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NURP 532 > Week 1 - Pediatric Fever > Flashcards

Week 1 - Pediatric Fever Flashcards

1
Q

Temperature of a fever

A

>= 100.4F or 38C

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2
Q

Accurate temperature measurement in children

A

Rectal thermometer in children < 3 y.o.

Oral thermometer in children > 5 y.o.

Axillary, temporal, tympanic thermometers are less accurate

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3
Q

Age stratification

Neonates?

A

0-28 days (4 weeks)

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4
Q

Age stratification

Young infants?

A

29 - 90 days (approx 3 months)

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5
Q

Age stratification

Young child?

A

3 months - 3 years

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6
Q

Normal rectal temperature range

A
  1. 9-100.2F
    (36. 6-37.9C)
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7
Q

Goal of fever

A

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

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8
Q

T/F Degree of fever correlates with severity of illness

A

False. The general appearance is a stronger indicator. So a low temperature does not negate a serious bacterial illness.

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9
Q

Goal of fever mgmt

A

Improve child’s comfort so they can follow plan of care

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10
Q

Physiology of fever

A

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

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11
Q

Fever mgmt recs: When?

A

Utilize when temp is > 102F (likely bacterial) or persistently > 101F

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12
Q

Fever mgmt recs: How? Pharm vs non pharm

A
  1. Non-pharmacological -
  • hydration
  • appropriate clothing and ambient temp
  • tepid water baths for temp > 104F
  • Do not allow shivering
  • Never use alcohol or ice baths
  1. 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
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13
Q

Causes of fever in neonates (2)

A

Congenital or acquired infections

1) late onset group B strep
2) acquired anatomic or physiologic dysfunction, i.e. renal

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14
Q

Causes of fever in all children (11)

A
  1. bacterial, fungal, parasitic, or viral infections
  2. vaccines
  3. biologic agents
  4. tissue damage
  5. malignancy - neoplasms
  6. drugs
  7. collagen-vascular disorders
  8. endocrine disorders
  9. inflammatory disorders - teething
  10. environmental - heat stroke
  11. if temp > 105.8F - likely CNS dysfunction such as malignant hyperthermia, drug fever, heat stroke
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15
Q

infants with meningitis don’t present with?

A

nuchal rigidity

do thorough neuro exam, fontanelles,

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16
Q

Definition of fever without a focus/source

A
  • Acute fever of unknown etiology after examining child that is < 24 months
    • < 24 months = higher risk for SBI, esp < 3 months old = need workup
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17
Q

Most infants < 90 days have causative agent as ________, however, still need to rule out _____ disease so require a _____ work-up.

A
  1. Viral
  2. Bacterial
  3. Sepsis
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18
Q

Birth - 2 years: Greatest risk of unsuspected occult bacteremia w/ E. coli. What are common SBIs with no clinical sx’s? (3)

A
  1. UTI
  2. PNA
  3. bacteremia
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19
Q

Any child < 3 years old who is ill-appearing should have the following tests…(10)

A
  1. CBC w/diff
  2. Glucose
  3. CRP
  4. PCT
  5. blood cultures
  6. CSF testing
  7. UA and culture
  8. CXR
  9. Stool cx if diarrhea with blood or mucus in stool
  10. If in season, rapid testing for influenza/RSV/enterovirus
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20
Q

Red Flags - Infants who need to be admitted to the hospital and for serious bacterial infections: (16)

A
  1. Prematurity
  2. Underlying health conditions
  3. Parents are unreliable historians and/or caretakers
  4. Ill or toxic-appearing
  5. Skin color is ashen, blue, mottled, or pale
  6. Lethargic, weak
  7. High-pitched cry, decreased response
  8. Poor feeding
  9. tachypnea or tachycardia
  10. Chest/abdominal retractions
  11. Petechiae
  12. Seizure
  13. Capillary refill > 3 seconds
  14. decrease UO
  15. Bulging fontanel
  16. Non-blanching skin rash
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21
Q

Subjective data – Associated symptoms - all children (7)

