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Fever in children

Fever in children. Dr. Osama Kentab, MD, FAAP, FACEP Assistant Professor of Paediatrics and emergency Medicine King Saud Bin Abdulaziz university for Health sciences Riyadh. Epidemiology. Very common sign and symptom of illness in childhood

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Fever in children

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  1. Fever in children Dr. Osama Kentab, MD, FAAP, FACEP Assistant Professor of Paediatrics and emergency Medicine King Saud Bin Abdulaziz university for Health sciences Riyadh

  2. Epidemiology • Very common sign and symptom of illness in childhood • May be indicative of an infection that is local or systemic; benign or invasive & life threatening • Normal body physiological reaction to pyrogen ( infective, inflammatory)

  3. Implications of body temperature • Is it beneficial? • Rate of bacteraemia is 2-3% in all febrile infants < 2months (Baker 1999; Kadesh et al 1998) • Infants < 2 months differ are less immunocompetent unique group of bacteria (GBS, Gram. Neg bacteria & listeria) • Young infants show relative inability to demonstrate clinical evidence of illness

  4. Assessment: Relevant history • Duration of fever • Pattern of fever: intermittent or continuous • Hx of contact: family members, friends, school mates • Hx travel abroad: country visited • Malaria endemic regions, enteric fever (Africa, Asia) Travel immunization, malaria prophylaxis • Travel to mountainous region, camping in forest (Rickettsial infection, Lyme disease) • Hx of Immunization

  5. Relevant symptoms • Systemic symptoms: Resp, ENT, Renal, GI • Rash: Pattern/type (macular, papular, ulcerative, erythematous, blanching) • Distribution (mucosal involvement-conjuctivitis, mucositis, buttocks and extremities(HSP) Oral ulcers (aphthous, herpes gingivostomatitis)

  6. Relevant clinical signs • Unwell – Toxic • Haemodynamic instability • Rash • Lower Respiratory signs • Joint involvement: Arthritis/ Athralgia: Reactive viral arthritis, Septic arthritis, HSP, Rheumatic fever, Chronic arthritis of childhood • Organomegaly: Hepatomegaly, Splenomegaly, +/- Anaemia: Systemic illness, Septicaemia, Lymphoproliferative disorders

  7. Causes of febrile illnesses in childhood • Common causes • URTI (viral or bact.) • LRTI • Gastroenteritis • UTI • Oral (dental abscess, hyperangina, herpetic gingivitis, mumps) • MSS (septic arthritis, osteomyelitis, cellulitis • Serious causes • URTI (epiglottitis, croup, retropharyngeal abscess) • LRTI • GI (appendicitis) • CNS (Meningitis, encephalitis) • Systemic (meningococcaemia, toxic shock syndrome

  8. Management of fever in young children

  9. Age < 29 days • CBCD,glucose,BUN,Creat,lytes, +/- cap.gasses • Blood culture • Urine cath (microscopy and culture) • LP (if infant unstable defer) • CXR (suspected respiratory disease) • NPW (suspected viral respiratory disease) • Stool for WBC, culture and heme test (suspected eneteric infection) Management of fever in young children

  10. Age < 29 days Cont’d • Supportive care • Antibiotics: Ampicillin AND Gentamycin OR Ceftriaxone/Cefotaxime Consider Acyclovir • Admit Management of fever in young children

  11. 29 to 60 days • CBCD, BNR • Blood culture • LP (if infant unstable defer) • Urine cath (microscopy and culture) • CXR (suspected respiratory disease) • Stool for WBC, heme test and culture (suspected enteric infection) Management of fever in young children

  12. 29-60 days Low risk Past history • Born >37 wks • Home with or before the mother • No subsequent admission • No prenatal,postnatal,or current antibiotics • No treatment for unexplained hyperbilirubinemia • No known immune deficiency Management of fever in young children

  13. 29-60 days Low risk P/E • Appears generally well (non-toxic) • No evidence of skin,soft tissue,bone, joint,or ear infection Management of fever in young children

  14. 29-60 days Low risk Laboratory • WBC >5k <15k • ANC <10K or band/neutrophil ratio < 0.2 • Urine <10 WBC/hpf, spun and negative Gram stain • CSF: Non-bloody ,< 8 WBC , normal glucose, protein, negative Gram stain and latex agg.test • Normal CXR (if it was done) • Stool (if diarrhea) <5 wbc/hpf Management of fever in young children

  15. 29-60 days Low Risk Option II • Ceftriaxone 50 mg/kg IV or IM • Re-evaluate in 24 hours and 48 hours • Optional second dose of ceftriaxone at second visit Option I • No antibiotics • Admit for observation OR • Re-evaluate in 24 & 48 hours Discharge only if: Reliable caregiver Has nearby telephone Adequate transportation Management of fever in young children

