Week 1 - Pediatric Fever Flashcards
Temperature of a fever
>= 100.4F or 38C
Accurate temperature measurement in children
Rectal thermometer in children < 3 y.o.
Oral thermometer in children > 5 y.o.
Axillary, temporal, tympanic thermometers are less accurate
Age stratification
Neonates?
0-28 days (4 weeks)
Age stratification
Young infants?
29 - 90 days (approx 3 months)
Age stratification
Young child?
3 months - 3 years
Normal rectal temperature range
- 9-100.2F
(36. 6-37.9C)
Goal of fever
mechanism utilized by the body in fighting infection–retards reproduction of bacteria and viruses; enhances neutrophil production and T-lymphocyte proliferation; aids in body’s acute reaction
T/F Degree of fever correlates with severity of illness
False. The general appearance is a stronger indicator. So a low temperature does not negate a serious bacterial illness.
Goal of fever mgmt
Improve child’s comfort so they can follow plan of care
Physiology of fever
Infection induces macrophages to release cytokines that function as endogenous pyrogens to circulate to anterior hypothalamus; the hypothalamus then increases the levels of prostaglandin E2 which raises the core temperature set point
Fever mgmt recs: When?
Utilize when temp is > 102F (likely bacterial) or persistently > 101F
Fever mgmt recs: How? Pharm vs non pharm
- Non-pharmacological -
- hydration
- appropriate clothing and ambient temp
- tepid water baths for temp > 104F
- Do not allow shivering
- Never use alcohol or ice baths
- Pharm mgmt -
- acetaminophen 10-15 mg/kg/dose q 4-6 hours (FIRST LINE)
- ibuprofen (children age 6+ months)
- Temp < 102.5F: 5 mg/kg/dose q 6-8 hours
- Temp >=102.5F: 10 mg/kg/dose q6-8 hrs
- No aspirin, no naproxen
- alternating acetaminophen and ibuprofen may increase risk of med error/toxicity
Causes of fever in neonates (2)
Congenital or acquired infections
1) late onset group B strep
2) acquired anatomic or physiologic dysfunction, i.e. renal
Causes of fever in all children (11)
- bacterial, fungal, parasitic, or viral infections
- vaccines
- biologic agents
- tissue damage
- malignancy - neoplasms
- drugs
- collagen-vascular disorders
- endocrine disorders
- inflammatory disorders - teething
- environmental - heat stroke
- if temp > 105.8F - likely CNS dysfunction such as malignant hyperthermia, drug fever, heat stroke
infants with meningitis don’t present with?
nuchal rigidity
do thorough neuro exam, fontanelles,
Definition of fever without a focus/source
- Acute fever of unknown etiology after examining child that is < 24 months
- < 24 months = higher risk for SBI, esp < 3 months old = need workup
Most infants < 90 days have causative agent as ________, however, still need to rule out _____ disease so require a _____ work-up.
- Viral
- Bacterial
- Sepsis
Birth - 2 years: Greatest risk of unsuspected occult bacteremia w/ E. coli. What are common SBIs with no clinical sx’s? (3)
- UTI
- PNA
- bacteremia
Any child < 3 years old who is ill-appearing should have the following tests…(10)
- CBC w/diff
- Glucose
- CRP
- PCT
- blood cultures
- CSF testing
- UA and culture
- CXR
- Stool cx if diarrhea with blood or mucus in stool
- If in season, rapid testing for influenza/RSV/enterovirus
Red Flags - Infants who need to be admitted to the hospital and for serious bacterial infections: (16)
- Prematurity
- Underlying health conditions
- Parents are unreliable historians and/or caretakers
- Ill or toxic-appearing
- Skin color is ashen, blue, mottled, or pale
- Lethargic, weak
- High-pitched cry, decreased response
- Poor feeding
- tachypnea or tachycardia
- Chest/abdominal retractions
- Petechiae
- Seizure
- Capillary refill > 3 seconds
- decrease UO
- Bulging fontanel
- Non-blanching skin rash
Subjective data – Associated symptoms - all children (7)
- Current level of activity/lethargy
- Activity level prior to fever onset
- Current eating and drinking pattern
- Eating or drinking pattern prior to fever onset
- Apperance
- Vomiting or diarrhea
- Urinary output
evaluation of fever in young infants 29-60 days (1-2 months)
- ill appearing, get:
- septic workup, admit
- healthy appearing, get:
- CBC/diff
- Blood culture
- UA and urine culture
- PCT
- CRP
- CXR if signs of respiratory symptoms/not clearly bronchiolitis
- if low criteria [well appearing, full term, no system anti, normal labs etc]:
- sent home with strict f/u in 12-24 hrs, seek care if worsens, or if culture is +, if unreliable caretakers
- high criteria:
- Admit and further workup
evaluation of fever in 60-90 day (2-3 month) infant
- if ill appearing = sepsis workup, admit
- if healthy appearing, get:
- CBC/diff
- Blood culture
- UA + culture
- PCT
- if immunized in past 24 hrs & temp < 101.5F, never mind!
