Fever as a PC in children

Question 1

What is the most common diagnosis in febrile children?

Answer 1

Most febrile children have a brief, self-limiting viral infection. Mild localized infections, e.g. otitis media or tonsillitis, may be diagnosed clinically.

Question 2

What is the clinical problem when assessing febrile children?

Answer 2

The clinical problem lies in identifying the relatively small proportion of children with a serious infection which needs prompt treatment.

Question 3

How is the temperature measured in children at hospitals?

Answer 3

In the hospital, it is measured: if less than 4 weeks of age, by an electronic thermometer in the axilla, if aged 4 weeks to 5 years, by an electronic or chemical dot thermometer in the axilla or infrared tympanic thermometer.

Question 4

What is fever in children?

Answer 4

A fever in children is a temperature over 37.5° C. In general, axillary temperatures underestimate body temperature by 0.5° C

Question 5

What is the septic screen?

Answer 5

Septic screen- blood culture, FBC inc wbc, CRP, Urine sample. Consider CXR, LP and PCR for viruses.

Question 6

Why is fever dangerous in infants?

Answer 6

Febrile infants less than 3 months of age can present with nonspecific clinical features and have a bacterial infection, which cannot be identified reliably on clinical examination alone.

Question 7

Why is it less likely for febrile infants to have viral infections?

Answer 7

During the first few months of life infants are relatively protected against common viral infections because of passive immunity acquired by transplacental transfer of antibodies from their mothers.

Question 8

What should you do if a clear cause of fever is unidentified in febrile infants?

Answer 8

Unless a clear cause for the fever is identified, they require urgent investigation with a septic screen and broad-spectrum intravenous antibiotic therapy given immediately to avoid the illness becoming more severe and to prevent spreading of the infection to other sites of the body.

Question 9

Risk factors for infection in children

Answer 9

1) Illness of other family members.
2) Specific illness prevalent in the community.
3) Lack of immunizations.
4) Recent travel abroad (consider malaria, typhoid, and viral hepatitis).
5) Contact with animals (consider brucellosis, Q fever, and haemolytic uraemic syndrome caused by Escherichia coli O157).
6) Increased susceptibility from immunodeficiency. This is usually secondary, e.g. post-autosplenectomy in sickle cell disease or splenectomy or nephrotic syndrome resulting in increased susceptibility to encapsulated organisms ( Streptococcus pneumoniae , Haemophilus influenzae , and Salmonella species), or rarely, primary immunodeficiency. In countries with high prevalence of HIV infection, undiagnosed HIV infection in the child must be considered.

Question 10

What are the red flag features in febrile children?

Answer 10

Red flag features include: fever over 38, colour- pale, mottled or cyanosed, level of consciousness is reduced, neck stiffness, bulging fontanelle, status epilepticus, focal neurological signs, or seizures, significant respiratory distress, bile-stained vomiting, severe dehydration or shock.

Question 11

Associated symptoms of fever

Answer 11

Rashes often accompany febrile illnesses. In some, the characteristics of the rash and other clinical features lead to a diagnosis, e.g. a purpuric rash in meningococcal septicaemia; in many, a specific diagnosis cannot be made clinically.

Question 12

How does meningococcal disease present?

Answer 12

Consider meningococcal disease in any child with fever and a non-blanching rash, particularly if any of the following features are present:
• an ill-looking child
• lesions larger than 2 mm in diameter (purpura)
• a capillary refill time of 3 seconds or longer
• neck stiffness.

Question 13

How does baterial meningitis present in a child?

Answer 13

Consider bacterial meningitis in a child with fever and any of the following features:
• neck stiffness
• bulging fontanelle
• decreased level of consciousness
• convulsive status epilepticus.
• Be aware that classic signs of meningitis (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants with bacterial meningitis.

Question 14

How does herpes simplex encephalitis present in a child?

Answer 14

Consider herpes simplex encephalitis in children with fever and any of the following features:
• focal neurological signs
• focal seizures
• decreased level of consciousness.

Question 15

How does pneumonia present in a child?

Answer 15

Consider pneumonia in children with fever and any of the following signs:
• tachypnoea (respiratory rate greater than 60 breaths per minute, age 0–5 months; greater than 50 breaths per minute, age 6–12 months; greater than 40 breaths per minute, age older than 12 months)
• crackles in the chest
• nasal flaring
• chest indrawing
• cyanosis
• oxygen saturation of 95% or less when breathing air.

Question 16

How does UTI present in a child?

Answer 16

Consider urinary tract infection in a child aged 3 months or older with fever and 1 or more of the following:
•	vomiting
•	poor feeding
•	lethargy
•	irritability
•	abdominal pain or tenderness
•	urinary frequency or dysuria.
•	Consider urinary tract infection in any child younger than 3 months with fever.

Question 17

How does septic arthritis/osteomyelitis present in a child?

Answer 17

Consider septic arthritis/osteomyelitis in children with fever and any of the following signs:
• swelling of a limb or joint
• not using an extremity
• non-weight bearing.

Question 18

How does Kawasaki disease present in a child?

Answer 18

Be aware of the possibility of Kawasaki disease in children with fever that has lasted 5 days or longer. Additional features of Kawasaki disease may include:
• bilateral conjunctival injection without exudate
• erythema and cracking of lips; strawberry tongue; or erythema of oral and pharyngeal mucosa
• oedema and erythema in the hands and feet
• polymorphous rash
• cervical lymphadenopathy.
• Ask parents or carers about the presence of these features since the onset of fever, because they may have resolved by the time of assessment.
• Be aware that children under 1 year may present with fewer clinical features of Kawasaki disease in addition to fever but may be at higher risk of coronary artery abnormalities than older children.