A
  1. Current level of activity/lethargy
  2. Activity level prior to fever onset
  3. Current eating and drinking pattern
  4. Eating or drinking pattern prior to fever onset
  5. Apperance
  6. Vomiting or diarrhea
  7. Urinary output
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22
Q

evaluation of fever in young infants 29-60 days (1-2 months)

A
  • 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
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23
Q

evaluation of fever in 60-90 day (2-3 month) infant

A
  • 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!
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24
Q

all infants this age that has fever need urinalysis

A

all infants < 3 months to rule out UTI

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25
Q

Subjective data - Current medications - all children (2)

A
  1. Immunization history (esp. recent immunizations)
  2. Meds used to treat fever, illness
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26
Q

ROS (7 areas)

A
  1. General appearance
  2. HEENT - conjunctivitis, swollen nodes, ear pain

3, Respiratory - RR, wheezing, crackles, retractions, cough, shortness of breath

  1. Cardiac - HR, chest pain
  2. GI - appetite, wt. loss, n/v/d
  3. GU - voiding pain, frequency
  4. Neuro - any changes in LOC, activity level
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27
Q

Objective Data - all children (3)

A
  1. Vital signs - BP, HR, RR, rectal/oral temp, percentiles
  2. Weight - kg
  3. Broselow tape
28
Q

Subjective data - Past Medical History of Neonates

A
  1. Prenatal, perinatal, and neonatal history
  2. Intrapartum fever
  3. Maternal strep group B status

4, Postnatal care

  1. Family hx of death of young infant from infection - any anomalies? immunodeficiency?
29
Q

Physical Exam - Neonates (3 areas)

A

Hands-off or Pediatric assessment triangle:

  1. General appearance and level of interaction
  2. Work of breathing
  3. Circulation to skin
30
Q

Young infants - work-up

A

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

31
Q

Inflammatory markers

A
  1. CRP (normal < 2 mg/DL - better sensitivity and predictive value than WBC
  2. PCT (normal < 0.5 ng/mL) higher cost, reduced availability, delay in availability of results
32
Q

Past medical history for Young children 3 months - 36 months (3)

A

As for neonates and very young infants plus:

  1. identify previous infectious episodes/risk factors for SBIs
  2. Incomplete immunization against strep pneumoniae or H flu b
  3. Neonatal and perinatal history if younger than 9 months
33
Q

Social history for young children (3 months - 3 years) (4)

A
  1. Exposure to contaminated drinking water/sewage
  2. Recent travel (particularly international travel)
  3. Attendance at daycare
  4. Exposure to sick individuals outside of the household
34
Q

Definition: fever of unknown origin

A
  • 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
35
Q

FUO - usually ______, may require _______ consult; ___% self-resolve

A
  1. viral
  2. ID
  3. 25
36
Q

Define prolonged fever

A

single illness in which fever that exceeds that than which is expected for the clinical diagnosis

Sometimes may have prolonged fever that precedes FUO

37
Q

common causes of FUO in < 6 yrs (6)

A
  1. UTI/pyelo
  2. respiratory infection
  3. local infection such as abscess
  4. Juvenile arthritis
  5. leukemia (rare)
  6. COVID
38
Q

common causes FUO in adolescents:

A
  1. TB
  2. Inflammatory bowl disease
  3. lymphoma
  4. Autoimmune diseases
  5. Covid
  6. chlamydia
39
Q

Work-up/labs in FUO (16)

A
  1. To be done in primary care
  2. CBC w/ diff
  3. ESR
  4. CRP
  5. UA and culture
  6. blood cultures
  7. CMP
  8. liver and renal function tests
  9. LDH
  10. RAF
  11. ANA
  12. uric acid levels
  13. PPD/mantoux skin test or CXR
  14. sinus XR, mastoid XR, GI XR
  15. echocardiogram
40
Q

W/u in FUO with red flags (5)

A
  1. Complete sepsis w/u
  2. If very toxic appearing, may need LP, CT scans in hospital
  3. May consult with ID
  4. May be followed with frequent visits
  5. Testing as symptoms/physical findings develop
41
Q

Kawasaki criteria

A

persistent fever for at least 5 days PLUS > 4 of these:

