Febrile child Flashcards
What are common organisms causing fever in children?
S.aureus E. coli N. meningiditis S. pneumoniae GAS
In neonates - Listeria, enterococcus, Group B strep (s. agalactiae)
S. pnuemoniae and HIB less common now due to immunisations
What are the most common sources of serious bacterial infections in infants?
UTI
What is considered a clinically significant fever in a child?
> or equal to 38 degrees
What are red flags for an unwell child?
Appearance, behaviour = best indication - appear unwell (pale, drowsy, lethargic), poor interaction and response, change in cry (weak, high pitched, continuous, inconsolable)
Tachypnoea, tachycardia
Cyanosis, pallor
Poor tone
Rapid breathing, grunting, crackles, decreased breath sounds
Decreased wet nappies
Poor peripheral perfusion
High risk patient - immunosuppressed, chronic lung disease, congenital heart disease
What would you want to determine on history?
- Timeline and onset of illness
- Localising symptoms - cough, coryza, diarrhoea, vomiting, headache, photophobia, nucal stiffness, abdo or joint pain
- Vaccination hx
- Travel hx
- Sick contacts or exposures
- Immunocompromised ?
- Relevant PMHx, medication history
What examinations would you perform on a febrile child (in GP)?
Vitals - temp, HR, RR
Fluid ax - cap refill, tissue turgor, peripheries (temp, colour), mucus membranes
Assess neck muscle tone & movement
ENT examination - localising signs
Cardiac & resp exam - ax work of breathing, localising signs
Abdominal exam - acute abdo, localising signs
Rashes
Joints - swelling, heat, tenderness
How would you assess a febrile child as low risk (green)?
Colour - normal
Activity/behaviour - normal social response, appears content, alert or easy to rouse, normal crying/not crying
Respiratory - normal RR, no distress
Circulation/hydration - no signs of dehydration
How would you assess a febrile child as being intermediate risk (yellow)?
Colour -
Activity/behaviour -
Respiratory
Circulation/hydration
What are features on observation & examination are suggestive of a seriously unwell child?
CNS - conscious state, arousal, posture (normally flexed), neck stiffness, bulging fontanelle (sepsis), focal neurological symptoms/seizures
Cardiac - bradycardia (sign of hypoxia), signs of poor perfusion/hydration (esp. decreased tissue turgor), tachycardia, widened or narrowed pulse pressure (in sepsis wide initially, later narrowed)
Resp - tachypnoea, resp distress, signs of airway obstruction, apnoea
Non-blanching purpuric rash
What are the most common causes of fever generally?
Self-limiting viral infection most common
Infection > inflammation > malignancy
Neonates and infants <3 months more likely to have serious bacterial infection (1/3 cf. <1% when >3 mths)
UTI most common serious infection in <3 months and pneumonia then UTI in >3 months
Important DDx to consider in fever without a focus?
Pneumonia - clinical examination features not reliable in children, may not have bronchial breathing or crackles
UTI - common cause PUO, especially in <6 months. Consider if vomiting without diarrhoea
Meningitis - if <12 months + febrile convulsion need to LP to exclude
Septic arthritis - local signs very late feature, need to consider early, especially if pain with movement of joint and non-weight bearing. Remember septic hip pain often referred to groin and knee
Kawasaki disease - consider if persistent fever >5 days
Non-infectious causes
How can severity of febrile child be assessed?
Clinical appearance - well vs. unwell
Red flags on hx or examination
Stratification into traffic light system
What are important features of intermediate risk on traffic light system?
Abnormal activity/behaviour responses (prolonged stimulation to wake, no smile) and decreased cry
Pale, decreased cap refil, dry mucus membranes, poor feeding and reduced urine output
Tachypnoea, crackles, O2 <95% RA
Tachycardia, fever >5 days, fever >39, non-weightbearing or swelling in joint
What are important features of high risk on traffic light system?
Pale/mottled/blue
Abnormal response/behaviour - appears ill, very drowsy/unrousable
Decreased tissue turgor
Decreased breath sounds, grunting, chest in-drawing, severe tachypnoea
Weak, high pitched or continuous cry
Non-blanching rash Bulging fontanelle Neck stiffness Status epilepticus Focal neurological signs or seizures
How should the febrile child be investigated?
Ix determined by whether they appear well vs. unwell, assessment of severity (clinical features, traffic light system), age and whether focus of infection determined clinically
How should a neonate (<28 days) be Ix and Rx?
All should be admitted - high risk of serious bacterial infection
ABCD
All have septic work-up including LP +/- CXR (as clinical resp findings less reliable, most will have a CXR)
Add PCR for HSV, parcovirus and enterovirus to LP
Empirical antibiotics (for septacaemia)
- fluclox + gent (if CSF normal) or fluclox + cefotaxime (if CSF unknown)
- Add acyclovir if appear very unwell/suspect encephalitis
How should infant (1-3 months) be Ix and Rx?
Admit if appears unwell
Full sepsis work up (+/- LP and CXR) - LP if appear very unwell or other suspicion for CNS infection
Empirical antibiotics (septacaemia) - Fluclox + gent (if normal CSF) or fluclox + cefotaxime (if unknown CSF)
Can be D/C with review in 12 hours if:
- Previously healthy
- looks well
- Urine clear
- WCC not markedly high and CXR/LP if taken clear
How should children >3 months be Ix and Rx?
If well - treat as appropriate +/- Urinalysis if focus not clear and boy <12 mths and girl < 2years
If look unwell admit child
If clear focus - treat with empirical antibiotics
If focus unclear - Ix with septic work-up +/- LP and CXR and empirical antibiotics
What are the empirical antibiotics for meningitis?
> 2 months = ceftriaxone +/- acyclovir if very unwell (HSV)
<2 months = ceftotaxime (ceftriaxone can cause biliary sludge) + benzylpenicillin +/- acyclovir
This covers addition bugs - listeria, GBS, enterococcus
What are the empirical antibiotics for UTI?
Acutely unwell (treat as pyelonephritis until proven otherwise) - gentamycin + benpen
Well >6 months - trimethoprim
What are the empirical antibiotics for pneumonia?
Mild = amoxycillin or roxithromycin (mycoplasma suspected)
Moderate = amoxycillin + roxithromycin
Severe = gentamycin + roxithromycin + flucloxacillin
