Fever in Children (incl. Sepsis)

Question 1

What features of a febrile illness are not predictive of the serious nature of the illness?

Answer 1

Degree of fever, rapidity of onset, response to antipyretics and febrile convulsions

Question 2

What are 5 things to consider in children with fever to help risk stratify them?

Answer 2

(1) Their colour, (2) Level of activity, (3) Respiratory signs, (4) Hydration, (5) Other

Question 3

List high risk features in paediatric fever.

Answer 3

Colour: pale, mottled, blue, ashen
Activity: no response to social cues, appears toxic, does not wake when roused, does not stay awake, weak/high-pitched crying
Respiratory: grunting, RR > 60, retractions
Hydration: reduced skin turgor
Other: non-blanching rash, bulging fontanelle, meningism, seizures, bilious vomiting, higher temp (>38 in <3 months, >39 in 3-6 months old)

Question 4

What are the main sources of infection to consider in infants?

Answer 4

Respiratory, meningeal, bacteraemia, bone + joint, skin/soft tissue, urinary, ENT

Question 5

What is the work-up for a child who has a corrected age infant <1 month (weighs <3.5 kg) + temperature of >38.

Answer 5

Full septic work-up: FBE, blood cultures, urine MCS (SPA), LP +/- CXR (if respi signs).
Admit for IV abx

Question 6

What is the work-up for a child who has a corrected age of 1-3 months + temperature of >38.

Answer 6

Full sepsis work-up: FBE, blood cultures, urine MCS. Consider LP and CXR (if respi signs).

Question 7

Discuss the disposition for a child who has a corrected age of 1-3 months + temperature of >38.

Answer 7

Discharge home with review within 12 hours (in ED/GP) if:

• previously healthy child who looks well
• WCC 5-15
• urine microscopy/CXR/LP clear

Admit for observation +/- empirical abx if child is unwall or any of the above criteria re not satisfied.

Question 8

Discuss the management of children > 3 months with a fever of >38 degrees.

Answer 8

Well-appearing: urine MCS (SPA is < 12 months or consider in-out IDC/clean cath). Discharge home with antipyretics PRN, medical review in 24 hours (or sooner).

Toxic child: full work-up (FBE, cultures, urine MCS, consider LP/CXR), admit for observation +/- empirical abx

Question 9

What are the empirical antibiotics for an infant <1 month (*RCH new) who presents with bacteraemia?

Answer 9

Cefotaxime 50 mg/kg and benzylpenicillin 60 mg/kg IV

Question 10

What are the empirical antibiotics for an infant <2 (*RCH new) month who presents with meningitis?

Answer 10

Amox/ampicillin/benzylpenicillin 50 mg/kg Q6H and cefotaxime 50 mg/kg Q6H

Question 11

In what children is ceftriaxone avoided?

Answer 11

In neonates, particularly if <41 weeks gestation, jaundiced or receiving calcium containing solutions (incl TPN)

Question 12

What are the empirical antibiotics for an infant > 2 month who presents with meningitis?

Answer 12

Ceftriaxone 50 mg/kg/dose (2g) IV Q12H
AND
Dexamethasone 0.15 mg/kg IV 6 hourly for 4 days

Question 13

What are the empirical antibiotics for an infant > 1 month who presents with bacteraemia?

Answer 13

Cefotaxime or ceftriaxone 50 mg/kg (max 2 grams) and flucloxacillin 50 mg/kg (max 2 grams) IV

This regime assumes meningitis cannot be excluded.

Question 14

What are the commonest organisms to cause sepsis in infants <3 months old?

Answer 14

E. coli, GBS.
Listeria is uncommon

Older infants: chlamydia and Bordetella pertussis more common.

Question 15

What are the commonest organisms to cause sepsis in older children?

Answer 15

N. meningitidis, S. pneumo, S. aureus, GAS, MRSA.

Mycoplasma >5 years

Question 16

Compare and contrast cold and warm shock in children.

Answer 16

Cold: narrow pulse pressure, prolonged cap refill. Underlying abnormal haemodyamics driven by myocardial dysfunction. More common in infants and neonates.

Warm shock: wide pulse pressure, driven by vasoplegia, rapid cap refill. More common in older children and adolescents.

Question 17

In tropical areas what infection should be considered in children and how is this treated?

Answer 17

Meliodosis; treat with meropenem.

Question 18

How is acyclovir dosed?

Answer 18

20 mg/kg IV Q8H (<3 months)

10 mg/kg IV Q8H (3 months - 12 years)

Question 19

What is the benefit of giving steroids in meningitis in children?

Answer 19

May reduce the risk/amount of hearing loss

Question 20

What are the two organisms that cause meningitis that we give benzylpenicillin for?

Answer 20

N. meningitidis, S. pneumoniae (pen sensitive)

Question 21

Why do we give ceftriaxone in meningitis? What organism does this cover?

Answer 21

HiB