Fever in Pediatrics

Question 1

Definition of pediatric fever

Answer 1

over 38ºC or 100.5F

Question 2

2 Endogenous pyrogens important in fever:

Answer 2

IL1 IL6

Question 3

Site of fever regulation: Effect of infection Effect of hypothalamic injury

Answer 3

Hypothalamus regulates core temperature infections alter this set point hypothalamic injury can cause erratic control

Question 4

Hyperpyrexia =

Answer 4

purposeful temp. elevation ≥ 41.5 C

Question 5

Hyperthermia =

Answer 5

uncontrolled temperature elevation

Question 6

Role in treating fever specifically:

Answer 6

May help control febrile seizures

Question 7

Common Viral and Bacterial Febrile Infections:

Answer 7

Viral = URI (e.g., RSV, influenza), GI (e.g., rotavirus), enteroviruses Bacterial = otitis media, strep pharyngitis, sinusitis, pneumonia

Question 8

Issue with treating pediatric fevers:

Answer 8

Infections and management vary tremendously by age.

Question 9

“the febrile infant” =

Answer 9

0-56 days

Question 10

The febrile infant is a risk of serious bacterial infections, such as:

Answer 10

bacteremia meningitis UTI bacterial enteritis skin/soft tissue infection bone/joint infections

Question 11

Signs and symptoms of febrile infant:

Answer 11

fever irritability lethargy poor feeding resp. distress N/V NO SYMPTOMS!

Question 12

Common organisms under <30 days:

Answer 12

E. coli GBS Listeria

Question 13

HSV 1 and 2 may also produce severe infection if…

Answer 13

infant is < 21 days old

Question 14

Work-up and management of febrile infants 0-28 days old:

Answer 14

ABX + anti-virals started and all get septic work-up → CBC, UA, UCx, BCx, LP, CXR if respiratory symptoms

Question 15

Work-up and management of febrile infants 29-56 days old:

Answer 15

Philadelphia Criteria:

• Needs reliable caregiver and ability to f/u at 24 hours in ED
• Low-risk criteria: if met, can be f/u as outpatient and NO ABX!
  
  • PE: well-appearing and w/out focus of infection
  • Hx: normal past history and normal perinatal hx
  • Lab criteria:
    
    • WBC 5-15K
    • Immature to total (I/T) ratio < 0.2
    • UA < 10 WBC/hpf + (-) gram stain
    • CSF < 10WBC/hpf + (-) gram stain
    • CXR w/o infiltrate

Question 16

“Febrile Young Child” =

Answer 16

2-36 months old

Question 17

2 most common causes of fever in ages 2-36 months:

Answer 17

Occult bacteremia

Occult UTI

Question 18

Occult bacteremia in child 2-36 months:

1. Common organisms:
2. Specific sub-pops with higher incidence
3. Management?

Answer 18

1. Hib and S. pneumo
2. Kids younger than 36 months and with a fever over 39C
3. Manage w/ WBC, absolute neutrophil count, blood culture and treat with empiric ABX

Question 19

Occult UTI in child 2-36 months:

1. Common organisms
2. What is commonly the only presenting symptom:
3. Possible sources of infection:
4. Risk factors for developing UTI
5. Sensitivity for dx UTI if >3 risk factors are present?
6. Role of circumcision
7. Which urine should you test?
8. Tests to run on urine?
9. Treatment for gram (-) enterics?

Answer 19

1. E. coli, enterococcus, gram (-) enterics
2. Fever is often only presenting sign
3. Can occur despite source of otitis, URI, or gastroenteritis
4. Risk factors:
   
   • Caucasian > Latino > AA
   • age ≤ 12 months
   • fever ≥ 39C
   • duration of fever ≥ 2 days
   • no source of fever
5. 88% sensitivity
6. 10x risk increase in uncircumcised males
7. Test catheterized or suprapubic urine only
8. UA, urine dipstick, urine cxs
9. cefixime, TMP-SMX

Question 20

Criteria for positive findings of urine analysis for child with UTI:

Answer 20

Dipstick is + for nitrites and +/- leukesterase

Microscopic UA has >10-15 WBC/hpf

Question 21

At what age is fever in pediatrics similar to that of adults?

Answer 21

> 3 yrs

Question 22

Fever in kids over 3 yrs

Overwhelming majority caused by:

Dx tests:

Answer 22

Most caused by viruses

If pharyngitis - rapid strep tests

Dysuria - UA and cultures

Tachypnea - lung auscultation, if there are rales do CXR