Pediatric Fever why/how old/ how to treat 1 2 Why is this important? Especially in infants, fever is the bell, alerting you that there could be a serious bacterial infection (SBI) Pediatric literature reports the number to be as high as 15% Undiagnosed bacterial infection such as meningitis and bacteremia can lead to overwhelming sepsis and death Undetected urinary tract infection can lead to pyelonephritis and scarring of the kidney 3 Serious Bacterial Infections bacterial meningitis bacteremia/sepsis UTI/pyelonephritis pneumonia (bacterial) bacterial enteritis cellulitis abscess septic arthritis 4 special challenges in this age group 0-2 mos limited immune system susceptible to perinatally and community acquired infections including B streptococcus (GBS), E. coli, Strep pneumonia and staph aureus Neonatal listeria monocytogenes and herpes simplex infections are rare but life threatening 5 Case Previously healthy 28 day old child is brought via ambulance with fever of 103 F, pulse ox 92%, BP 70/42 with febrile seizure. 2 year old sibling is hospitalized with RSV pneumonia. 6 Pre-hospital treatment IV access, normal saline 20ml/kg bolus if access obtained, IV ativan intranasal versed, ativan or valium suppository tylenol suppository child may require oxygen or bagging if infection is respiratory 7 Febrile Seizures simple febrile seizures 7075% of all febrile seizure 6 mos to 5 yrs less than 15 minutes neurologically healthy both before and after the seizure No risk for cognitive impairment genetic component boys slightly more freq than girls 8 Complex febrile seizures 20-25 % of all febrile seizures same criteria as simple febrile seizures, however seizure lasts more than 15 minutes or are several seizures in rapid succession. oral diazepam is essential if you don’t want any more of prolonged seizure activity 9 Symptomatic febrile seizure preexisting neurologic abnormality and preexisting illness 5% of febrile seizures 1/3 of children who have one febrile seizure will have another one 10 11 treatment of febrile seizure intranasal midazolam/(Versed), IV alprazolam/ativan, diazepam(valium) IV or rectal If febrile seizures become a recurring problem, oral diazepam(Valium) has the least side effects compared with valproic acid or phenobarbital. Diazepam can be given orally at the onset of fever. 12 history points How was the temp taken? Axillary and tympanic temps can be inaccurate in infants how is the child feeding (poor or slow) fussy or lethargic? Premature or term? is mom GBS positive or HSV? did the child spend time in the NICU or did they receive antibiotics in the newborn nursery? Are any of the siblings ill? 13 Ill Appearing Infants full sepsis workup includes: chest x-ray is indicated only if there are respiratory symptoms * CBC, CMP, CRP, blood cultures lumbar puncture (missed meningitis #1 malpractice) broad spectrum antibiotics Bramson RT, Meyer TL, Silbiger ML etal. The futility of the chest radiograph in the febrile infant without respiratory symptoms. Pediatrics. 1993; 92(4):524-526 14 Young infants 0-28 days with a source of infection Even if the child has bronchiolitis or viral respiratory infection the sepsis workup should be done. These infants are still at risk for SBI 15 Fever in Children over 90 days a different approach 16 History points Parents subjective reports of fever are usually accurate. Infants still need a rectal temp. Immunization history should be specific. Ask how many doses of pneumococcal conjugate and H-flu vaccine have been administered. Recent immunizations may actually be the cause of fever in some cases Exposure to sick contacts, travel history previous hospitalizations, changes in mental status, eating, irritability, apnea h/o neglect or abuse 17 More history points was an antipyretic given in the right dose? Has the child been snoring complaining of ear pain, cough or sore throat 18 physical exam quality of the cry fearful of the exam? skin color/cyanosis or jaundice hydration/ assess fontanelle in an infant, tears, oral mucosa smiling, playful? capillary refill 19 More physical exam points dyspnea, grunting, flaring, retractions, tachypnea irritability, inconsolability, lethargy, absent eye contact mottled skin, cold hands and feet, cyanosis, hemorrhagic rash younger children with meningitis do not typically have adult findings of Kernigs or Brudzinskis signs 20 Children at highest risk pts with recently inserted medical devices/ foreign bodies (VP shunts, central lines, pacemakers) sickle cell disease immunocompromised pts (malignancy, chemo, neutropenia, cystic fibrosis, diabetics) premature infants are at risk for bronchiolitis and necrotizing enterocolitis HIV 21 Diarrhea/vomiting/fever/winter check fecal leukocytes, if greater than 5 per HPF suspect bacterial etiology. salmonella, campylobcter, shigella, yersinia low grade fever, vomiting and diarrhea + day care center likely has rotavirus 22 Well Appearing Young Infants less than 60 days of age At risk for serious bacterial illness (SBI) days 0-28. The rate is nearly 20%. 8.8% of well appearing infants 29-56 days have culture positive infections These children too require a full sepsis evaluation. 23 Parameters for low risk infants Rochester Criteria full term, normal prenatal and post natal histories, no postnatal antibiotics, well appearing, no focal infection UA neg, WBC 5-15K, ABS band count, stool less than 5 WBCs treatment for low risk pt-home, 24 hr followup, no antibiotics treatment for high risk pt hospitalize and antibiotics 24 In Summary The treatment of pediatric fever depends on several parameters age and general appearance of the child perinatal factors such as prematurity, ICU stay and antibiotic exposure co-morbidities such as shunts, hereditary disorders seizure activity 25 CREDITS Evaluation of the Febrile Young Infant: An Update, EB Medicine, Pediatric Emergency Practice, February 2013, Volume 10, Number 2 Medscape, Febrile Seizure Tintanelli, Images/photos courtesy of Africa, David Castillo Dominici, papaija 2008, artztsamui, Clare Bloomfield all on Free Digital photos.net 26 27