Fever in children

1
Fever in children

• Dr. Osama Kentab, MD, FAAP, FACEP
• Assistant Professor of Paediatrics and emergency
  Medicine
• King Saud Bin Abdulaziz university for Health
  sciences
• Riyadh

2
Epidemiology

• Very common sign and symptom of illness in
  childhood
• May be indicative of an infection that is local
  or systemic benign or invasive life
  threatening
• Normal body physiological reaction to pyrogen
  ( infective, inflammatory)

3
Thermoregulation

• Central thermostat
• Thermoregulatory center in hypothalamus
• Receive input from
• -Peripheral receptors
• -Temp of blood around hypothalamus
• Acts on autonomic,endocrine behavioral
  mechanisms

4
Physiologic changes controlling body temp

• Set point decreases to normal
• Heat loss
• -obligate heat loss
• -vasodilatation
• -sweating
• -cold preference behavior
• (65 Radiation,30 evap)

• Set point increases
• Heat generation
• -? cell metabolism
• -muscle activity
• -involuntary shivering
• Heat conservation
• -vasoconstriction
• -heat preference behavior

5
Body temperature variations

• Age
• Time of the day (Less in small infants).
• Sex MgtF
• Race? Black gt white
• Environmental (false fevers)
• -Ambient air temp -Excess
  bundling
• -Feeding (within 1 hour) -Exercise
• -Teething (50 will have a new temp on day of
  eruption

6
Implications of ?body temperature

• Is it beneficial?
• Rate of bacteraemia is 2-3 in all febrile
  infants lt 2months (Baker 1999 Kadesh et al 1998)
• Infants lt 2 months differ are less
  immunocompetent unique group of bacteria (GBS,
  Gram. Neg bacteria listeria)
• Young infants show relative inability to
  demonstrate clinical evidence of illness

7
What is the normal temperature?

• Rectal 36.6 to 38 C
• Ear 35.8 to 38
  C
• Oral 35.5 to 37.5
  C
• Axillary 34.7 to 37.3 C
• Canadian pediatric society statement,Pediatric
  Child Health 2000

8
Measurement sites

• Core body temperature
• Rectal / Oral /Axillary /TM
• -indirect
• -artifact
• -lag time

9
Rectal Temperature

• Slow to change in relation to changing core
  temperature
• Affected by the depth, local blood flow and
  presence of stool
• Rectal perforation has been described
• ?Gold standard
• Robinson,J Pediatr,1998

10
Recommended Sites

• lt 2 yrs 1.Rectal
  (definitive)
• 2.Axillary
  (screening)
• 2-5 yrs 1.Rectal
• 2.Tympanic
• 3.Axillary
• gt 5 yrs 1.Oral
• 2.Tympanic
• 3.Axillary
• Canadian pediatric society statement,Pediatric
  Child Health 2000

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Assessment Relevant history

• Duration of fever
• Pattern of fever intermittent or continuous
• Hx of contact family members, friends, school
  mates
• Hx travel abroad country visited
• Malaria endemic regions, enteric fever (Africa,
  Asia) Travel immunization, malaria prophylaxis
• Travel to mountainous region, camping in forest
  (Rickettsial infection, Lyme disease)
• Hx of Immunization

12
Relevant symptoms

• Systemic symptoms Resp, ENT, Renal, GI
• Rash Pattern/type (macular, papular, ulcerative,
  erythematous, blanching)
• Distribution (mucosal involvement-conjuctivitis,
  mucositis, buttocks and extremities(HSP) Oral
  ulcers (aphthous, herpes gingivostomatitis)

13
Relevant clinical signs

• Unwell Toxic
• Haemodynamic instability
• Rash
• Lower Respiratory signs
• Joint involvement Arthritis/ Athralgia Reactive
  viral arthritis, Septic arthritis, HSP, Rheumatic
  fever, Chronic arthritis of childhood
• Organomegaly Hepatomegaly, Splenomegaly, /-
  Anaemia Systemic illness, Septicaemia,
  Lymphoproliferative disorders

