Febrile Child Flashcards
Also look at Anki (Paeds in primary care)
What are the infections that predispose a child to congenital abnormalities?
TORCH
T - toxoplasmosis
O - other .e.g HIV
R - Rubella
C - CMV
H - Herpes
What question can we ask if we want to QUICKLY screen for a child development (in history taking)
‘Compared to his/her peers/siblings, how do you think is he/she doing?’
What is the recommended feeding amount for a baby?
Aiming for 150-200 mls/kg per 24 hours
How much ml is 1 ounce (1 oz)?
1 oz = 30 ml
*as parents in the UK will usually give that amount when asked how much they baby feeds/ is there in the bottle
When is the appropriate time for weaning?
Weaning is roughly 6 - 9 months
*in practice it may be even at 4 months - if a child clearly want to try solids etc, no reason to stop them
Mesenteric Adenitis
- characteristics of infection
- type of pathogen likely to cause it
- other symptoms
- management
- enlarged lymph nodes (mostly abdominal ones)
- viral pathogen (possibly same viruses causing cold or flu)
- other possible symptoms: fever, pain, feeling unwell, nausea and vomiting, cold-like symptoms, sore throat
- Management: analgesia (paracetamol, ibuprofen), antibiotics (if other bacterial condition develops), surgical review (to role out appendicitis)
What is a paediatric equivalent to an adult neck stiffness (in meningitis)?
what is a possible diagnosis for these ‘red flag’ symptoms?
- easy bruising
- weight loss/ night sweats
- rapid presentation
- lymph nodes enlarged
Lymphoma/ Leukaemia
What are possible late complications of undetected UTI in children?
- renal scarring
- early onset hypertension *it is also a possible sign of a structural abnormality in renal system
If a febrile child and unsure diagnosis = always check for UTI (urinalysis)
What’s the typical age at which febrile seizures commonly occur?
What stage of the fever do they usually happen?
- 6 months - 6 years
- happen usually at the beginning of the fever
What meds can you give a child in order to relieve their fever?
- Ibuprofen
- Paracetamol
- Calpol
Measles symptoms
- fever
- macular rash
- conjunctivitis
- coryza
- Koplik spots (mouth)
Possible complication of Measles
encephalitis (during the onset of acute illness) -> death
- blindness, deafness
- bacterial pneumonia
Presentation of Scarlet fever
What pathogen is responsible for it?
Scarlet fever (due to group A Streptococcus)
- rash
- strawberry tongue
- bacterial tonsillitis (exudate)
Possible complications of Scarlet fever
- Rheumatic Fever
- Glomerular Nephritis
Treatment of Scarlet Fever
Antibiotic: Penicillin V (oral) for 10 days
Slapped Cheek
- pathogen causing it
- symptoms
- complications
- Parvovirus B19
- symptoms: fever, red cheeks/rash
- complications: usually not dangerous, but dangerous in pregnancy (Hydrops Foetalis - foetal heart failure due to severe anaemia caused by destruction of RBCs)
- What are the characteristics of a common rash in infants with viral illness?
- Do we need to worry about that?
- Characteristics: blanching and macular
- If it’s blanching and a child is otherwise well, no need to worry
What are possible causes of non-blanching rash?
- meningitis
- vasculitis
Characteristics of a chickenpox rash
- vesicular
- different stages
- fever and then rash
Treatment for impetigo
Topical: FuciBET
oral: Flucloxacillin
What’s a possible complication of pre-orbital cellulitis?
What is the best IV treatment option?
Pre-orbital cellulitis -> it can progress to orbital cellulitis (affect vision)
*hospital admission is required
Treatment option: IV cephalosporins
*possible treatment with Vancomycin, Clindamycin, or Doxycycline due to resistance
‘hand, foot and mouth disease’
- what type of pathogen causes it
- does the child need to be isolated?
- what’s treatment?
- viral illness
- it is common in the nurseries - child does not need to be isolated although disease is contagious
- child is usually well
No need for treatment, possible use anaelgesia if painful; should resolve on its own in a week time
Do we give Ibuprofen in chickenpox?
NO - no NSAIDs as that will increase the risk of Necrotising Fascitis
What do we need o to remember about the vaccination schedule (roughly)
- lots of vaccines in 2, 3, 4th months of life
- then when 1 year old
- then yearly vaccine (flu)
- 12-13 girls HPV vaccine
- 14 years ACWY
What are signs of dehydration?
- sunken eyes
- sunken fontanelle (in infants)
- dry mucous membranes (look at the tongue)
- mottled skin/cold extremities
- skin turgor
- prolonged cap refill
- increased HR, poor pulse volume
Where would you manage the child based on ‘Traffic light’ system?
- green
- amber
- red
- green - manage at home
- amber - safety netting (careful planning); possible paeds admission unit
- red - admission to hospital
Why do we worry about a baby that is <3 months old and have a fever of 38C or above?
