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
Time of day when core temperature is lowest
AM; 0400-0800
Time of day when core body temperature peaks
Early PM; 1600-1800
Age stratification
Neonates?
0-28 days (4 weeks)
Age stratification
Young infants?
29 - 90 days (approx 3 months)
Age stratification
Young child?
91 days to <= 36 months
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?
- 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
- Naproxen - not good -
- alternating acetaminophen and ibuprofen may increase risk of med error/toxicity
- avoid ASA!!
Causes of fever in neonates (2)
Congenital or acquired infections, i.e. 1) late onset group B strep, or 2) acquired 2/2 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
What age group who presents with a fever requires an automatic sepsis work-up including blood cx and empiric antibiotic therapy initiation?
Any young infant < 3 months/90 days
Definition of fever without a focus
An acute febrile illness < 5 days in which the etiology of the fever is not apparent after careful history and physical examination of a child less than 24 months of age
Most infants < 90 days have causative agent as ________, however, still need to rule out _____ disease so require a _____ work-up.
- Viral
- Bacterial
- Sepsis
Birth - 24 months: Greatest risk of unsuspected occult bacteremia w/ E. coli. What are common SBIs? (3)
- UTI
- PNA
- bacteremia
Any child < 36 months 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 (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 UOP
- 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
Subjective data - Social History - very young children (29-90 days) (5)
- Ill contacts
- Recent travel history of child and household contacts
- Exposure to animals, kitty litter
- Vaccination status of household members
- Identify household members: primary caregiver, exposure to recent immigrants, homelessness and poverty
Subjective data - Past Medical History of very young children (29-90 days) (3)
- Chronic illness
- Perinatal infection
- Congenital anomalies
Subjective data - Family history - very young children (29-90 days) (2)
- Mother’s medical history, e.g. HIV+ 2. Genetic illness
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
Physical Exam - VERY YOUNG CHILDREN (29 DAYS-90 DAYS) (9 areas)
- General - toxic appearing? consolable?
- Integumentary - rash? Petechiae? Skin color?
- HEENT - reddened TM, otitis media, pharyngitis, strep throat, gingival stomatitis
- Respiratory - bronchiolitis, croup, crackles, wheezing
- GI - rigid, board-like abdomen
- GU - male circumcision
- MSK - decreased ROM
- Neuro - nuchal rigidity, neurologic exam
- Psychiatric
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
Neonates - While awaiting work-up results, start empiric antibiotic therapy? If so, what? (3)
Yes. 1. Ampicillin AND cefotaxime (c/f meningitis) or gentamicin
- Add acyclovir if HSV concern and workup performed
- Add vancomycin if c/f meningitis
Neonates - additional work-up
Refer to ER because will also need: ANC with CBC LP - CSF and culture (bacterial/viral, consider HSV PCR)
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
Young Infants low risk factors (10)
- well-appearing
- previously healthy
- full term
- no focal bacterial infection
- no systemic abx in past 72 hrs
- negative UA
- normal WBC/ANC
- normal PCT < 0.3 ng/ml 9. CXR, no infiltrates
- Stool smear negative
Very young infants (29-60 days) empiric antibiotics (4)
- CTX or cefotaxime
- Add acyclovir if HSV concern and w/u performed
- Add vancomycin if c/f meningitis
- Add gentamicin for broader gram-negative coverage
Young infants (61-90 days) (1)
More likely to have a fever 2/2 immunization If given < 24 hrs and temp < 101.5F - continue monitoring If given > 48 hrs – further w/u (same as 29-60 day infant)
Young infants (61-90 days) empiric antibiotics (2)
- CTX or cefotaxime
- Add vancomycin if indicated
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
Neonates/very young infants < 42 days with vesicular skin lesions, abnormal CSF, or seizures
HSV PCR/cx from CSF, mouth/throat, umbilicus and perirectal
LP recommended in (2):
- all febrile neonates
- infants/young children with clinical signs of meningitis (nuchal rigidity, petechiae, anormal neuro findings)
Rapid viral testing recommended (3):
- done depending on seasonality
- Positive for influenza may make them susceptible to SBI
- Positive for RSV may still have a significant risk of UTI
CXR recommended (4):
- Young children > 1 mo w/ respiratory sx (tachypnea, retractions, focal, breath sounds, O2 sat <95%)
- Fever >102.2F
- WBC > 20K
