Febrile Child Flashcards
1
Q
What constitutes fever?
A
- Temperature> 38C (axillary)
- Do not disregard parental perception that “child felt hot” or fevers recorded at home
- Most accurate way to measure is axillary temperature with digital thermometer (<3 months)
- Can use tympanic thermometer >3 months (retract pinna)
2
Q
Infectious causes of fever in children?
A
- Viral
- Most common cause in well, fully vaccinated children (10-12 episodes per year in toddlers)
- Bacterial
- Occult bacteraemia (rare if fully vaccinated)
- UTI: 7% of infants with fever without clinical focus
- Pneumonia
- Meningitis
- Otitis media
- Septic arthritis and osteomyelitis Cellulitis
- Abscess
3
Q
Viral causes of acute fever in children?
A
Influenza, RSV, adenovirus, para-influenza, parechovirus, enterovirus, EBV, HSV, VZV etc
4
Q
Bacterial causes of acute fever in children?
A
– Neonates:
• Group B Strep, E.Coli, Pneumococcus, Staph spp, Salmonella, Listeria
– Older children:
• Pneumococcus, Staph spp, E.Coli, Salmonella
5
Q
Risk factors for serious bacterial infections?
A
- Age
– <3 months (especially <4 weeks) = 10-15% of fever caused by bacterial infections
– UTI most common
– also think about pneumonia, sepsis, meningitis, osteomyelitis - Higher fever
– T>40 increased risk bacterial infection <3 months compared to T38 BUT can be afebrile and septic - Not immunised:
– Up to 7% risk serious bacterial infection vs <1% if immunised - Prematurity:
– Correct for gestational age (3 month old ex- 28 week infant has sepsis risk of term newborn) - Maternal factors for neonates:
– Group B strep, HSV, prolonged rupture of membranes - Recent antibiotics (last 3-7 days):
– Can mask signs and symptoms of sepsis / meningitis especially in young infants <3months - Appears ill / signs of toxicity
6
Q
What are the signs of toxicity in fever?
A
- Alertness/activity/arousal (decreased)
- Breathing difficulties
- Tachypnoea, grunting, respiratory distress, or shallow irregular respiration
- Circulation (colour, capillary refill <3 seconds)
- Decreased fluids in (< 50% normal/24hrs) or fluids out (< 4 wet nappies/24hrs), skin turgor, mucous membranes
• Vital signs:
– heart rate
– respiratory rate
– blood pressure
– pulse oximetry
– repeated temperature measurement
• A septic child may be hypothermic
7
Q
What are normal paediatric ranges for heart rate?
A
8
Q
How do you determine if there is a serious infection?
A
- Clinically identifiable source of fever
- Resuscitate if necessary
- Treat infection
- Fever without clinical source
- How do we identify which children need further investigation and treatment?
- Age of child
- Immunisation status of child
- History of illness
- Examination and vital signs
- Appearance: sick or well?
- Signs of toxicity
- Specific risk factors
9
Q
What difficulties are there in assessing young children & infants with fever without a clinical focus?
A
- Often lack localising signs: meningitis,UTI, sepsis, pneumonia
- Signs may be difficult to elicit especially in an irritable infant
- Signs may be nonspecific:
- – diarrhoea & vomiting: gastroenteritis, UTI, or meningitis
- – abdominal pain: appendicitis, lower lobe pneumonia
- Upper respiratory tract infection does not rule out coexisting serious bacterial illness in young children
10
Q
What do you ask on history for a febrile child?
A
- Age
- Fever duration and pattern
- Height of fever
- Activity, alertness, playfulness
- Intake
- Output (urine, diarrhoea, vomiting)
- Systemic complaints (cough, breathing, rhinitis, ear discharge, pain, dysuria, limp…
- Premorbid (underlying illnesses, prematurity, development
- Immunization, travel, infectious contacts Specific parental concerns
- In neonates- antenatal and intra-partum events
11
Q
What examination do you perform in a febrile child?
A
- Head to toe, back to front!
- Walk
- Fontanelle
- ENT
- Lymph nodes
- Rash/petechiae/bruise/lumps/external genitalia
- Chest, CVS, abdomen
- Neurological meningeal irritation, cranial nerves, subtle seizures
- Musculoskeletal joints, bones, limb movements- relative paucity/asymmetry, weight bearing, limp
12
Q
Causes of fever in neonates and infants <3 months old?