all infants this age that has fever need urinalysis
all infants < 3 months to rule out UTI
Subjective data - Current medications - all children (2)
- Immunization history (esp. recent immunizations)
- Meds used to treat fever, illness
ROS (7 areas)
- General appearance
- HEENT - conjunctivitis, swollen nodes, ear pain
3, Respiratory - RR, wheezing, crackles, retractions, cough, shortness of breath
- Cardiac - HR, chest pain
- GI - appetite, wt. loss, n/v/d
- GU - voiding pain, frequency
- Neuro - any changes in LOC, activity level
Objective Data - all children (3)
- Vital signs - BP, HR, RR, rectal/oral temp, percentiles
- Weight - kg
- Broselow tape
Subjective data - Past Medical History of Neonates
- Prenatal, perinatal, and neonatal history
- Intrapartum fever
- Maternal strep group B status
4, Postnatal care
- Family hx of death of young infant from infection - any anomalies? immunodeficiency?
Physical Exam - Neonates (3 areas)
Hands-off or Pediatric assessment triangle:
- General appearance and level of interaction
- Work of breathing
- Circulation to skin
Young infants - work-up
All to be done in ER, w/u same except not full sepsis with low-risk factors; can be discharged home with f/u in 12-24 hours; will be admitted only if caregivers unable to provide follow-up and/or care
Inflammatory markers
- CRP (normal < 2 mg/DL - better sensitivity and predictive value than WBC
- PCT (normal < 0.5 ng/mL) higher cost, reduced availability, delay in availability of results
Past medical history for Young children 3 months - 36 months (3)
As for neonates and very young infants plus:
- identify previous infectious episodes/risk factors for SBIs
- Incomplete immunization against strep pneumoniae or H flu b
- Neonatal and perinatal history if younger than 9 months
Social history for young children (3 months - 3 years) (4)
- Exposure to contaminated drinking water/sewage
- Recent travel (particularly international travel)
- Attendance at daycare
- Exposure to sick individuals outside of the household
Definition: fever of unknown origin
- 100.5F at least once daily x 14 or more days and dx not apparent after careful hx, PE, and noninvasive tests
- temp > 101+ on several occasions > 3 weeks and no dx with 1 week intense investigation
FUO - usually ______, may require _______ consult; ___% self-resolve
- viral
- ID
- 25
Define prolonged fever
single illness in which fever that exceeds that than which is expected for the clinical diagnosis
Sometimes may have prolonged fever that precedes FUO
common causes of FUO in < 6 yrs (6)
- UTI/pyelo
- respiratory infection
- local infection such as abscess
- Juvenile arthritis
- leukemia (rare)
- COVID
common causes FUO in adolescents:
- TB
- Inflammatory bowl disease
- lymphoma
- Autoimmune diseases
- Covid
- chlamydia
Work-up/labs in FUO (16)
- To be done in primary care
- CBC w/ diff
- ESR
- CRP
- UA and culture
- blood cultures