- Cause of most pediatric PNAs (80%) is viral though challenging to establish whether viral or bacterial
Suggestive of serious bacterial infections (SBI) (5):
- UA: > 10 WBCs/hpf, bacteria, and/or positive leukocytes and/or nitrite findings
- WBC > 15K 3. ANC > 10K 4. CRP > 40 5. PCT > 0.5
Past medical history for Young children 91 days - 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
Family history for Young children 91 days - 36 months (5)
- Episodes of recurrent infections among siblings and first cousins
- History of maternal fetal loss
- Parental HIV
- Chronic infections (hep B, hep C, TB) of immediate or extended family
- Presence of acute illness in the family (e.g. croup or respiratory infection)
Social history for young children (91 days - 36 months) (4)
- Exposure to contaminated drinking water/sewage
- Recent travel (particularly international travel)
- Attendance at daycare
- Exposure to sick individuals outside of the household
DDx in children 3-36 months (8)
- URIs, LRIs
- GI disease
- Musculoskeletal infections
- UTIs, pyelonephritis
- Occult bacteremia
- Omphalitis
- Mastitis
- Other skin or soft tissue infections
Definition: fever of unknown origin and prolonged fever
Fever that lasts more than 3 weeks without discovered cause during 1 week of diagnostic w/u, w/ daily documented rectal fever of > 101F (38C) or oral fever > 100F
FUO - usually ______, may require _______ consult; ___% self-resolve
- viral
- ID
- 25
Definition: 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
DDx in child age < 6 y.o. with FUO/prolonged fever (5)
- UTI/pyelo
- respiratory infection
- local infection such as abscess
- JRA
- leukemia (rare) Make sure to include COVID
DDx in child > 6 y.o. but younger than adolescent with FUO/prolonged fever (4)
- TB
- IBD
- lymphoma
- AI diseases
Make sure to include COVID
DDx in adolescent with FUO/prolonged fever (6)
- TB
- IBD
- AI
- abscesses
- chlamydia
- lymphoma
Make sure to include COVID
Work-up in FUO (16)
- To be done in primary care
- CBC w/ diff
- ESR
- CRP
- UA and culture
- blood cultures May add as necesarry:
- CMP 8. liver and renal function tests
- LDH
- RAF
- ANA
- uric acid levels
- PPD or CXR
- sinus XR, mastoid XR, GI XR
- EBV
- CMV
Red flags in FUO (13)
- < 1 month old
- bulging fontanelles
- marked wt. loss
- high WBC
- high ESR/CRP
- seizures
- dehydration
- meningitis
- decreased feeding
- decreased diapers
- per parents, child is “not right”
- increased lethargy
- extreme parental anxiety
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 - seasonal - more common when?
late winter and early spring
Kawasaki - self-limited and what complications? (4)
- systemic vasculitis
- CAD
- coronary aneurysms
- acquired heart disease
Kawasaki - diagnosis
- 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
- labs: CBC with diff normocytic anemia, leukocytosis, thrombocytosis, neutrophilia with bands
- increased CRP/ESR
- electrolytes - hyponatremia, high creatinine
- LFTS - low albumin, elevated ALT
- UA - sterile pyuria (pus without bacteria)
- Lipids - abnormal
Imaging studies in Kawasaki
- Echo
- EKG
Kawasaki mgmt
- In hospital
- More effective when done before 10th day of illness
- IVIG
- Moderate-high ASAP until afebrile 2-3 days
- 2nd dose IVIG if still febrile
- C/S until afebrile
- Echo f/u
- Delay vaccines at least 11 months after receipt of IVIG
Kawasaki: higher risk for complications
Males age < 6 months or age > 9 years
Kawasaki Disease - Stage 1 (acute)
- Lasts about 10 days
- High fever for >= 5 days - may not respond to antipyretics, abx
- Conjunctival hyperemia, edema of hands and feet, polymorphous erythematous rash, unilateral lymphadenopathy
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
- Non-specific EKG changes
- Prevention: IVIG + aspirin therapy (an exception to Reye Syndrome)
Kawasaki Disease - Stage 3 (convalescent)
- About 1-2 months following 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
- Bow 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 iin children < 24 months with fever without a focus
UTI
Complicated UTI s/s
UTI w/fever, toxicity, and dehydration,
or a UTI occurring in a child 3-6 months of age
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 pyelo
- Cephalexin (age > 6 months)
- Cefixime (age > 6 months)
- Macrobid (age > 1 month)
Duration of tx
- 2-24 months or febrile: 7-14 days
- > 24 months and afebrile: 3-5 days can be appropriate
Protocol for child needing renal and bladder u/s
For any 2 y.o who has had first UTI/recurrent UTI/pyelonephritis
Pediatriac referral to GU
- High-risk - immunocompromised, abnormal u/s
- Age < 3 months
- 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
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