A
- Higher risk of serious bacterial illness (UTI, pneumonia, bacteraemia, meningitis) because:
- Developing immune system
- Incomplete vaccination at this age
- Causative organisms:
- Group B Streptococcus
- Listeria monocytogenes
- E.Coli
- 9-19% febrile neonates presenting to ED have SBI (population selection – look sicker or sent in by GP)
13
Q
Evaluation of fever in neonates and infants <3 months old?
A
- Neonate (<28 days corrected age)
- FBC and blood cultures
- Urine microscopy and culture (catheter or supra-pubic aspirate)
- LP (unless contra-indicated)
- +/- CXR (tachypnoea, saturations, work of breathing)
- Admit for empiric antibiotics and paediatric review
- DEFG! (Don’t ever forget glucose!)
- Poor ability to localise infection – do not present with classic signs of meningitis
- May not appear that unwell
- Deteriorate rapidly, high morbidity and mortality
- Presence of a viral illness (URTI) does not rule out coexisting bacterial infection, and may increase risk of meningitis in neonate!
14
Q
Evaluation of fever in neonates and infants <3 months old?
A
15
Q
Which antibiotics for fever < 3months?
A
Refer to local protocols
- Meningitis:
- Ampicillin and Cefotaxime (plus Acyclovir)
- UTI or fever with no focus (meningitis excluded):
- Ampicillin and Gentamicin
- Severe sepsis / septic shock:
- Gentamicin,Cefotaxime,Vancomycin,Acyclovir
16
Q
Summary: febrile infant <3 months age?
A
- Neonates
- Serious bacterial infection until proven otherwise:
- Need a full septic work up including LP, and treatment with parenteral antibiotics.
- Neonate with a focus of UTI will often have generalised sepsis as well (bacteraemia and meningitis), and should therefore have LP if look unwell or if blood cultures positive.
- Serious bacterial infection until proven otherwise:
- 1-3 months
- If septic / toxic should collect urine and blood, start parenteral antibiotics, LP once stable
- Bronchiolitis: supportive care
- Bacterial focus egUTI or pneumonia: treat with antibiotics
- LP if blood cultures are positive
17
Q
Causes for occult bacteraemia - Fever in older infants (>3months) and young children (< 3years)?
A
Causative organisms:
- Haemophilus influenzae,
- Neisseria meningitidis,
- Escherichia coli,
- Staphylococcus aureus,
- Streptocccus pyogenes,
- Salmonella sp.
18
Q
Approach to febrile child? (NSW Health Guideline)
A
19
Q
Approach to febrile child (3month-3year)?
A
20
Q
Investigations for a febrile neonate?
A
- FBC
- CRP (and pro-calcitonin)
- Urine collection
- Urinalysis and urine microscopy and culture
- CSF microscopy, culture and PCR
- Chest x-ray
21
Q
Is a normal FBC (WCC) helpful in evaluating a febrile child/neonate?
A
- A normal WBC count (5X109/L to 15 x 109/L) does not rule out SBI
- In fully vaccinated children a high WBC count (>20x109/L) increases possibility of SBI: especially pneumonia or bacteraemia
- Incomplete immunisation:
- Pre-test risk of bacteraemia 5%
- Treating febrile children with WBC>15x109 with parenteral antibiotics reduces chance SBI by 75%
- Do not use WBC alone to guide treatment
22
Q
How do you interpret CRP and procalcitonin in a febrile child?
A
- • C-Reactive Protein rises 12 hours after onset fever
- – >80mg/L may indicate SBI (Sn 40-50%, Sp 90%)
- – <20mg/L may indicate SBI less likely (Sn 80%, Sp 70%)
- • Pro-calcitonin rises earlier than CRP.
- – >2ng/mL may indicate SBI (Sn 40-50%, Sp 90%)
- – <0.5ng/mL may indicate SBI less likely (Sn80%, Sp 70%)
- • Single values not as useful as serial values
23
Q
How common is UTI in children <12months?
A
- ▪ 7% of febrile infants <12 months of age with fever without identifiable source have UTI1. Untreated may cause pyelonephritis, renal scarring.
- ▪ UTI may be associated with sepsis in young infants.
24
Q
How do you collect urine in children?