- CMP
- liver and renal function tests
- LDH
- RAF
- ANA
- uric acid levels
- PPD/mantoux skin test or CXR
- sinus XR, mastoid XR, GI XR
- echocardiogram
W/u in FUO with red flags (5)
- Complete sepsis w/u
- If very toxic appearing, may need LP, CT scans in hospital
- May consult with ID
- May be followed with frequent visits
- Testing as symptoms/physical findings develop
Kawasaki criteria
persistent fever for at least 5 days PLUS > 4 of these:
- bilateral conjunctival injection, nonpurluent
- change in lips and oral cavity (red, cracked strawberry tongue, diffuse redness mucosa)
- cervical lymphadenopathy (unilateral); > 1.5 cm nodes
- polymorphous exanthema rash in extremities, trunk, perineal regions
- changes in peripheral extremities (edema hands & feet) or perineal area
can also be incomplete who lack classic sx’s = coronary artery abn can confirm dx too
Kawasaki - self-limited and what complications? (4)
- systemic vasculitis
- CAD
- coronary aneurysms
- acquired heart disease
Kawasaki labs if incomplete KD dx
- based on symptoms
A. fever >= 5 days + 4 of the following:
- a. dry, cracked mucous membranes (90% incidence)
- b. maculopapular (or morbilliform) rash, or macular rash in perianal area (70-90%)
- c. Changes in extremities such as edema of hands and feet, erythema of palms and soles (acute), or desquamation of fingers and toes (subacute)
- d. bilateral, non-purulent conjunctivitis
- e. strawberry tongue
- f. Asymmetric ant. cervical lymphadenopathy
- g. irritability h. ST, gallop rhythms, innocent flow murmurs, murmurs of aortic or mitral regurgitation
- incomplete dx include:
albumin > 3
urine > 10 WBC
platelet > 450,000 after 7 days of fever
anemia
total WBC > 15,000
elvation of ALT
coronary artery abnormalities (confirms)
Imaging studies in Kawasaki
- Echo (baseline then repeat 2 wks, then 6-8 wks)
- EKG
Kawasaki mgmt
EARLY DIAGNOSIS TO PREVENT ANEURYSMS!
Treatment more effective before 10th day of illness
IVIG to control vascular inflammation
high dose aspirin (antiplatelet effect) - need inactiavted flu shott
baseline echo, then 2 wks, then 6-8 wks after onset
delay live vaccines at least 11 months after admin of IVIG
Kawasaki: higher risk for complications
Males age < 6 months or age > 9 years
Kawasaki Disease - Stage 1 (acute)
- Lasts about 10 days
- Perisistent high fever for >= 5 days - may not respond to antipyretics, abx
- PLUS Conjunctival hyperemia, edema of hands and feet, polymorphous erythematous rash, unilateral lymphadenopathy
- strawberry tongue = classic (no ulcers/pharyngeal exudate)
- lymph node > 1.5cm (non tender to slightly firm)
- tachycardia, gallop rhythms, flow murmurs, mitral regurg or aortic regurg
Kawasaki Disease - Stage 2 (subacute)
- Day 11-25
- Fever disappears
- Most symptoms resolve
- Desquamation of fingers, toes, groin, and perianal region
- Thrombocytosis
- Coronary aneurysms seen on echo REFER TO ECHO!