14
Causes of febrile illnesses in childhood

• Common causes
• URTI (viral or bact.)
• LRTI
• Gastroenteritis
• UTI
• Oral (dental abscess, hyperangina, herpetic
  gingivitis, mumps)
• MSS (septic arthritis, osteomyelitis, cellulitis

• Serious causes
• URTI (epiglottitis, croup, retropharyngeal
  abscess)
• LRTI
• GI (appendicitis)
• CNS (Meningitis, encephalitis)
• Systemic (meningococcaemia, toxic shock syndrome

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Protocols for Identification of Low Risk Infants Protocols for Identification of Low Risk Infants Protocols for Identification of Low Risk Infants Protocols for Identification of Low Risk Infants Protocols for Identification of Low Risk Infants
Rochester 1985-1988 Boston 1992 Philadelphia 1993-1999 Pittsburgh 1999-2000
Age(days) 0-60 28-89 29-56 0-60
Past health gt37 wk,home with or before mom,no susequent hosp,no prenatal, post,or current ATB,no treatment for unexplained hyperbole,no chronic diseases - No known immundef. Rochester
Temp C ?38.0 ?38.0 ?38.0 ?38.0
Infant Obs.score no Yes Yes no
WBC 5-15,000 lt20,000 lt15,000 lt5gt15
Bands/BNR - lt1.5x10?/L lt0.2 BNR no
LP No Yes Yes lt8 wbc Yes ? 5
urine 10WBC/hpf - 10WBC/hpf EUA ? 9
Stool(if diarrhea) 5 wbc/hpf - - lt 5
CXR - - Yes Neg if sx
ATB(Ceftrx) No Yes No 34.7??
SBI in low risk Pts () 1.1 5.4 0 0
NPV() 98.9 94.6 100 100
Sens () 92.4 Not stated 100 100
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Age lt 29 days

• CBCD, glucose,BUN,Creat,lytes, /- cap.gasses
• Blood culture
• Urine cath (microscopy and culture)
• LP (if infant unstable defer)
• CXR (suspected respiratory disease)
• NPW (suspected viral respiratory disease)
• Stool for WBC, culture and heme test (suspected
  eneteric infection)

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Age lt 29 days

• Contd
• Supportive care
• Antibiotics
• Ampicillin AND
• Gentamycin OR Ceftriaxone/Cefotaxime
• Consider Acyclovir
• Admit

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29 to 60 days

• CBCD, BNR
• Blood culture
• LP (if infant unstable defer)
• Urine cath (microscopy and culture)
• CXR (suspected respiratory disease)
• Stool for WBC, heme test and culture (suspected
  enteric infection)

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29-60 days Low risk

• Past history
• Born gt37 wks
• Home with or before the mother
• No subsequent admission
• No prenatal,postnatal,or current antibiotics
• No treatment for unexplained hyperbilirubinemia
• No known immune deficiency

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29-60 days Low risk

• P/E
• Appears generally well (non-toxic)
• No evidence of skin,soft tissue,bone,
• joint,or ear infection

21
29-60 days Low risk

• Laboratory
• WBC gt5k lt15k
• ANC lt10K or band/neutrophil ratio lt 0.2
• Urine lt10 WBC/hpf, spun and negative Gram stain
• CSF Non-bloody ,lt 8 WBC , normal glucose,
  protein, negative Gram stain and latex agg.test
• Normal CXR (if it was done)
• Stool (if diarrhea) lt5 wbc/hpf

22
29-60 days Low Risk

• Option II
• Ceftriaxone 50 mg/kg IV or IM
• Re-evaluate in 24 hours and 48 hours
• Optional second dose of ceftriaxone at second
  visit

• Option I
• No antibiotics
• Admit for observation OR
• Re-evaluate in 24 48 hours