This age group is likely to show no focal/ localised signs, therefore even a serious illness may not manifest itself clearly
Investigations used in An Infection Screen
- FBC
- blood cultures
- urine culture
- CXR
- stool MC&S if diarrhoea
- LP (especially if unwell and <3 months old with raised WCC
- U&E
- ABG
- glucose
Spot diagnosis: what is this?
Measles
Notes:
Measles -> viral infection
Symptoms:
- Fever, rash (starts head- body), red maculo-papular (red-brown)
- 3C’s (cough, coryza and conjunctivitis)
- Non purulent conjunctivitis
- Pathognomonic sign: Koplik spots (prodromic viral enanthem of measles manifesting two to three days before the measles rash itself.
- Incubation 10 days prior to rash
- MMR live vaccine 13m and prior to school
Complications: encephalitis, pneumonia, hepatitis- disability deafness, blindness
Spot diagnosis: what is this?
Scarlet fever
Notes:
- Children (<10)
- Streptococcal infection (most strep A)
Symptoms:
- fever, sore throat, rash (toxins)
- Strawberry tongue (or white strawberry tongue is coated usually earlier in illness)
- Rash- like sandpaper to touch
Management: Penicillin V 10 days
* Notifiable
Complications: OM, pneumonia, meningitis Later (immune complexes)- RF, GN
Spot diagnosis: what is this?
Parvovirus B19 / Slapped cheek
Notes:
- Usually mild illness
- Age 3-15
Symptoms:
- Rash: bright red to cheeks and can spread to body
- May have non-specific illness
NB - caution if:
- harm to pregnant women (if not had previously- check serum if exposure esp <20 weeks)
Lifelong immunity if infected before
- immunocompromised (possible serious illness) and flare-ups in Sickle-Cell
Spot diagnosis: what is this?
Eczema Herpeticum
Notes:
- HSV1 (cold sores)
- affect pts with underlying inflammatory skin conditions- atopic eczema (when eczema comes to contact with HSV)
- Commonly face and neck (but can be widespread and potentially serious)
Symptoms: rash (sore and itchy), fever, systemic upset and Lymph nodes
*Rash: vesicular/blistering- on normal or inflamed skin)
Treatment: antivirals ASAP - may need admission for IVs
Advice to avoid immunosupressed: very young/old etc (not contagious to those with normal immunity)
What is this?
Roseola
What is this?
Treatment
Kawasaki Disease (may lead to coronary arteries aneurysm)
Investigation to do: ECHO
Treatment: Aspirin (in that case we do not bother about Reye) an immunoglobulin
Criteria for diagnosis of Kawasaki disease
What’s that?
Henoch Schonlein Purpura (HSP)
- an IgA mediated small vessel vasculitis
- usually seen in children following infection
Features
- palpable purpuric rash (with localized oedema) over buttocks and extensor surfaces of arms and legs
- abdominal pain
- polyarthritis
- features of IgA nephropathy may occur e.g. haematuria, renal failure
Tetrad: Rash, abdominal pain, arthralgia, nephritis (+/- diarrhoea, rectal bleeding, haematuria)
Treatment
- analgesia for arthralgia
- treatment of nephropathy is generally supportive. There is inconsistent evidence for the use of steroids and immunosuppressants
Prognosis
- usually excellent, HSP is a self-limiting condition, especially in children without renal involvement
- around 1/3rd of patients have a relapse
What’s that?
Hand Mouth and Foot disease
Notes:
- Viral (enterovirus:- coxsackievirus, enterovirus 71- rare complication is encephalitis)
Symptoms:
Non-specific symptoms- coryzal, cough, anorexia, fever Mouth ulcers Rash- papules and vesicles
- Contagious while unwell
Management: Conservative management
What’s that?
Chicken Pox/ Varicella-Zoster virus
What’s that?
Mumps
Pathogen: RNA paramyxovirus
Clinical features
- fever
- malaise, muscular pain
- parotitis (‘earache’, ‘pain on eating’): unilateral initially then becomes bilateral in 70%
Management
- rest
- paracetamol for high fever/discomfort
- notifiable disease
Complications
- orchitis - uncommon in pre-pubertal males but occurs in around 25-35% of post-pubertal males. Typically occurs four or five days after the start of parotitis
- hearing loss - usually unilateral and transient
- meningoencephalitis
- pancreatitis
What’s that?
Impetigo and bullous impetigo
What is that?
Pre-orbital cellulitis
Notes
- usually children <5 (5-10) (but can affect any age) *in young children the orbital septum not fully developed)
- Infection/inflammation of soft tissues superficial to orbital septum
- orbital function remains in tact
Cause__: Can come from superficial site- insect bite, folliculitis, trauma, can spread from any URTI infection
! in children can be caused by sinusitis
IMPORTANT can rapidly progress to orbital cellulitis involves deeper tissues within orbit- fat and muscles and thus orbital dysfunction= requires urgent admission/imaging/surgical assessment
Complications: abscess, Cavernous Sinus Thrombosis, Intracranial abscess, loss of vision, death
Symptoms: redness and swelling around eye, warmth and tenderness +/- malaise, irritability and fever (caution with fever- think orbital as differential) (less common: pain or visual disturbance).
