Fever Flashcards
What are the 2 categories of fever?
- Fever with known source (focal infection)
2. Fever of unknown origin (FUO)
What is the criteria for fever?
- Fever in neonate ( 38 oC (100.4 oF)
What is the pathophys of fever?
- Fever occurs as a result of rise in hypothalamic set point
A. Endogenously produced pyrogens release prostaglandins
What are the conditions that can cause fever?
- Infections
- Malignancies
- Autoimmune disorders
- Metabolic diseases
- Immunizations / Medications
- CNS abnormalities
- Exposure to excessive heat
What are the key points to remember for fever?
- Advocate for immunizations
- Check the urine, it is a more common source than you may realize
- Reassure parents that fevers are one of our bodies best defenses against infection and are usually a GOOD thing
How do the different modes of temperature measurements differ?
- A RECTAL (it hurts the parents more….) temperature of 100.4 F or 38 C
- Oral temps vary by 1 degree F (0.6 C)
- Axillary temps vary by 2 degrees F (1.1 C)
- Tympanic thermometers are often as accurate as rectal temps
When are tympanic thermometers NOT indicated?
- Not reliable enough to use in neonates and infants
What are the benefits of a fever?
- Alters the optimal growth environment for microbe replication
- Simulates further immune activity to fight infection
- Fever induced anorexia reduces glucose availability for microbes
Define herd immunity
- Herd immunity (when a critical mass of the population is immunized so that certain microbes do not circulate around that group…)
- It protects the few uncovered people in the population to a large extent.
- If a critical number of unimmunized people are around, certain microbes can have a resurgence or “outbreak”
What are the potential vaccine reactions?
- dTap can cause fever for up to 48 hours post vaccination
- MMR can cause fever 7-10 days post vaccination
- In well-appearing infants who just received their 2 or 4 month shots and present with fever, you may elect to do blood/urine testing or close outpatient monitoring WITHOUT testing
What are the most common source of fever in infants over 3 months?
Viruses
What are common bacterial infection sources?
- UTI’s (always consider the urine in an infant/child with fever and no source)
- Otitis media
- Pneumonia
What conditions do toddlers and infants NOT usually get?
- Strep throat
- Sinusitis
- Bronchitis
When must children with a fever be seen immediately?
- Infant 100.4 F
- Temp > 40.6 C at any age
- Crying inconsolably or whimpering
- Crying when moved or even touched
- Difficult to awaken
- Stiff neck
- Petechial rash
- Respiratory difficulty
- Drooling and is unable to swallow anything
- Seizures
- Hx sickle cell disease, splenectomy, HIV, chemotherapy, organ transplant, chronic steroids
- Looks “very sick”
What are pertinent components to a hx for fever?
- Duration of fever
- Type of thermometer used
A. Oral, axillary, tympanic, rectal
B. Rectal > tympanic > oral > axillary - Range of fever
- Associated sxs
- Chronic medical conditions
- Meds taken
- Allergies
- Fluid intake
- Urine output
- Exposures
- Travel hx
What is included in the physical exam for a fever?
- General appearance
- Vitals
A. Temperature
B. HR
C. RR
D. SO2
E. BP - Fontanelles
- Skin/Scalp
- Eyes
- Sinuses: age > 5-6
- Oropharynx
- Neck
- Cardiac
- Resp
- Abd
- MSK
- GU
- Neuro
A. Level of consciousness
B. Pupils
C. Reflexes
D. Moving extremities
E. Muscle tone
F. Muscle strength
G. Kernig / Brudzinski
What do the dx studies for a child with a fever depend on?
1. Overall appearance A. Toxicity, hydration 2. Physical exam findings 3. Age* A. Less than 3 months = septic workup 4. Underlying medical conditions 5. Suspected etiology of fever
How is a pt with a fever managed?
- Most children can be treated in outpatient setting:
A. Viral infections
B. Focal bacterial infections - Some children may require inpatient treatment
What does treatment of a fever include?
- Fever control measures
A. Acetamenophen = 15mg/kg per dose q 6-8 hrs
B. Ibuprofen = 10mg/keg per dose q 6-8 hrs - Hydration
- Antibiotics if bacterial origin
True/false: you should order labs to reassure yourself that a kid with a fever is healthy
False
1. Ordering lab tests to make yourself feel better about a kid should not be reassuring
A. Meningitis often does not present with an elevated WBC count on CBC
B. Normal lab studies should not at all reassure you about a neonate with a complaint
True/false: every child with a fever should be treated?