  1. bilateral conjunctival injection, nonpurluent
  2. change in lips and oral cavity (red, cracked strawberry tongue, diffuse redness mucosa)
  3. cervical lymphadenopathy (unilateral); > 1.5 cm nodes
  4. polymorphous exanthema rash in extremities, trunk, perineal regions
  5. 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

42
Q

Kawasaki - self-limited and what complications? (4)

A
  1. systemic vasculitis
  2. CAD
  3. coronary aneurysms
  4. acquired heart disease
43
Q

Kawasaki labs if incomplete KD dx

A
  1. 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
  1. 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)

44
Q

Imaging studies in Kawasaki

A
  1. Echo (baseline then repeat 2 wks, then 6-8 wks)
  2. EKG
45
Q

Kawasaki mgmt

A

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

46
Q

Kawasaki: higher risk for complications

A

Males age < 6 months or age > 9 years

47
Q

Kawasaki Disease - Stage 1 (acute)

A
  • 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
48
Q

Kawasaki Disease - Stage 2 (subacute)

A
  • 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)
49
Q

Kawasaki Disease - Stage 3 (convalescent)

A
  • 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
50
Q

UTI symptoms in neonates (8)

A
  • Jaundice
  • Hypothermia
  • FTT
  • Sepsis
  • Vomiting or diarrhea
  • Cyanosis
  • Abdominal distention
  • Lethargy
51
Q

UTI symptoms in Toddlers & Preschoolers

A
  • malaise, irritability
  • difficulty feeding
  • Poor weight gain
  • Fever
  • Vomiting or diarrhea
  • Malodor
  • Dribbling
  • Abdominal pain/colic
52
Q

UTI symptoms in School-Age children

A
  • Classic dysuria with frequency, urgency and discomfort
  • Malodor
  • Enuresis
  • Abdominal/flank pain
  • Fever/chills
  • Vomiting or diarrhea
  • Malaise
53
Q

___ is the most common cause of SBI in children < 24 months with fever without a focus

A

UTI

54
Q

Complicated UTI s/s

A
  • < 2 yrs
  • Upper urinary tract (pylo)
  • Hx medical problem
  • Abnormal anatomy
  • Drug resistant pathogen
  • Fever, toxicity, dehydration
55
Q

UTI Diagnosis on UA

A

Positive findings on

  • Urine luekocyte esterase
  • Nitrites
  • Leukocyte count, or
  • Gram stain
56
Q

Empiric tx for Pediatric UTI

A
  • 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
57
Q

Protocol for child needing renal and bladder u/s

A
  • < 2 y.o with first UTI
  • all children with fever + pyelonephritis
  • recurrent UTI/
58
Q

Pediatriac referral to GU

A
  • High-risk - immunocompromised, abnormal u/s
  • Age < 3 months = need sepsis workup
  • congenital abnormalities
  • Pyelonephritis
  • Recurrent UTI (about 3 episodes)
59
Q

Lab review:

High WBC + High neutrophils + bandemia

Bacterial, viral, malignancy?

A

Bacterial infection

60
Q

Lab review:

Slightly elevated WBC + elevated lymphocytes + no bands

Bacterial, viral, malignancy?

A

Viral infection

(bands are immature neutrophils and are increased if bacterial infection)

61
Q

Lab review:

Fever + sore throat + atypical lymphocytes + increased LFTs

What specific infection?

A

Infectious mononucleosis

62
Q

Lab review:

Decreased WBC + very high eosinophils

Bacterial, viral, malignancy?

A

Leukemia/malignancy

If slightly high eosinophils - allergic reaction

If very high eosinophils like > 20K, think lymphoma/leukemia

63
Q

UTI risk factors

A
  • > 102.2F
  • Females < 1 yr old
  • Uncircumcised males
  • Duration of fever (> 24-48 hrs)
  • Absence of another infection
64
Q

Low risk for young infant with fever unknown origin

A
  • 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
65
Q

FUO, LB only if have 1 of these:

A
  • 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
66
Q

define fever without origin (FUO)

A

_>_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

67
Q

Do you give empiric antibiotics for FUO?

A

NO!

NURP 532 (13 decks)

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