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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

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
slide7
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
slide12
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
slide14
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)

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
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
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.

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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