Febrile Child Flashcards
1
Q
What are the differentials for a cold, quiet, off food and fever in a baby?
A
- Collagen vascular disorders such as SLE and JIA and other systemic vasculitis disorders such as Kawasaki’s disease (cause high fevers)
- Infection - thorough examination needed as symptoms are non-specific
- Drug reactions - certain drugs can cause malignant hyperthermia and in a toddler accidental ingestion of toxic substances should always be considered particularly if there is an altered conscious level or other associated symptoms
- Certain malignancies e.g. lymphoma, leukaemia
- Rarely - diabetes inspidius can present with fever, poor growth and unsettled behaviour
2
Q
What can happen alongside a febrile illness?
A
Febrile illness can also cause decompensation in other conditions e.g. metabolic disorder, diabetes and hypopituitarism which may cause a child to have altered behaviour alongside a febrile illness
3
Q
What are differentials for a fever?
A
- Viral gastroenteritis - most common cause of fever and vomiting in pre-school children
- Septicaemia - important to consider as can present non-specifically in children of this age
- UTI
- Kawasaki disease - typically fever lasting >5 days which is often high and unresponsive to abx and antipyretics
- Meningitis - can present non-specifically in children of this age
4
Q
What are the signs and symptoms of Kawasaki disease?
A
- Rare condition mainly affecting children <5yrs
- Cervical lymphadenopathy
- Bilateral non-purulent conjunctival injection (red sclera)
- Mucosal changes e.g. strawberry tongue/bright red cracked lips
- Red rash
- Peripheral skin changes such as redness or oedema of hands/feet (later they peel)
- High grade fever lasting >5 days (can diagnose if not reached 5 days) - characteristically resistant to antipyretics and abx
- Child often very miserable
- Need to rule out other conditions like toxic shock syndrome, staph scalded skin, scarlet fever, measles and JIA
5
Q
What is suspected with an altered conscious level?
A
CNS infection and increased ICP or organ (brain) dysfunction due to possible sepsis or metabolic disturbance e.g. hypoglycaemia
6
Q
What systems review questions do you want to ask to narrow down your differentials?
A
- CNS: any photophobia, moving normally, irritable/unsettled, any pain, cry normal or high pitched
- ENT: pulling at ears, difficulty/pain on swallowing, nasal discharge (URTI)
- Respiratory: cough, noisy breathing e.g. stridor or wheeze, struggling to breathe (LRTI)
- Abdominal: abdominal pains, distension, diarrhoea, blood/mucus in stool, vomiting (intra-abdominal/GI cause such as appendicitis/abscess, intussusception or pyelonephritis)
- Urinary: passing urine normally, smelly/discoloured, pain on passing urine
- General: rash, normal complexion, how much fluid/diet have they tolerated in the last 24 hrs
- Joints/bones: joint swelling, redness, pain or reduced movement, sepsis associated with osteomyelitis/septic arthritis
7
Q
What can cause a non-blanching rash?
A
Petechial/purpuric:
- Idiopathic Thrombocytopenia Purpura (ITP) - very low platelets, mucosal bleeding, often occurs after a viral illness/vaccination (self-limiting 1-2 weeks)
- HSP - typically symmetrical on legs and buttocks
- NAI - bruising (ecchymoses) or other non-blanching marks e.g. petechiae
8
Q
What else is asked in the history for a non-specific presentation?
A
- PMH: other significant illnesses or infections, previous atypical infections or frequent severe infections may raise suspicion of immune disorder, any known conditions increasing risk of infection e.g. sickle cell
- MH: regular meds, any contraindications or interactions with medicines, last doses of paracetamol/ibuprofen (how many in 24hrs), allergies, immunocompromising meds e.g. steroids
- Immunisations: up to date?
- Pregnancy and birth history: born at term, complications or illnesses in neonatal period
- Developmental hx: concerns about developmental progress, reached their milestones, indwelling devices (neurodevelopmental problems)
- FH + SH: consanguineous parents, who is in their family, hx of sibling death, anyone else unwell with similar symptoms, significant medical problems, social situation for family
9
Q
What are red flags for possible sepsis/serious illness?
