  • Definition of Fever

  • Measuring Fever

  • Approach to Managing Febrile Patient

    • <30 days old

    • 1-3 months old

    • >3 months old


What is a fever

What is a fever?

  • Pathophysiology

    • Increased hypothalamic set point

  • Pyrogens

    • Exogenous (eg: Gram Neg. LPS)

    • Endogenous (eg: IL-1, IL-6, TNF)

  • Prostaglandin E-2

    • Central effects

    • Peripheral effects


No seriously what is a fever

No, seriously, what is a fever?

  • Various definitions

    • Wunderlich 1868 Das Verhalten der Eigenwdrlne in Krankheilen

      • 25,000 patients: several million measurements

      • Axillary measurements

      • Fever >38C

  • Landmark Studies

    • Fever ≥ 38.0C


Temperature measurement

Temperature Measurement

  • Variations in temperature

    • diurnal, age, gender, prandial state

  • Axillary < Oral < Rectal


Here at home

Here at Home


Febrile child

  • 275 subjects

    • 5 temperature measurements

      • 4 temple (nurse x 2, parent x 2), 1 rectal

  • Results

    • good correlation (r=0.68)

    • “fair” agreement; 95% CI difference: -1.0C to +1.5C


Case 1

Case 1

  • 25 day old female

    • Mother thought “baby feels warm”, measured rectal temp: 38.3C

      • Otherwise, no concerns.

What else do you want to know on history?


History

History

  • Length/Duration of Illness

  • Antipyretic use

  • Birth History (maternal fever, GBS, PROM, STIs)

  • Medical History (immunocompetency)

  • Immunization status

  • Sick contacts

  • Behaviour/Localizing symptoms

    • eg: HNT, Resp, GI, GU


Case 11

Case 1

  • On Exam

    • 38.4C, 132bpm, RR26, 100% Room Air

    • Otherwise examines well.

      • No focus of infection identified.

What do you want to do with this patient?


30 days old

<30 days old

  • Rate of serious bacterial illness

    • Approximately 9% to 12%

  • Immature Immune systems

    • -decreased opsonin activity

    • -impaired neutrophil chemotaxis

    • -decreased macrophage function

  • • Unimmunized Status

  • • Limited sick behaviours


Febrile child

Infants between 1 and 28 days old with a fever should be presumed to have a serious bacterial infection. (Level A Recommendation)


30 days old1

<30 days old

  • Admit

  • Full Septic Workup

    • CBC with differential

    • Blood Culture

    • Urine dip, R+M

    • Urine Culture

    • LP

  • IV Antibiotics

    • Ampicillin/Cefotaxime

    • ?Acyclovir

  • Chest Xray

    • Only if 1 of: RR>50, Coryza, Cough, Nasal flaring,Grunting, Stridor, Rales, Rhonchi, Wheezing, ?WBC>20

  • Stool Culture

    • If diarrhea or >5WBC/Hpf


Febrile child

Bugs

  • Commonly:

    • Group B Streptococcus

    • Listeria Monocytogenes

    • E. Coli

    • Enterococcus

  • Less Commonly:

    • S. pneumoniae, H. influenzae, N. meningitidis

  • Rarely:

    • S. aureus, Salmonella


Case 2

Case 2

  • 62 day old male

    • Mother concerned about possible increased lethargy for 1 day

    • Rectal temperature 38.6C

    • Review of systems otherwise negative

    • Healthy, Immunizations UTD, normal pregnancy

• P/E:

-Vitals: 38.7C, 133bpm, RR24, 100% Room Air

-otherwise examines well (no focus of infection)


Management strategies

Management Strategies


Rochester criteria

Rochester Criteria

  • Management

    • Option 1:

      • Admission

      • Observation

      • No Abx

    • Option 2:

      • Full Septic Workup

      • Single Dose IM Ceftriaxone

      • F/U 24 hours

        • Only if reliable parents!

