Febrile child

Question 1

Probabiglity diagnosis

Answer 1

Viral URTI infection incl. common cold, pharyngitis, tonsillitis

Otitis media

Acute bronchitis

Roseola

Gastroenteritis

Post immunisation

Question 2

Serious disorders not to be missed

Answer 2

Infection:

Bacterial:

• Meningitis/encephalitis
• Septicaemia/bacteraemia
• Epiglottitis
• Pneumonia
• Oteomyelitis/septic arthritis
• Tuberculosis
• Orbital cellulitis
• Septic arthritis
• Urinary infection
• Pertussis
• Abscess

Viral:

• Epstein—Barr mononucleosis
• Exanthemata eg measles, varicella e.g. fifth disease, hand-foot-mouth disease
• Bronchiolitis/croup
• HIV/AIDS

Cancer:

• Leukaemia/lymphoma
• Neuroblastoma/sarcoma

Other:

• Acute appendicitis

Question 3

Pitfalls (often missed)

Answer 3

Tuberculosis

Rheumatic fever

Endocarditis

Tropical infections e.g. malaria

Atypical infections e.g. zoonoses

Henoch Schonlein purpura

Kawasaki disease (persistent fever)

Heatstroke/hot car

Question 4

Masquerades checklist

Answer 4

Drugs e.g. penicillin, antihistamines

Urinary tract infection

Question 5

Is the patient trying to tell me something?

Answer 5

?parental

?Munchaussen by proxy

Question 6

Key history

Answer 6

Obtain detailed account from parents of the symptoms and circumstances, esp. associations such as

• vomiting
• diarrhoea
• sweating
• cough
• wheeze
• headache
• other pain
• cognition
• photophobia an
• urinary symptoms

Immunisation (past and recent),

Infectious contacts

Animal contact

Travel.

Past history: ?splenectomy.

Question 7

Key examination

Answer 7

General features:

• appearance of the child
• interaction and level of activity
• colour, hydration
• chest movement
• vital signs including peripheral perfusion.

Examine skin looking for evidence of rashes, vesicles and purpura.

Examine the ears and throat.

Basic neurological signs, esp. neck stiffness and fontanelles.

Question 8

Key investigations (only if necessary)

Answer 8

First line:

• FBE/ESR
• urinalysis
• MCU

Consider:

• CXR
• blood culture
• lumbar puncture

Question 9

Diagnostic tips

Answer 9

Fever is regarded as a temperature >38° (rectal or tympanic).

Most fevers in children are caused by viruses and are self limiting.

Consider a fever of ≥38.5°C as significant and warranting close scrutiny.

Fever itself is not harmful until it reaches 41.5°C.

Temperatures >41°C are usually due to CNS infection or the result of human error, e.g.:

• shutting a child in a car on a hot day
• overwrapping a febrile child

Distinguish between focal causes, e.g. tonsillitis, and no apparent focus when a more detailed history and examination is required.

Be very mindful of septicaemia and endocarditis.

All febrile neonates should be considered for a full septic work-up and admitted for parenteral antibiotics.

Question 10

Management

Answer 10

Treatment of low-grade fevers should be discouraged.

Treatment of high-grade fevers includes:

• Rx of the causes (where appropriate) + adequate fluid intake
• Paracetamol (acetaminophen) is the preferred antipyretic
• since aspirin is potentially dangerous in young children.
• The usual dose of 10–15 mg/kg every 4–6 h may represent undertreatment.
• Use 20 mg/kg as loading dose and then 15 mg/kg maintenance.

Evidence favours tepid sponging for 30 mins + paracetamol.

Question 11

Advice to parents

Answer 11

Dress the child in light clothing (stripping off is unnecessary)

Do not overheat with too many clothes, rugs or blankets

Give frequent small drinks of light fluids, esp. water

Sponging with cool water and using fans is not effective