What’s that?
Meningococcal disease
What’s that?
Meningococcal septicaemia
- a very late sign of a disease
*child is very sick
ABCDE in a sick child
What to look for in A?
Airway – Is it obstructed?eg secretions, foreign body, stridor
ABCDE in a sick child
What to look for in B?
B – Breathing – Is the child struggling to breathe?
Assess respiratory rate, look for recession/accessory muscle use, check oxygen saturation, auscultate the chest
ABCDE in a sick child
What to look for in C?
C – Circulation – Is there evidence of poor circulation?
Assess colour skin, heart rate, capillary refill time (on sternum and fingers/toes), blood pressure, warm or cold hands/feet?
ABCDE in a sick child
What does D mean? What do we assess?
D – Disability – What is the child’s neurological state?
Assess pupil response to light, limb tone and movement, AVPU score/GCS, temperature, glucose, urinalysis
ABCDE in a sick child
What does E mean? What do we assess?
E – Exposure – Have you exposed the child and examined top-to-toe?
Rashes – viral rash, infectious disease rash, non-blanching rash (septicaemia?)
Any evidence of injury/trauma
What signs to look for in an abdominal examination of an unwell child?
Tummy – Is this soft? Distended? Tender? What are the bowel sounds like? Any masses?Any hernias?(In boys, never forget to examine the testis - testicular torsion = surgical emergency)
What antipyretics would you use in a child ?
Antipyretics if a child is distressed:
o Paracetamol
o Ibuprofen
*Do not use both antipyretics together routinely (change agents if one isn’t working)
Should you use Ice or cold bath in a child with a fever?
Do not use cold water baths or ice (shivering can increase basal body temperature)
Safety netting advice for a child with a fever
Safety Netting: When to seek further advice
- Seizure
- Non-blanching rash
- Parents/carer feel child is worsening
- Fever >5 days
What medications and when give to a child with a seizure?
- rectal diazepam repeated once after 5 minutes if the seizure has not stopped
- or one dose of buccal midazolam
When to do ‘infection screen’ on a child with a fever?
The following children will require an infection screen in hospital:
- All children < 3 months old with fever
- Fever without apparent source and red or amber criteria on NICE Traffic Light System
- Any child with red criteria on NICE Traffic Light System
What investigations does ‘Infection Screen’ consist of?
- FBC
- Blood Cultures
- CRP
- Urine Culture
- CXR
- Stool MC&S if diarrhoea
- Lumbar puncture (especially in unwell <3month old who are unwell with raised WCC)
- U&E
- ABG
Orbital Cellulitis
- symptoms
Symptoms: Ptosis, orbital pain (can be severe-compartment syndrome), visual disturbance/loss, proptosis, chemosis, fever, headache, systemic symptoms, ( uncommon: vomiting, altered consciousness consider meningeal involvement)
Orbital Cellulitis
- investigations
- management
Investigations: FBC, swab, Ct sinus/orbits or MRI, LP
Management: Po co-amoxiclav, IV cephalosporin (plus flucloxacillin and or metronidzole – covering for staph and anaerobes).
Alternatives (if Penicillin allergy): include clinadmycin and quinolone
When is LP contraindicated in a picture of meningitis?
LP contraindicated in the face of widespread purpura, severe coagulopathy and cardiovascular shock
What are contraindications to giving a vaccine?
Confirmed anaphylaxis to a previous dose (or a vaccine with the same antigen) or to a component of the vaccine (eg neomycin, streptomycin, polymyxin B in some vaccines)
Influenza and yellow fever: confirmed anaphylaxis to egg
Who should not receive a live vaccine?
- pregnant women
- immunocompromised
- timing frame with receiving another life vaccine
Croup
- pathogen
- symptoms
- management
Pathogen: Para-influenza virus (RSV next common)
Symptoms: barking cough, stridor, hoarse voice
Management:
A. Symptomatic: Paracetamol, Ibuprofen, fluids
B. Steroids (single, oral dose) e.g. Dexamethasone
Viral URTI
- pathogen (common)
- symptoms
- management
Pathogen: Rhinovirus
Symptoms: cough (green sputum), sneezing, sore throat, hoarse voice
Management:
Symptomatic - Ibuprofen, Paracetamol ,fluids
* use CENTOR criteria to assess for the need of antibiotic treatment
UTI
- pathogen
- symptoms/investigation finding
- management
Pathogen: E.Coli
Investigations: Nitrites + Leucocyte on urinalysis
Symptoms: abdominal pain, hematuria, burning pain on passing urine
Management:
A. Send the sample - Clean catch urine sample or MSU
B. Antibiotics
Tonsillitis
- pathogen
- presentaiton
- management
Pathogen: Group A beta-haemolytic streptococcus
* often viral
Presentation: Exudates (bacterial), tender cervical lymphadenopathy, sore throat, absence of a cough
*use CENTOR criteria to assess if bacterial and if Abx needed
Management:
symptoms relief by Ibuprofen or Paracetamol; Abx depends on if bacterial or not
