Febrile child

Question 1

Management for <1mo febrile child

Answer 1

• Discuss with registrar/consultant
• Full sepsis work-up: FBE/film, blood culture, urine culture (SPA), LP ± CXR
• Admit for empirical antibiotics

Question 2

Management for 1-3mo febrile child

Answer 2

• Discuss with registrar/consultant
• Full sepsis workup: FBC/film, blood culture, urine culture (SPA) ± CXR (only if respiratory symptoms or signs) ± LP
• Discharge home with review within 12 hours if the child is:
  
  • Previously healthy
  • Looks well
  • WCC 5,000 - 15,000
  • Urine microscopy clear
  • CXR (if taken) clear
  • CSF (if taken) negative
• If the child is unwell or above criteria are not all satisfied, admit to hospital for observation +/- empiric i.v. antibiotics

Question 3

Localising signs to look for on examination of febrile child.

Answer 3

Ear, nose and throat examination, neck stiffness, work of breathing, abdominal signs, skin rash, joint swelling

Question 4

Contraindications to lumbar puncture

Answer 4

1. Coma: absent or non-purposeful response to painful stimulus - squeeze ear-lobe firmly for up to 10 seconds.
2. A child over 3 months of age should push you away and seek a parent.
3. Signs of raised intracranial pressure: eg drowsy, diplopia, abnormal pupillary responses, unilateral or bilateral motor posturing or papilloedema (NB papilloedema is an unreliable and late sign of raised ICP in meningitis; a bulging fontanelle in the absence of other signs of raised ICP, is not a contraindication).
4. Cardiovascular compromise/ shock
5. Respiratory compromise
6. Focal neurological signs or seizures
7. Recent seizures (within 30 minutes or not regained normal conscious level afterwards).
8. Coagulopathy/thrombocytopenia
9. Local infection (in the area where an LP would be performed)
10. The febrile child with purpura where meningococcal infection is suspected.

Question 5

Complications of lumbar puncture

Answer 5

1. Failure to obtain a specimen / need to repeat LP/ >Traumatic tap (common)
2. Post-dural puncture headache (fairly common) - up to 5-15%
3. Transient/persistent paresthesiae/numbness (very uncommon)
4. Respiratory arrest from positioning (rare)
5. Spinal haematoma or abscess (very rare)
6. Tonsillar herniation (extremely rare in the absence of contraindications above)

Question 6

Methods of obtaining urine specimens from babies.

Answer 6

1) Suprapubic aspiration (SPA) - preferred method
2) Catheter specimens - useful after failed attempt at SPA
3) Clean catch urine - children who are unable to void on request (undress baby, use clean pie dish to catch urine)
4) Midstream urine (MSU) - children who can void on request

Question 7

Management of febrile child >3mo with no clear focus of infection (child looks well)?

Answer 7

• If < 12 months boys or <2 yrs girls -urine, can do SPA up to 12 months of age
• If > 12 months - Consider Urine m,c,s
• Discharge home on symptomatic treatment
• Arrange medical review within 24 hr, or sooner if deteriorates

Question 8

Management of febrile child >3mo with no clear focus of infection (child looks unwell)?

Answer 8

Full sepsis workup: FBE, blood culture, urine culture ± CXR (if respiratory symptoms or signs) ± LP Admit to hospital for observation +/- i.v. antibiotics

Question 9

Management of febrile child >3mo with no clear focus of infection (child looks miserable but is still relatively alert, interactive and responsive)?

Answer 9

• If < 12 months boys or <2 yrs girls -urine, can do SPA up to 12 months of age
• iIf > 12 months - Consider Urine m,c,s
• Discuss with registrar or consultant prior to any investigations

Question 10

Differentials for asthma

Answer 10

<2 years – hesitant to call it asthma (reative airways disease)

Differentials

• Bronchiolitis
• GORD
• CF
• Vascular ring
• Congenital lesions

Children

• Bronchitis
• CF
• GORD
• Cardiac failure
• Suppuratives lung disease
• Mediastinal mass