A
- A child who looks unwell to a parent or health care professional
- Altered conscious level
- Pale
10
Q
What can a child sitting very still indicate?
A
Doesn’t like to be moved:
- May represent pain on movement and the site of this should be sought
- Neck stiffness - meningitis (may be absent in younger children and babies or only seen in later stages of illness)
11
Q
When does the anterior fontanelle usually close?
A
18-24 months
12
Q
What is the management for a red score on PEWS?
A
- Inform a senior
- Examine a child and A-E assessment (providing any emergency intervention required)
- In the hospital setting, even if you suspect serious bacterial infection e.g. meningococcal septicaemia, the 1st line abx is IV/interosseous cephalosporin.
- In community if meningitis is suspected but no rash then give Benzylpenicillin if transfer to hospital is delayed
- Antipyretics should not be used for sole purpose of reducing a fever - can be considered if a child is distressed. They do not prevent febrile convulsions. Do not give paracetamol and ibuprofen together and only continue if the child’s distress returns
13
Q
How do you plot height/length on a growth chart in children?
A
- Measure length until age 2, measure height after aged 2
- A child’s height is usually slightly less than their length
14
Q
What are the clinical features of meningitis in neonates?
A
- Poor feeding
- Lethargy, irritability
- Apnoea
- Listlessness
- Fever, hypothermia
- Seizures
- Jaundice
- Pallor
- Bulging fontanelle
- High-pitched cry
- Floppiness
15
Q
What are the clinical features of meningitis in infants/young children?
A
- Fever, hypothermia
- Lethargy
- N+v
- Bulging fontanelle
- Neck stiffness
- Altered alertness
- Opisthotonus (dramatic abnormal posture)
- Irritability
- Poor appetite
- Seizures
16
Q
What are the clinical features of meningitis in older children?
A
- Fever, hypothermia
- Headache
- N+v
- Neck stiffness
- Photophobia
- Altered alertness
- Seizures
- Poor appetite
- Opisthitonus
- Hypothermia
17
Q
What is the management for meningitis?
A
- Call a senior and request that they urgently review the child as you are worried they are seriously ill
- Protect the airway and give high flow oxygen
- Obtain IV/intrarosseous access
- Take bloods for FBC, CRP, blood culture, lactate, whole blood real time PCR testing for meningococcus and pneumococcus
- Prescribe an antipyretic
- Perform LP if not clinically contraindicated and take urine culture
- Start abx
18
Q
What are the investigations for meningitis?
A
- Obs and give high flow O2 (triggering red for sepsis > increased risk of hypovolaemia) - oxygen demand may be higher so by providing supplementary oxygen (even if sats are norma), oxygen delivery is improved
- FBC, CRP, U+Es, LFTs
- Blood cultures
- Blood gas with lactate: lactate >4mmol/l - high sepsis risk
- Coagulation screen
- Whole blood PCR
- Blood glucose
- Perform LP unless contraindicated - shouldn’t delay abx, take blood glucose before
- Urine sample (if source of infection unclear) - clean catch sample or an in/out catheter or suprapubic aspiration if severely unwell
19
Q
What is done to test CSF?
A
- Microscopy and gram stain
- Culture and sensitivity
- Protein
- Glucose
- Virology
- PCR for virology, pneumococcus and meningococcus
20
Q
What is the treatment for meningitis?
A
- A child >3 months with suspected meningitis should be treated with IV ceftriaxone at a dose of 80mg/kg daily
- Ceftriaxone should not be administered at the same time as calcium containing infusions. In this situation, cefotaxime should be used instead.
- An infant <3 months with suspected meningitis should be treated with IV cefotaxime with either amoxicillin or ampicillin (listeria cover).
21
Q
What would be the test results for streptococcus pneumoniae meningitis?
A
- Raised neutrophils
- Low glucose
- Gram positive coccus