- Non-specific EKG changes
- Prevention: IVIG + aspirin therapy (an exception to Reye Syndrome)
Kawasaki Disease - Stage 3 (convalescent)
- 1-2 months after initiation of s/s
- Lasts until ESR back to normal
- Most symptoms disappear
- Onychomadesis of toenails - period shedding of proximal end of toinail 2 months after recovery
- Beau lines are deep transverse grooves on nailbed
- Cardiac findings: abnormalities of cardiac vessels, myocarditis
UTI symptoms in neonates (8)
- Jaundice
- Hypothermia
- FTT
- Sepsis
- Vomiting or diarrhea
- Cyanosis
- Abdominal distention
- Lethargy
UTI symptoms in Toddlers & Preschoolers
- malaise, irritability
- difficulty feeding
- Poor weight gain
- Fever
- Vomiting or diarrhea
- Malodor
- Dribbling
- Abdominal pain/colic
UTI symptoms in School-Age children
- Classic dysuria with frequency, urgency and discomfort
- Malodor
- Enuresis
- Abdominal/flank pain
- Fever/chills
- Vomiting or diarrhea
- Malaise
___ is the most common cause of SBI in children < 24 months with fever without a focus
UTI
Complicated UTI s/s
- < 2 yrs
- Upper urinary tract (pylo)
- Hx medical problem
- Abnormal anatomy
- Drug resistant pathogen
- Fever, toxicity, dehydration
UTI Diagnosis on UA
Positive findings on
- Urine luekocyte esterase
- Nitrites
- Leukocyte count, or
- Gram stain
Empiric tx for Pediatric UTI
- Bactrim - 1st line for uncomplicated lower UTI (age > 2 months)
- Amoxicillin/augmentin - for young children with uncomplicated UTI or pyelonephritis
- Cephalexin (age > 6 months)
- Cefixime (age > 6 months)
- Macrobid (age > 1 month)
Duration of tx
- age 2-24 months or febrile: 7-14 days
- age > 24 months and afebrile: 3-5 days can be appropriate
Protocol for child needing renal and bladder u/s
- < 2 y.o with first UTI
- all children with fever + pyelonephritis
- recurrent UTI/
Pediatriac referral to GU
- High-risk - immunocompromised, abnormal u/s
- Age < 3 months = need sepsis workup
- congenital abnormalities
- Pyelonephritis
- Recurrent UTI (about 3 episodes)
Lab review:
High WBC + High neutrophils + bandemia
Bacterial, viral, malignancy?
Bacterial infection
Lab review:
Slightly elevated WBC + elevated lymphocytes + no bands
Bacterial, viral, malignancy?
Viral infection
(bands are immature neutrophils and are increased if bacterial infection)
Lab review:
Fever + sore throat + atypical lymphocytes + increased LFTs
What specific infection?
Infectious mononucleosis
Lab review:
Decreased WBC + very high eosinophils
Bacterial, viral, malignancy?
Leukemia/malignancy
If slightly high eosinophils - allergic reaction
If very high eosinophils like > 20K, think lymphoma/leukemia
UTI risk factors
- > 102.2F
- Females < 1 yr old
- Uncircumcised males
- Duration of fever (> 24-48 hrs)
- Absence of another infection
Low risk for young infant with fever unknown origin
- Well appearing, easily consolable
- previously healthy
- full-term infant (> 37 weeks)
- normal UA, WBC, and PCT
- ANC < less than 1,500 bands
- appears well
- no focal bacterial infection; nl CXR if performed
- Reliable caregivers and follow up,
- discharge home and close f/u in 12–24 hours
- If low-risk criteria not met = be admitted and have LB and CSF studies
- Empiric antibiotics should not be administered until LB is obtained to avoid masking or undertreating an undx meningitis
- no systemic anti w/in 72 hrs
- negative UA
- negative leuocyte/nitrate
- WBC 5-15k
- ANC < 1500 bands
- Procalcitonin > 0.3
- no discrete infiltrate son CXR
- stool smear negative
FUO, LB only if have 1 of these:
- WBC count < 5,000 microL or > 15,000 microL (N 5-15k)
- Absolute band count > 1,500 microL (N 2500-6000)
- PCT > 0.5 ng/ml (N < 0.5)
- CRP > 20 mg/L (N 0.8-1)
- Pneumonia on CXR
define fever without origin (FUO)
_>_100.5F at least once daily x 14 days+ and dx not apparent after careful hx, PE, tests
or
>101F+ on several occasions >3 weeks, failure to reach diagnosis, despite 1 week intense investigation
Do you give empiric antibiotics for FUO?
NO!
