Fever in pediatric practice
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BY DR M OSAMA HUSSEIN MD
International Neonatology Training Program" INTP
FEVER IN PEDIATRIC PRACICE
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Term DefinitionFever Rectal temperature of 38°C (100.4°F)*
Fever without source
Acute febrile illness in which the etiology of the fever is not apparent after a careful history and physical examination
Serious bacterial infection
Meningitis, sepsis, bone and joint infections, urinary tract infections, pneumonia, enteritis
Toxic appearance
Clinical presentation characterized by lethargy, evidence of poor perfusion, cyanosis, hypoventilation or hyperventilation
Lethargy Poor or absent eye contact; failure of child to recognize parents or to interact with persons or objects in the environment
DEFINITIONS OF TERMS IN PRACTICE GUIDELINE ON THE MANAGEMENT OF FEVER IN INFANTS AND YOUNG CHILDREN
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Infant appears generally well
Infant has been previously healthy:
Born at term (≥37 weeks of gestation)No perinatal antimicrobial therapyNo treatment for unexplained hyperbilirubinemiaNo previous antimicrobial therapyNo previous hospitalizationNo chronic or underlying illnessNot hospitalized longer than mother
Infant has no evidence of skin, soft tissue, bone, joint or ear infection
Infant has these laboratory values:
White blood cell count of 5,000 to 15,000 per mm3 (5 to 15 × 109 per L)
Absolute band cell count of ≤1,500 per mm3 (≤1.5 × 109 per L)
Ten or fewer white blood cells / high-power field on microscopic examination of urine
Five or fewer white blood cells per high-power field on microscopic examination of stool in infant with diarrhea
ROCHESTER CRITERIA FOR IDENTIFYING FEBRILE INFANTS
AT LOW RISK FOR SERIOUS BACTERIAL INFECTION
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Why we pay special attention to fever ?
• Parental concern• “fever phobia”
• Clinician concern• we don’t want to miss a life threatening infection
• Most common complaint in pediatric visits
• Some of these kids are sick• most do well without intervention• need an approach to sort them out
BY DR M OSAMA HUSSEIN MD
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Fever Without a Source
• Fever without a source “FWS”= fever with no apparent cause
• “Fever of Unknown Origin”= a febrile illness of at least three weeks' duration, at least 38.3°C on at least three occasions and failure to establish a diagnosis in spite of intensive evaluation.
BY DR M OSAMA HUSSEIN MD
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Pediatric Fever AlgorithmNon toxic appearing, 28 – 90 days and “Low Risk”
No
Blood Culture, Urine Culture, CSF Cx, antibx +/-CXR
Yes
ADMITOutpatient Management
Option 1Blood Cx, Urine Cx, CSF Cx, ceftriaxone 50 mg/kg IV/IM, re-eval in 24 hours
Option 2Blood Cx, Urine Cx, Re-eval in 24 hours
Fever 38°C
BY DR M OSAMA HUSSEIN MD
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Child 3 to 36 months with FWS: Occult Bacteremia
• S. pneumoniae>>H. influenzae>N. meningitidis– conjugate vaccine for H influenzae virtually
eliminated this type of bacteremia
BY DR M OSAMA HUSSEIN MD
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Child 3 to 36 months with FWS: Practice Guidelines
• Toxic - Admit with full work up• Non-toxic – Consider workup when fever is
39°C
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Pediatric Fever Algorithm
Appears toxic?
Yes
Full sepsis work up and antibiotics and admit
No
Temperature ≥ 39
No Yes
No testing, assure follow up in 48
hrs
Selective workup
Child 3 to 36 months with FWS
BY DR M OSAMA HUSSEIN MD
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Child 3 to 36 months with FWS: Practice Guidelines
• Toxic - Admit with full work up• Non-toxic – Consider workup when fever is
39°C (102.2°F)
BY DR M OSAMA HUSSEIN MD
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Child 3 to 36 months with FWS: Occult Pneumonia
• Children with high fever and leukocytosis are more likely to have occult bacterial pneumonia– some suggest getting CXR with no resp symptoms
and WBC>20,000 and temp39.5°C (103.1°F)
BY DR M OSAMA HUSSEIN MD
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Pediatric Fever Algorithm
Appears toxic?