  • 233 infants

  • Low Risk Criteria

    -appear well

    -previously healthy

    -WBC 5.0-15.0

    -Bands <1.5

    -Urine <10 WBC/Hpf

    -Stool <5 WBC/Hpf (if diarrhea)

    -NOTE: No LP criteria!

    • NPV = 98.9%


Philadelphia criteria

Philadelphia Criteria

  • 747 patients

  • Low Risk Criteria

    • WBC <15

    • Urine WBC <10/Hpf

    • Benign urine on R+M

    • CSF WBC <8/mm3

    • CSF Negative Gram Stain

    • Negative CXRay

  • NPV = 98%

  • Management

    • Full septic workup

    • Outpatient

    • No antibiotics


Philadelphia results

Philadelphia Results


Boston criteria

Boston Criteria

  • 503 patients

  • Low Risk Criteria

    • Not ill appearing

    • No ear, soft tissue, joint, bone infection identified

    • WBC <20

    • CSF WBC <10

    • Urine neg. leukocytes

  • NPV = 95%

  • Management

    • Full septic workup

    • Outpatient therapy

    • IM ceftriaxone


Pittsburgh criteria

Pittsburgh Criteria

  • 404 patients

  • Low Risk Criteria

    • Well appearance

    • Not premature, No Abx, Not ill

    • WBC >5 and <15

    • Bands <1500/mm3

    • CSF WBC <5

    • Urine WBC <9/mm3

    • Urine negative Gram stain

    • Stool WBC <5 (if done)

    • Negative CXRay (if done)

  • NPV = 100%

  • Management

    • Full septic workup

    • Admission

    • Observation

    • No Abx


1 3 month old

1-3 month old

  • High Risk Management

    • Full Septic Workup

    • Admission

    • Empiric Antibiotics

      • Cefotaxime

      • Ceftriaxone

  • “Low Risk” Management

    • Guided by your study of choice


Case 3

Case 3

  • 2 year old male

    • 2 days of increased lethargy, decreased appetite

    • Rectal temperature 38.7C

  • - Healthy

  • - Immunizations UTD

  • - Review of Systems negative

• P/E: Vitals 38.7C, 125bpm, RR24, 99% Room Air

-examines and appears well (no focus of infection)


Alberta s routine immunization schedule

Alberta’s Routine Immunization Schedule

Two months

  • DTaP-IPV-Hib1

  • Pneumococcal conjugate

  • Meningococcal conjugate

    Four months

  • DTaP-IPV-Hib

  • Pneumococcal conjugate

  • Meningococcal conjugate

    Six months

  • DTaP-IPV-Hib

  • Pneumococcal conjugate

  • Meningococcal conjugate


Prevnar vaccine pcv7

Prevnar Vaccine (PCV7)

  • Covers Serotypes 4,6B,9V,14,18C,19F,23F

  • Polysaccharide conjugated to protein

  • Introduced in Calgary July 2002


3 months old

>3 months old


Urine studies

Urine Studies

  • Clinical decision rule to identify febrile young girls at risk of urinary tract infectionGorelick MH et al. Arch Pediatr Adoles Med 2000;154(4):386-390

  • 1469 females <2 year of age with UTI

2 of 5:

-Less than 12 months old

-White race

-Temperature of 39.0°C or higher

-Fever for 2 days or more

-Absence of another source of fever on examination

Sensitivity: 95%

Specificity: 31%


What about boys

What about boys?

  • No Clinical Decision Rule

  • Urine Cultures

    • All boys <6 months

    • Uncircumcised boys <12 months


Chest radiography

Chest Radiography

Level B Recommendation:

A chest radiograph should be obtained in febrile children aged younger than 3 months with evidence of acute respiratory illness.

Level C Recommendation:

Consider a chest radiograph in children older than 3 months with a temperature >39.0C and a WBC count greater than 20.


Questions

Questions?


Summary

Summary

  • Sick?

    • Full Septic Workup/Admission/Empiric Abx

  • <30 days old

    • Full Septic Workup/Admission/Empiric Abx

  • 1 to 3 months old

    • Let the landmark studies guide you

  • >3 months

    • Let the immunization status guide you


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