A
- • <12 months:
- – Supra-pubic aspirate (1% contamination rate, perform with full bladder at level of pubic crease through anterior abdominal wall) or in/out catheter specimen (10% contamination rate)
- – Clean catch (25% contamination rate)
- – If doing clean catch try “quick wee” technique
- • >12 months:
- – Clean catch or mid-stream urine if possible (25% contamination rate)
- • Bag urines:
- – 50% contamination rate so do not send for culture
25
Q
How reliable are urinalysis results?
A
- Meta-analysis of 95 studies showed dipstick positive (for leukocyte esterase or nitrite) has r sensitivity 88% and specificity 79% for diagnosing urinary tract infections (UTI) in children
- False negative rate especially <2years (due to urine not staying in bladder very long, therefore white cells do not accumulate)
26
Q
How do you interpret urine microscopy and culture?
A
- • Microscopy:
- – >100 WBC suggests infection
- – >10 epithelial cells suggests contamination
- • Culture positive if:
- – Growth single organism >108 CFU/L (>105 CFU/mL) by any collection technique
- – Single organism at >106-8 CFU/L (>103-5 CFU/mL) from catheter
- – Single organism any growth from supra-pubic aspirate
27
Q
What are normal values for CSF?
A
28
Q
What indicates, on CSF:
- Bacterial meningitis
- Viral meningitis
- TB meningitis
A
29
Q
How do you interpret CSF culture and PCR? What organisms are PCR of CSF fluid available for?
A
- • Any bacterial growth abnormal, may have no growth if previous antibiotic treatment
- • PCR available for:
- – N.meningitidis,
- – S. Pneumoniae
- – Group B Strep
- – HSV (can have false negative <72 hours illness)
- – Enterovirus
- – Parechovirus
30
Q
What are some contraindications to lumbar puncture in a child?
A
- Decreased level of consciousness
- Unstable vitals (shock, impending respiratory failure)
- Focal neurological signs
- Infection at local site
- Bleeding disorder
- If contra-indications exist start antibiotics early. LP can be done later once patient is stable.
31
Q
When to consider obtaining a CXR in a child?
A
- Consider in case of
- Respiratory abnormality (tachypnoea)
- Low oxygen saturations
- Prolonged fever or cough or high fever (temperature>39C) with no identifiable source
- Young children may have pneumonia without clinical signs of decreased air entry, bronchial breathing, dullness to percussion e.g. small child with early pneumonia
32
Q
When would you start empiric antibiotics and what would you use?
A
- Indications for empiric antibiotics:
- – Where possible (without causing treatment delay) after appropriate cultures have been taken
- – Febrile Neonates and infants under three months after a complete septic work up
- – Any toxic/severely unwell child
- Which antibiotic?
- – Use local guidelines
- – If septic 3rd generation cephalosporin (cefotaxime or ceftriaxone) plus aminoglycoside (gentamicin) plus staphylococcal cover (vancomycin) plus consider acyclovir
33
Q
Where can you find information for antibiotic choice?
A
- • Australia: Antibiotic guidelines (e-Therapeutic Guidelines)
- • RCH guidelines
- • Children’s Hospital Westmead antibiotic cards
- • Local hospital guidelines
34
Q
How would you counsel parents regarding a febrile child?
A
- Common parental concerns: fever causing harm, specific aetiological fears
- Parents seek information (cause for the fever, management, prevention) and reassurance
- Some general advice for parents:
- ▪ A fever is the body’s way of fighting infection
- ▪ Know about the warning signs of serious illness
- ▪ Risks of overmedicating and over the counter cold, flu & cough preparations
- ▪ Anti-pyretics do not prevent febrile convulsions
35
Q
Parental counselling: when to seek early review?
A
Seek early review if:
- ▪ Child’s condition appears to be worsening
- ▪ Reduced fluid intake-output
- ▪ Fever prolonged beyond five days
- ▪ Parental anxiety/gut feeling “Something is not right with my child…”
36
Q
Parental counselling: when to seek urgent review?
A
Urgent review in case of (warning signs of serious illness):
- ▪ Lethargy/irritability, reduced alertness
- ▪ Feed refusal/intolerance or excessive ongoing fluid loss
- ▪ Respiratory distress
- ▪ Pallor (very reliable), reduced urine output
- ▪ Worsening symptoms
- ▪ Non blanching rash