Yes
Full sepsis work up and antibiotics and admit
No
Temperature ≥ 39
No Yes
No testing, assure follow up in 48 hrs
Selective workup
Child 3 to 36 months with FWS
BY DR M OSAMA HUSSEIN MD
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Summary of Testing: 3 to 36 months and FWS, non-toxic, temp ≥39 C
• Urine– All females < 2 years– Males
• Uncircumcised <12 months• Circumcised < 6 months
• Stool culture– If bloody diarrhea or >5 wbc’s/hpf
• CXR– If respiratory symptoms or hypoxic
• LP– Signs of meningitis
• Blood cultures and Antibiotics– Option 1: All with fever ≥ 102.2– Option2 : All with fever ≥ 102.2 and WBC ≥ 15,000– Option3: Practitioner/immunization dependent
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Fever with a Source
• More common than fever without a source• Clinically identifiable viral or bacterial illnesses
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Fever with a Source: Viral– Varicella– Measles (recent outbreaks)– Mumps (recent Midwest
outbreaks)– Adenovirus
(pharyngoconjunctival fever)– Coxsackie infections
• Herpangina→• Hand-foot-and-mouth
– Croup– Bronchiolitis (as in our case)– Influenzae
BY DR M OSAMA HUSSEIN MD
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Fever with a Source: Viral
• Pediatric exanthems– Roseola (HHV 6)– Fifths disease (Parvo
B19)→
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Fever with a Source: Bacterial
• Clinically evident bacterial infections– Readily diagnosed from H&P• Pneumonia• Meningitis• Septic arthritis• Osteomyelitis• Lymphadenitis• Cellulitis/Abscess• Bacterial enteritis
BY DR M OSAMA HUSSEIN MD
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Antipyretics
• Triage protocols– acetaminophen by protocol
• Acetaminophen dose– 15 mg/kg q 4 hr prn
• Ibuprofen dose (for greater than 6 months old)– 10 mg/kg q 6 hr prn
BY DR M OSAMA HUSSEIN MD
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Bug Drugs: <1 month
• Ampicillin and gentamycin– covers GBBS, E. coli, Listeria monocytogenes– ampicillin specifically for Listeria and provides
some synergy with gentamycin for GBBS• Consider acyclovir– Maternal history of Herpes (especially if primary
outbreak with vaginal delivery) or any noted skin or mucosal lesions
BY DR M OSAMA HUSSEIN MD
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Bug Drugs: 1-2 months
• Ampicillin and cefotaxime– covers the < 1 month etiologic agents and also S.
pneumoniae– with cefotaxime you don’t have to worry about
oto/renal toxicity associated with gentamycin
BY DR M OSAMA HUSSEIN MD
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Bug Drugs: >2 months
• Ceftriaxone– covers S. pneumoniae, H. influenzae, and N.
meningitidis– theoretically shouldn’t give < 1 month because of
biliary sludging • Add vancomycin if any concern for S.
pneumoniae on LP in any age range (resistant strains have been appearing in CSF)
BY DR M OSAMA HUSSEIN MD
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Kawasaki’s Disease
• Fever for at least 5 days' duration and the presence of 4 of the following – Extremities changes (erythema, edema, and
desquamation) – Conjunctivitis (no exudate).– Polymorphous rash (not vesicular) is usually generalized – Cervical lymphadenopathy usually unilateral and greater
than 1.5 cm– Lip or oral cavity changes (erythema, dry/fissured or
swollen lips, and strawberry tongue)
BY DR M OSAMA HUSSEIN MD
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Febrile Seizures
• Simple Febrile Seizure– 1 event in a 24 hour period– Non-focal
• Complex– Whenever it is not simple– Consider larger work-up
• 30% chance of recurrence
BY DR M OSAMA HUSSEIN MD
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Febrile Seizures
• Work up for the source of the fever• “Strongly consider LP” for under 12 months –
AAP guidelines• Brain imaging not often necessary• Need to explain to parents why you aren’t
worried about the seizure
BY DR M OSAMA HUSSEIN MD
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Pediatric Fever Summary: Golden Rules
• A toxic appearance demands immediate action– Work-up/antibiotics and admit
• Know the age-specific algorithm for FWS• Test the urine (most common SBI)• Look for specific bacterial and viral etiologies• Careful follow up must be assured• Recommendations continue to evolve with
new immunizationsBY DR M OSAMA HUSSEIN MD
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Fever with xanthem Infectious causes
Virus: Classic viral exanthem: Measles, Rubella, VZV, Parvovirus,
Roseola Others:, HSV, EBV, HBV, Enterovirus, Dengue
Bacteria: Scarlet fever, Staph infection (sepsis, 4S,toxic shock syndrome), Meningococcemia, typhoid
Mycoplasma Rickettsial infection
Noninfectious cause Allergy: Food, drug, toxin, serum sickness Uncertain cause: Kawasaki disease
BY DR M OSAMA HUSSEIN MD
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Clinical Manifestation Incubation: 8-12 days, the average interval between
appearance of rash in the source case and subsequent cases is 14 days, with a range of 7-18 days.
Prodromal period: fever 2-4 day + 3C cough coryza conjunctivitis Koplik spot
Rash: erythematous maculopapular rash facesole in 72 hr. face and trunk: mostly distributed pneumonia
Convalescence cough may persist for 1 week
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BY DR M OSAMA HUSSEIN MD
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BY DR M OSAMA HUSSEIN MD
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Complication Pneumonia Otitis media Diarrhea Meningoencephalitis Croup Subacute sclerosing panencephalitis (SSPE)
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Treatment and Care Supportive and Symptomatic Vit A supplementation
6 mo-2 yr hospitalized with measles and complication
> 6 mo who have risk for severe measles and vit A deficiency:
immunodef, vitamin A def, impaired intestinal absorption, malnutrition, recent immigration from high mortality rated due to measles
Antibiotic for superimposed bacterial infection
BY DR M OSAMA HUSSEIN MD
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Treatment and Care Isolation: Airborne Precaution
1-2 day before onset of symptom or 3-5 days before onset of rash
4 days after onset of rash in healthy children
For the duration of illness in immunocompromised pt.
