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Febrile Child

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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  1. Febrile Child Ping-Wei Chen PGY-1 Emergency Medicine Dr. Lorraine Mabon

  2. Objectives • Definition of Fever • Measuring Fever • Approach to Managing Febrile Patient • <30 days old • 1-3 months old • >3 months old

  3. 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

  4. 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

  5. Temperature Measurement • Variations in temperature • diurnal, age, gender, prandial state • Axillary < Oral < Rectal

  6. Here at Home

  7. 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

  8. 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?

  9. 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

  10. 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?

  11. <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

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

  13. <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

  14. Bugs • Commonly: • Group B Streptococcus • Listeria Monocytogenes • E. Coli • Enterococcus • Less Commonly: • S. pneumoniae, H. influenzae, N. meningitidis • Rarely: • S. aureus, Salmonella

  15. 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)

  16. Management Strategies

  17. 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%

  18. 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

  19. Philadelphia Results

  20. 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

  21. 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

  22. 1-3 month old • High Risk Management • Full Septic Workup • Admission • Empiric Antibiotics • Cefotaxime • Ceftriaxone • “Low Risk” Management • Guided by your study of choice

  23. 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)

  24. 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

  25. Prevnar Vaccine (PCV7) • Covers Serotypes 4,6B,9V,14,18C,19F,23F • Polysaccharide conjugated to protein • Introduced in Calgary July 2002

  26. >3 months old

  27. 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%

  28. What about boys? • No Clinical Decision Rule • Urine Cultures • All boys <6 months • Uncircumcised boys <12 months

  29. 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.

  30. Questions?

  31. 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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