Discharge only if Reliable caregiver Has nearby
telephone Adequate transportation
23
61-90 days Low Risk

• Option I
• No LP
• No antibiotics
• Admit for observation OR
• Re-evaluate in 24 hours

• Option II
• LP if normal
• Ceftriaxone 50 mg/kg (IV or IM) OR
• NO antibiotics
• Admit for observation.
• OR
• Re-evaluate in 24 hours

Discharge only if Reliable caregiver Has nearby
telephone Adequate transportation
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29-90 days High risk

• Toxic
• Positive labs
• Concerning history /social factors

• Admit
• Supportive care
• Meningitis
• Ceftriaxone and Vancomycin
• Non-meningitis
• Ampicillin and
• Ceftriaxone OR Gentamycin

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3-36 months

• Toxic looking
• Fever, meningeal signs, lethargic, limb,
  mottled
• Admit, septic work-up, parenteral antibiotics
• Focal bacterial infection
• OM, pharyngitis, sinusitis, etc (excluding SBI).
• Oral/parenteral antibiotics, outpatient care
• Well looking
• Risk for occult bacteremia and serious
  bacterial infection
• Previous decision analysis( Pre-H. flu
  immunization)
• Current decision analysis

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3-36 months

• High risk/toxic
• Admit
• Supportive care
• Septic work-up
• IV antibiotics
• Meningitis----gtVanco Ceftriaxone
• Non-meningitis ----gt Ceftriaxone

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3-36 months

• Non-toxic
• If lt3 yrs,temp gt39
• Obtain CBC,Blood culture,Urinalysis culture
• Stool culture,CXR as indicated
• If WBCgt15k ---gtEmpiric antibiotics
• (Ceftriaxone,Clavulin,Biaxin, omnicef or
  Suprax )
• If urine is positive treat as UTI
• If WBC normal ,urine is negative no therapy
  needed

28
3-36 months

• Contd
• IF Temp lt 39, Non-toxic, No focus of infection
• NO INVESTIGATIONS ARE REQUIRED
• Follow up all in 24 hours

29
Management of fever in children with underlying
illness
30
Oncology patients

• At risk of overwhelming sepsis
• CBC, CXR, blood culture, urine culture, and LP
  when clinically indicated
• Neutropenic patients at risk for Pseudomonas and
  other gram negative
• Broad spectrum antibiotics

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Acquired Immunodeficiency Syndrome

• Repeated risk of infection with common bacterial
  pathogens, risk of Pneumocytsis carinii,
  mycobacterial infections, cryptococcosis, CMV,
  Ebstein-Barr virus.
• Low CD4 septic work up and broad spectrum
  antibiotic

32
Sickle Cell Anemia

• Functional asplenia susceptible to overwhelming
  infection esp. encapsulated organisms such as
  pneumococci and H. flu
• Parvovirus can cause aplastic crisis
• Osteomyelitis should be suspected in fever and
  bone pain
• CBC, retics,blood culture, stool culture, and
  urine culture recommended
• Ceftriaxone
• Hospitalization recommended

33
Congenital Heart Diseases

• Children with valvular heart disease are at risk
  for endocarditis
• Fever without obvious source with a new or
  changing murmur hospitalization, serial blood
  cultures, echo, antibiotics against S.viridans,
  S aureus, S. fecalis, S. pneumo,
  enterococci, H. flu, and other gram neg rods
• Suggested antibiotics include Vancomycin and
  Gentamycin until cultures are known

34
Ventriculoperitoneal shunts

• Must be evaluated for shunt infection esp if
  patient displays headache, stiff neck, vomiting,
  or irritability
• Shunt reservoir should be aspirated and examined
  for pleocytosis and bacteria
• Most common pathogen is S. epidermidis
• CT head also warranted

