Febrile Child

Ping-Wei ChenPGY-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– 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?

• 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

• Variations in temperature – diurnal, age, gender, prandial state

• Axillary < Oral < Rectal

Here at Home

• 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

• 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

• 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 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

• 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

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

<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

Bugs

• Commonly:– Group B Streptococcus– Listeria Monocytogenes– E. Coli– Enterococcus

• Less Commonly:– S. pneumoniae, H. influenzae, N. meningitidis

• Rarely: – S. aureus, Salmonella

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

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

• 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

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• 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

• High Risk Management– Full Septic Workup– Admission– Empiric Antibiotics

• Cefotaxime• Ceftriaxone

• “Low Risk” Management– Guided by your study of

choice

Case 3

• 2 year old male– 2 days of increased lethargy, decreased appetite– Rectal temperature 38.7C

• P/E: Vitals 38.7C, 125bpm, RR24, 99% Room Air -examines and appears well (no focus of infection)

- Healthy- Immunizations UTD- Review of Systems negative

Alberta’s Routine Immunization Schedule

Two months • DTaP-IPV-Hib1• Pneumococcal conjugate• Meningococcal conjugateFour months • DTaP-IPV-Hib• Pneumococcal conjugate• Meningococcal conjugateSix months • DTaP-IPV-Hib• Pneumococcal conjugate• Meningococcal conjugate

Prevnar Vaccine (PCV7)

• Covers Serotypes 4,6B,9V,14,18C,19F,23F• Polysaccharide conjugated to protein• Introduced in Calgary July 2002

>3 months old

Urine Studies

• Clinical decision rule to identify febrile young girls at risk of urinary tract infection

Gorelick MH et al. Arch Pediatr Adoles Med 2000;154(4):386-390

• 1469 females <2 year of age with UTI2 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?

• No Clinical Decision Rule• Urine Cultures– All boys <6 months– Uncircumcised boys <12 months

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?

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