  16. 61-90 days Low Risk Option I • No LP • No antibiotics • Admit for observation OR • Re-evaluate in 24 hours Option II • LP & if normal: • Ceftriaxone 50 mg/kg (IV or IM) OR • NO antibiotics • Admit for observation. OR • Re-evaluate in 24 hours Discharge only if: Reliable caregiver Has nearby telephone Adequate transportation Management of fever in young children

  17. 29-90 days High risk • Toxic • Positive labs • Concerning history /social factors • Admit • Supportive care • Meningitis Ceftriaxone and Vancomycin • Non-meningitis Ampicillin and Ceftriaxone OR Gentamycin Management of fever in young children

  18. 3-36 months • Toxic looking Fever, meningeal signs, lethargic, limb, mottled • Admit, septic work-up, parenteral antibiotics • Focal bacterial infection OM, pharyngitis, sinusitis, etc (excluding SBI). • Oral/parenteral antibiotics, outpatient care • Well looking Risk for occult bacteremia and serious bacterial infection • Previous decision analysis( Pre-H. flu immunization) • Current decision analysis Management of fever in young children

  19. 3-36 months High risk/toxic • Admit • Supportive care • Septic work-up • IV antibiotics • Meningitis---->Vanco + Ceftriaxone • Non-meningitis ----> Ceftriaxone Management of fever in young children

  20. 3-36 months • Non-toxic • If <3 yrs,temp >39 : • Obtain CBC,Blood culture,Urinalysis & culture • Stool culture,CXR as indicated • If WBC>15k --->Empiric antibiotics (Ceftriaxone,Clavulin,Biaxin, omnicef or Suprax ) • If urine is positive treat as UTI • If WBC normal ,urine is negative no therapy needed Management of fever in young children

  21. 3-36 months Cont’d • IF Temp < 39, Non-toxic, No focus of infection NO INVESTIGATIONS ARE REQUIRED • Follow up all in 24 hours Management of fever in young children

  22. Management of fever in children with underlying illness Management of fever in young children

  23. Oncology patients At risk of overwhelming sepsis • CBC, CXR, blood culture, urine culture, and LP when clinically indicated • Neutropenic patients at risk for Pseudomonas and other gram negative • Broad spectrum antibiotics Management of fever in young children

  24. Acquired Immunodeficiency Syndrome • Repeated risk of infection with common bacterial pathogens, risk of Pneumocytsis carinii, mycobacterial infections, cryptococcosis, CMV, Ebstein-Barr virus. • Low CD4; septic work up and broad spectrum antibiotic Management of fever in young children

  25. Sickle Cell Anemia • Functional asplenia susceptible to overwhelming infection esp. encapsulated organisms such as pneumococci and H. flu • Parvovirus can cause aplastic crisis • Osteomyelitis should be suspected in fever and bone pain • CBC, retics,blood culture, stool culture, and urine culture recommended • Ceftriaxone • Hospitalization recommended Management of fever in young children

  26. Congenital Heart Diseases • Children with valvular heart disease are at risk for endocarditis • Fever without obvious source with a new or changing murmur; hospitalization, serial blood cultures, echo, antibiotics against: S.viridans, S aureus, S. fecalis, S. pneumo, enterococci, H. flu, and other gram neg rods • Suggested antibiotics include Vancomycin and Gentamycin until cultures are known Management of fever in young children

  27. Ventriculoperitoneal shunts • Must be evaluated for shunt infection esp if patient displays headache, stiff neck, vomiting, or irritability • Shunt reservoir should be aspirated and examined for pleocytosis and bacteria • Most common pathogen is S. epidermidis • CT head also warranted Management of fever in young children

  28. Febrile Seizures • 455 children with simple febrile seizure -1.3% with bacteremia -5.9% UTI - 12.5% with abnormal chest x-ray -Normal CSF in all who had an LP (135) Trainor J, et al: Clin Pediatr Emerg Med 1999 Management of fever in young children

  29. Febrile Seizures 486 children with bacterial meningitis -complex seizures present in 79% -93% of those with seizures were obtunded -of the few with “normal” LOC, 78% had nuchal rigidity Green SM, et al: Pediatrics 1993 Management of fever in young children

  30. Febrile Seizures • Synopsis of the American Academy of Pediatric practices parameters on the evaluation and treatment of children with febrile seizures • LP strongly considered in the first seizure in infants less than 12 month because signs and symptoms of meningitis may be absent in this age group • 12-18 months LP should be considered because sign of meningitis may be subtle in this age group • 18+ months LP only if signs and symptoms of meningitis (Peditrics 1999) Management of fever in young children