Isolated room (negative pressure ventilation)
Prevention: immunization 9-15 months 4-6 years
BY DR M OSAMA HUSSEIN MD
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Rubella RNA virus: Family Togaviridae, genus
Rubivirus IP: 14-21 days Infectivity: 7 days before – 5 days after onset
of rash
BY DR M OSAMA HUSSEIN MD
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Clinical Manifestation Prodromal period 1-5 days MP rash for < 3 days LN at postauricular and cervical area CBC: normal range Dx: viral isolation
Serologic test: CF, HI, IgM ELISA
BY DR M OSAMA HUSSEIN MD
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BY DR M OSAMA HUSSEIN MD
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Rubella Complication
arthritis thrombocytopenia meningoencephalitis
Treatment: supportive Isolation:
droplet precaution for 7 days after onset of rash, contact precaution for congenital rubella until >
1 yr-old Prevention: immunization
BY DR M OSAMA HUSSEIN MD
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Chickenpox VZV, HHV-3: Transmission
airborne contact vesicular fluid vertical transmission
Incubation period: 14-16 days, (10-21days)
Infectivity: winter season Most contagious: 1-2 days before onset of rash
until crusting of lesion.
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Clinical Manifestation Prodromal period: 2-3 days Generalized, pruritic, vesicular rash 250-500
lesions involving skin and oral mucosa Complication
Herpes Zoster, Shingles Congenital varicella: Scar, limb, ocular, CNS
defect Bacterial infection Severe chickenpox CNS: encephalitis, cerebellar ataxia, Reye’s
Syndrome
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BY DR M OSAMA HUSSEIN MD
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BY DR M OSAMA HUSSEIN MD
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BY DR M OSAMA HUSSEIN MD
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Treatment and care Supportive and symptomatic
antipruritic drug for severe case: ACV, famciclovir,
valacyclovir Isolation:
Airborne and contact isolation 1-2 days before rash until crusting of all lesion.
Prevention Immunization
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Child Care and School Children may return to school when all lesion
are crusted.
For compromised children with prolonged course should excluded for the duration of the vesicular eruption.
Older children and staff members with zoster should be instructed to wash their hands if they touch potentially infectious lesion
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Hand-foot-mouth Disease coxackie virus type 16 (A 16) most
common, other include A5, A7, A9, A10, B2, B5(31) and enterovirus 71
Fever, sore throat, drooling DDx from Herpes gingivostomatitis Self-limited, symptomatic treatment
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HFMD
BY DR M OSAMA HUSSEIN MD
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BY DR M OSAMA HUSSEIN MD
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Roseola Infantum
Exanthem subitum 3 mo- 3 yr. (6 mo-1 yr) HHV-6,7: DNA virus, Herpesviridae Uncertain incubation period (9-10 days)
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Clinical Manifestation High fever 39-41 c for 3-4 days
nonspecific symptom bulging AF febrile convulsion
MP Rash after defervescence CBC: normal range of WBC, lymphocyte
predominated
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BY DR M OSAMA HUSSEIN MD
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Erythrema infectiosum (Fifth Dz) Parvovirus (PV) B19 Family Parvoviridae 3-15 year Droplet transmission Incubation period: 4-14 days S/S: lowgrade fever, constitutional symptoms, arthralgia Classical 3 phases
Sunburn-like rash both cheek (classic slapped-cheek appearance) 2-4
Day 1-4 after facial rash macular – to – morbiliform eruption at extremities (extensor surface)
Lacy pattern: some w/o classic slapped-cheek pattern
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Meningococcemia N meningitidis: GNDC, bean shape Clinical manifestation
acute febrile illness petechiae, hemorrhagic manifestation:
purpura fulminan rapid progressive with HT or coma meningoencephalitis
Diagnosis: gram stain, antigen detection, buffy coat smear and culture
Treatment: penicillin, CTX, CRO
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BY DR M OSAMA HUSSEIN MD
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Scarlet fever GAS or S aureus: pyrogenic exotoxin (SPE) Acute febrile illness with:
Sore throat Gooseflesh or coarse sand-paper rash within
12-48 hr. Most intense at pressure area: axilla, groin Pastia’s line Strawberry tongue Pustule (Staph scarlet)
Desquamation begins toward the end of the 1st week
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BY DR M OSAMA HUSSEIN MD
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Scarlet fever
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Scarlet fever
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Scarlet fever
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Staphylococcal scalded skin syndrome (SSSS/4S) Staphylococcus toxigenic strain phage
group 2 with epidemolylic toxin A and B Start with local infection e.g. purulent
conjunctivitis, otitis media, nasopharyngeal infection
Fever, MP rash or erythroderma with periorificial and flexural accentuation with Nikolski sign
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BY DR M OSAMA HUSSEIN MD
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Impetigo contagiosa
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BY DR M OSAMA HUSSEIN MD