35
Febrile Seizures

• 455 children with simple febrile seizure
• -1.3 with bacteremia
• -5.9 UTI
• - 12.5 with abnormal chest x-ray
• -Normal CSF in all who had an LP (135)
• Trainor J, et al Clin Pediatr Emerg Med 1999

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Febrile Seizures

• 486 children with bacterial meningitis
• -complex seizures present in 79
• -93 of those with seizures were obtunded
• -of the few with normal LOC, 78 had
  nuchal rigidity
• Green SM, et al Pediatrics 1993

37
Febrile Seizures

• Synopsis of the American Academy of Pediatric
  practices parameters on the evaluation and
  treatment of children with febrile seizures
• LP strongly considered in the first seizure in
  infants less than 12 month because signs and
  symptoms of meningitis may be absent in this age
  group
• 12-18 months LP should be considered because sign
  of meningitis may be subtle in this age group
• 18 months LP only if signs and symptoms of
  meningitis
• 
  (Peditrics 1999)

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Febrile Seizures

• Routine lab (CBC, lytes, Ca, phos, Mg, or
  glucose) should not be performed in simple
  febrile seizure
• Neuro-imaging should not be performed routinely
  on simple febrile seizure
• EEG is not performed in a neurologically healthy
  child with simple febrile seizure
• Anticonvulsant therapy is not recommended in
  simple febrile seizure

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DDx Fever with rash

• Viral exanthems
• Streptococcal infection
• Staphylococcal scalded skin syndrome / Toxic
  shock syndrome
• Kawasaki disease
• Meningococcal disease
• Henoch Schonlein purpura (HSP)

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Measles

• paramyxo virus
• Spread by respiratory droplets
• Incubation period 7 12 days
• CF prodromal period (fever, conjuctivitis,
  coryza, dry cough, koplik spots /-
  lymphadenopathy) florid maculopapular rash
  appearing over head and neck spreading to cover
  the whole body X 3-4 days
• Infectious from the prodromal period until 4 days
  after rash appeared
• Dx Measles Antibodies in saliva or serum
• Complications OM, pneumonia, encephalitis,
  subacute sclerosing pan encephalitis

41
Chicken pox (Varicella)

• varicella zoster DNA virus, IP 14 21 days
• Fever malaise X 5-6 days followed by crops of
  skin lesions that go through stages of macules,
  papules, vesicles, and crusting
• Infectious 2 days before rash until vesicles
  dry/crust
• Complications Secondary bact. Infection of
  lesions, haemorrhagic varicella, pneumonia,
  encephalitis, ataxia at 7-10 days after rash
• Severe illness in immunocompromised adults, preg.
  Women neonates

42
Rubella (german measles)

• RNA rubella virus
• Incubation period 14 21 days
• Fever, rash, posterior cervical lymph node
• Complications Deafness,encephalitus, Congenital
  rubella syndrome
• Rx Symptomatic

43
Roseola infantum (Human herpes virus type 6)
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Roseola infantum

• Caused by Human herpes DNA virus type 6 7
• Many children already infected by 2 years
• Incubation period 5- 15 days
• CF short febrile illness x 3- 5 days and an
  erythematous rash
• Complication Meningoencephalitis Sz

45
Erythema infectiosum (Fifth dis/ Slapped cheek
dis)

• Human parvo virus B19
• Incubation period 7 17 days
• Head ache malaise
• rash on face ( slapped cheek app.) spreading to
  the trunk and limbs with maculopapular lesion
  evolving to a lace- like reticular pattern
• Complications Aplastic crisis with underlying
  chronic haemolytic anaemia, Aseptic meningitis,
  Hydrops fetalis

46
Hand, Foot Mouth disease

• Caused by coxsackie A16, A19 and Enterovirus 71
  RNA viruses
• Incubation period 4 7 days
• CF fever, malaise , head ache, pharyngitis,
  vesicular lesions on the hands and feet including
  palms soles
• May be complicated by chronic recurrent skin
  lesions
• Rx Symptomatic