- False
2. The American Academy of Pediatrics does NOT recommend treating fever in most kids!!
True/false: temp of the fever is indicative of severity of infection
- How high a fever gets does NOT necessarily mean that there is a more severe infection.
- IT DOES NOT distinguish between viral and bacterial causes
How does your body temperature change throughout the day?
- Your brain very closely regulates body temperature keeping it between 97 and 100 degrees
- Your body temperature CHANGES THROUGHOUT THE DAY (peaking in late afternoon)
When are fevers dangerous?
- Kids with overwhelming disease or poor cardiac/respiratory reserve (i.e.- when the increased metabolic demand of a fever may be too taxing)
- Kids who have seizure disorders who have difficult to control seizures in the presence of fever (the seizure threshold is lower with fever)
- A sick looking kid should be more concerning than the actual temperature
What special populations need extra attention when they have a fever?
- Immunocompromised kids
- Kids with a seizure disorder
- Neonates
- Kids with congenital malformations (kidney’s, heart, etc) or adrenal insufficiency
- Unimmunized kids
True/false: antipyretics prevent febrile seizures
- False
- Nothing helps really, except anticonvulsants which are more harmful than beneficial in kids with simple febrile seizures
- With very worried parents or more severe cases, you may consider having Diastat at home for prevention at illness onset
How do you address a fever that isn;t reducing with meds?
This does not suggest a worse or more worrisome infection. It just means that your child’s body is still fighting off the infection
What does a neonate with a bacterial infection require?
- Even any bacterial infection identified in an afebrile neonate requires a full septic work up!!
- Neonates with any bacterial infection generally disseminate that infection rapidly…If they have an otitis, it will end up in their blood and meninges soon enough
What is the chance of developing bacteremia with a fever in a neonate?
- 10%
A. This number DOES NOT CHANGE if there is clinical or documented RSV positive bronchiolitis!
B. Get your supplies and do a full sepsis quickly. Give antibiotics and admit them.
What is the chance of developing bacteremia with a fever in a neonate with low risk criteria?
Even meeting low risk criteria (clean tap, CBC, negative U/A, etc) it is still 5%
What common organisms can cause fever/bacteremia?
Group B Strep, E coli, Listeria, Enterococcus
True/False: Urinalysis is a good screen for UTI in neonates and culture is unnecessary.
False. 20% of culture positive UTI’s in neonates have a COMPLETELY NORMAL U/A!!!
What makes an infant high risk for bacteremia?
- Prematurity
- Any antibiotic administration since birth
- History of unexplained jaundice
- Any re-hospitalization
- Chronic disease
- Hospitalized for longer duration than mother following birth
- Maternal perinatal fever
- Lack of follow up/ unreliable caretakers
- Evidence of bacterial infection on physical examination (except AOM)
- Laboratory evaluation
A. WBC >15k or 1500
D. Spun urine >5 WBC/hpf
What is the most common source of fever in neonates?
Viral
What is the less common sources of fever in neonates?
1. UTI A. E coli 2. Meningitis A. E coli, Grp B Strep, Listeria monocytogenes 3. Skin / soft tissue infections A. Staph aureus 4. Bacteremia A. Grp B Strep, E coli
What are the hx components for a neonate with a fever?
1. Mood / behavior A. Irritability, feeding, activity 2. Associated sxs A. Resp, GI 3. Exposure to sick contacts 4. Siblings, babysitters, daycare 5. Previous illness 6. Abx use 7. Birth hx A. Maternal fever B. Mom’s Grp B Strep status C. Maternal hx STD’s D. Prolonged rupture of membranes E. Nursery hx
What are the pe components for a neonate with a fever?
- Vital signs
- Appearance
A. Irritability
B. Inconsolability
C. Poor perfusion
D. Poor muscle tone
E. Decreased activity
F. Lethargy - Signs of localized infection
- Limb swelling or inflammation
- Skin / mucus memb lesions
What dx studies need to be performed for a neonate with a fever?