  31. Febrile Seizures • Routine lab (CBC, lytes, Ca, phos, Mg, or glucose) should not be performed in simple febrile seizure • Neuro-imaging should not be performed routinely on simple febrile seizure • EEG is not performed in a neurologically healthy child with simple febrile seizure • Anticonvulsant therapy is not recommended in simple febrile seizure Management of fever in young children

  32. DDx Fever with rash • Viral exanthems • Streptococcal infection • Staphylococcal scalded skin syndrome / Toxic shock syndrome • Kawasaki disease • Meningococcal disease • Henoch Schonlein purpura (HSP)

  33. Measles • paramyxo virus • Spread by respiratory droplets • Incubation period: 7 – 12 days • CF: prodromal period (fever, conjuctivitis, coryza, dry cough, koplik spots +/- lymphadenopathy) florid maculopapular rash appearing over head and neck spreading to cover the whole body X 3-4 days • Infectious from the prodromal period until 4 days after rash appeared • Dx: Measles Antibodies in saliva or serum • Complications: OM, pneumonia, encephalitis, subacute sclerosing pan encephalitis

  34. Chicken pox (Varicella) • varicella zoster DNA virus • Incubation period 14 – 21 days • Fever & malaise X 5-6 days followed by crops of skin lesions that go through stages of macules, papules, vesicles, and crusting • Infectious 2 days before rash until vesicles dry/crust • Complications: Secondary bact. Infection of lesions, haemorrhagic varicella, pneumonia, encephalitis, ataxia at 7-10 days after rash • Severe illness in immunocompromised adults, preg. Women & neonates

  35. Rubella (german measles) • RNA rubella virus • Incubation period: 14 – 21 days • Fever, rash, posterior cervical lymph node • Complications: Deafness,encephalitus, Congenital rubella syndrome • Rx: Symptomatic

  36. Roseola infantum (Human herpes virus type 6)

  37. Roseola infantum • Caused by Human herpes DNA virus type 6 & 7 • Many children already infected by 2 years • Incubation period: 5- 15 days • CF: short febrile illness x 3- 5 days and an erythematous rash • Complication: Meningoencephalitis & Sz

  38. Fifth Disease

  39. Erythema infectiosum (Fifth ds/ Slapped cheek ds) • Human parvo virus B19 • Incubation period: 7 – 17 days • Head ache & malaise • rash on face ( slapped cheek app.) spreading to the trunk and limbs with maculopapular lesion evolving to a lace- like reticular pattern • Complications: Aplastic crisis with underlying chronic haemolytic anaemia, Aseptic meningitis, Hydrops fetalis

  40. Hand, Foot & Mouth disease • Caused by coxsackie A16, A19 and Enterovirus 71 RNA viruses • Incubation period: 4 – 7 days • CF: fever, malaise , head ache, pharyngitis, vesicular lesions on the hands and feet including palms & soles • May be complicated by chronic recurrent skin lesions • Rx: Symptomatic

  41. Infectious mononucleosis (Glandular fever) • Ebstein Barr (DNA) virus • CF: fever, lymphadenopathy, tonsillitis, headache, malaise, myalgia, splenomegaly, petechiae on soft palate, rash (macular, maculopapular, urticarial or erythema multiforme) • DX: EBV specific IgM; Paul Bunnell test • Complication: Splenic rupture, ataxia, facial nerve palsy, aplastic anaemia, interstitial pneumonia • Rx: Symptomatic

  42. UTI in childhood • UTI is common • VUR is assoc with renal scarring particularly in the 1st year pf life • chronic renal failure • Neonates – irritability, refusal of feeds, vomiting, FTT, prolonged NNJ, toxic/extremely unwell • Pre-school: vomiting, poor wt. Gain, fever, malaise, freq, dysuria, enuresis, haematuria, loin pain

  43. UTI (2) • Inv: Urine m/c/s x 2 (or 1 SPA urine sample) – mid stream, clean catch, bag, SPA urine sample • Pyuria, organism on microscopy • Significant bacteruria > 10 5 org/ml or and growth from SPA • Treatment: Antibiotics PO or iv • Commence low dose prophylactic antibiotic • Refer to the Paediatrician for further investigations

  44. Meningococcal disease • Gram neg. diplococci • Nasopharyngeal carriage in 25% • Invasive disease in 1% carriers • 15% meningitis; 60% Septicaemia + endotoxaemia; fulminant septicaemic shock with circulatory failure & wide spread purpura • Rx: Antibiotics; management of shock, anticipate ventilatory failure • Transfer to PICU and contact public health dept • Prognosis: Poor if <1 year, better if evolution of ds slower; overall mortality approx. 30%

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