47
Infectious mononucleosis (Glandular fever)

• Ebstein Barr (DNA) virus
• CF fever, lymphadenopathy, tonsillitis,
  headache, malaise, myalgia, splenomegaly,
  petechiae on soft palate, rash (macular,
  maculopapular, urticarial or erythema multiforme)
• DX EBV specific IgM Paul Bunnell test
• Complication Splenic rupture, ataxia, facial
  nerve palsy, aplastic anaemia, interstitial
  pneumonia
• Rx Symptomatic

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UTI in childhood

• UTI is common
• VUR is assoc with renal scarring particularly in
  the 1st year pf life
• chronic renal failure
• Neonates irritability, refusal of feeds,
  vomiting, FTT, prolonged NNJ, toxic/extremely
  unwell
• Pre-school vomiting, poor wt. Gain, fever,
  malaise, freq, dysuria, enuresis, haematuria,
  loin pain

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UTI

• Inv Urine m/c/s x 2 (or 1 SPA urine sample)
  mid stream, clean catch, bag, SPA urine sample
• Pyuria, organism on microscopy
• Significant bacteruria gt 10 5 org/ml or and
  growth from SPA
• Treatment Antibiotics PO or iv
• Commence low dose prophylactic antibiotic
• Refer to the Paediatrician for further
  investigations

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Meningococcal disease

• Gram neg. diplococci
• Nasopharyngeal carriage in 25
• Invasive disease in 1 carriers
• 15 meningitis 60 Septicaemia endotoxaemia
• fulminant septicaemic shock with circulatory
  failure wide spread purpura
• Rx Antibiotics management of shock, anticipate
  ventilatory failure
• Transfer to PICU and contact public health dept
• Prognosis Poor if lt1 year, better if evolution
  of ds slower overall mortality approx. 30

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Kawasaki disease

• Systemic vasculitis of early childhood
• 80 cases lt 4 years MF ratio 1.51
• No single diagnostic test 5/6 clinical criteria
• fever gt5 days
• Changes in the mucous membrane of URT
• Changes in the peripheral extremities (oedema,
  desquamation
• Polymorphous rash (urticarial, maculopapular,
  multiforme)
• Cervical lymph adenopathy
• Exclusion of staphylococcal streptococcal
  infection others (Measles, drug reaction, JCA)
• Coronary aneurysm fever 3 / 4 criteria

52
Kawasaki disease

• Other features irritability, arthritis, aseptic
  meningitis, hepatitis, hydropic gall bladder
• 20-30 Myocarditis, pericarditis, arthymia,
  cardiac failure, coronary aneurysm
• Rx High dose IV Ig 2g/Kg over 12-18 hrs
• High dose Aspirin 30mg/Kg/day until fever
  resolves then 3-5mg/Kg/day
• Cardiac echo for coronary aneurysm

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Investigation

• According to the differential diagnosis
• Indicated if child is unwell and or no cause
  identified
• full infection screen
• Urinalysis Urine m/c/s
• where no focus of infection
• All children lt2 years where SS of UTI is non
  specific and diagnosis has implication for future
  management
• With urinary symptoms
• Before starting antibiotics

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Complete Infection Screen

• FBC blood film WBC differential, band
  neutrophil ratio
• CRP
• Throat swab virology, m/c/s
• Urine m/c/s
• Blood c/s
• Blood for PCR and rapid antigen screen
  meningococcal, pneumococcal,
• Stool m/c/s virology
• CXR
• LP for CSF analysis protein, glucose, m/c/s

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Treatment

• Temp control antipyretics (paracetamol,
  Ibuprofen) exposure avoid dehydration
• Sick / deteriorating child supportive mx with
  best guess antimicrobial therapy
• Specific cause
• Indication for referral to paediatric team
• Unwell/ toxic
• Unknown source or cause of fever particularly in
  early childhood
• Associated systemic symptoms signs
• Fever gt 14 days (PUO)