1. WBC count A. low risk for serious illness 2. Blood culture A. Always obtain in infant less than 90 days old 3. U/A 4. Ur C & S 5. Stool C & S A. If blood and mucus in stool B. Infant with diarrhea 6. Lumbar Puncture is indicated when: A. Age 28 days or less B. Ill appearing C. High risk for bacterial infection D. Prior to administration of empiric abx E. Invasive infection: Cellulitis, abscess F. Seizures 7. CSF Analysis A. Cell count B. Glucose C. Protein D. Bacterial culture E. Viral studies (culture & PCR) If sxs suggest viral meningitis 8. CXR A over 50 breaths/min B. Rales, rhonchi, wheezing C. Intercostal retractions D. Grunting E. Stridor F. Nasopharyngeal flaring G> Cough
When is a lumbar puncture indicated in a neonate with a fever?
- Age 28 days or less
- Ill appearing
- High risk for bacterial infection
- Prior to administration of empiric abx
- Invasive infection
- Cellulitis, abscess
- Seizures
How is the CSF analyzed?
- Cell count
- Glucose
- Protein
- Bacterial culture
- Viral studies (culture & PCR)
A. If sxs suggest viral meningitis
How is a neonate with a fever managed?
1. Obtain following studies regardless of clinical appearance: A. CBC w/ diff B. Blood cultures C. U/A & Urine culture D. CSF culture 2.. CXR A. If signs or sxs of resp illness 3. Require inpatient treatment A. Includes empiric abx
What is the emperic tx for neonates with a fever?
- Abx Therapy
A. Ampicillin and cefotaxime
B. Ampicillin and gentamicin
-Provides empiric coverage against pathogens common in this age group:
-Grp B Strep, E coli & other gram neg bact, enterococcus, Listeria monocytogenes - Acyclovir
A. Indicated in ill appearing neonates with mucocutaneous vesicles and maternal hx genital HSV
How are ill appearing infants under 3 months, well appearing infant 30-60 days, ill appearing 61-90 days, months managed?
1. Obtain following studies regardless of clinical appearance: A. Blood cultures B. Urine culture C. CSF culture 2.CXR A. If signs or sxs of resp illness 3. Require inpatient treatment A. Includes empiric abx
What are the emperic tx for a febrile infants 1-3 months?
- Empiric abx therapy to include 2 classes of abx:
A. Cefotaxime or Ceftriaxone - Additional abx added based on RF, hx, physical exam:
A. Ampicillin: Listeria coverage up to 8 weeks of age
B. Vancomycin
-Soft tissue infections, Strep pneumoniae meningitis not suseptible to cephalosporins
-All infants 29-60 days of age
How are well appearing infants 29-60 days treated?
- Empiric abx therapy
A. Ceftriaxone
How are ill appearing infants 61-90 days treated?
- Empiric abx therapy
A. Ceftriaxone
How are well appearing infants 61-90 days with a fever managed?
1. Obtain following studies regardless of overall appearance: A. CBC w/ diff B. Blood cultures C. Urine culture 2. CSF Analysis A. Indicated if WBC 15,000 3. CXR A/ If signs or sxs of resp illness 4. Outpatient treatment A. Includes empiric abx
How are well appearing infants 61-90 days treated?
- Empiric abx therapy
A. Ceftriaxone
What are the discharge criteria for neonates?
A minimum of 48 hours must pass after obtaining negative cultures before discharging neonates
What are the discharge criteria for infants > 28 days?
If appear well, can be discharged 36 after after obtaining negative cultures
What is the criteria for FUO?
- Fever > 38.3C (101F)
- Minimum 8 days duration
- No apparent diagnosis
What are the mc causes of FUO?
- Evaluation of FUO usually begins as an outpatient
- FUO usually caused by common disorders, often w/ unusual presentation
- 3 most common etiologic categories of FUO in children are infectious diseases, connective tissue diseases, and neoplasms
What asst sxs may be present with FUO?
Associated sxs Red eyes Nasal discharge Pharyngitis N/V/D Rash Bone pain
How is FUO treated?
- Treat source of fever once identified
2. Referral to peds rheumatology, peds cardiology, peds GI, etc.
Define an incompletely immunized pt?
- Incompletely immunized means that they have not received their primary series of 2, 4, and 6 month vaccines
- Therefore, any infant under age 6 months, by definition, is incompletely immunized
What is the mc cause of fever in an immunized child over 6mo?
- Most commonly viral etiology of fevers
2. At significantly lower risk of SBI (
When should UTIs be suspected in males?
- Check urine studies in all boys under 6 months with fever and no source
- Check urine in uncircumcised males up to 12 months of age
- After 12 months of age, consider on a case by case basis
