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

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)

Implications of body temperatureIs it beneficial?Rate of bacteraemia is 2-3% in all febrile

infants < 2months (Baker 1999; Kadesh et al 1998)

Infants < 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

Assessment: Relevant historyDuration of feverPattern of fever: intermittent or

continuousHx of contact: family members, friends,

school matesHx 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

Relevant symptomsSystemic symptoms: Resp, ENT, Renal, GIRash: Pattern/type (macular, papular,

ulcerative, erythematous, blanching)Distribution (mucosal involvement-

conjuctivitis, mucositis, buttocks and extremities(HSP) Oral ulcers (aphthous, herpes gingivostomatitis)

Relevant clinical signs Unwell – ToxicHaemodynamic instabilityRashLower Respiratory signsJoint involvement: Arthritis/ Athralgia:

Reactive viral arthritis, Septic arthritis, HSP, Rheumatic fever, Chronic arthritis of childhood

Organomegaly: Hepatomegaly, Splenomegaly, +/- Anaemia: Systemic illness, Septicaemia, Lymphoproliferative disorders

Causes of febrile illnesses in childhood

Common causesURTI (viral or bact.)LRTIGastroenteritisUTIOral (dental abscess,

hyperangina, herpetic gingivitis, mumps)

MSS (septic arthritis, osteomyelitis, cellulitis

Serious causesURTI (epiglottitis,

croup, retropharyngeal abscess)

LRTIGI (appendicitis)CNS (Meningitis,

encephalitis)Systemic

(meningococcaemia, toxic shock syndrome

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 >37 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 <20,000 <15,000 <5>15

Bands/BNR - <1.5x10/L <0.2 BNR no

LP No Yes Yes <8 wbc Yes 5

urine 10WBC/hpf - 10WBC/hpf EUA 9

Stool(if diarrhea) 5 wbc/hpf - - < 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

Management of fever in young children

8

Age < 29 days CBCD,glucose,BUN,Creat,lytes, +/-

cap.gassesBlood cultureUrine 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)Management of fever in young children 9

Age < 29 days

Cont’dSupportive careAntibiotics: Ampicillin AND Gentamycin OR Ceftriaxone/Cefotaxime Consider AcyclovirAdmit

Management of fever in young children 10

29 to 60 days CBCD, BNRBlood 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)


29-60 days Low riskPast historyBorn >37 wksHome with or before the motherNo subsequent admissionNo prenatal,postnatal,or current

antibioticsNo treatment for unexplained

hyperbilirubinemiaNo known immune deficiency


29-60 days Low riskP/EAppears generally well (non-toxic)No evidence of skin,soft tissue,bone, joint,or ear infection


29-60 days Low riskLaboratoryWBC >5k <15kANC <10K or band/neutrophil ratio < 0.2Urine <10 WBC/hpf, spun and negative Gram

stainCSF: Non-bloody ,< 8 WBC , normal glucose,

protein, negative Gram stain and latex agg.test

Normal CXR (if it was done)Stool (if diarrhea) <5 wbc/hpf


29-60 days Low Risk

Option IICeftriaxone 50

mg/kg IV or IMRe-evaluate in 24

hours and 48 hoursOptional second

dose of ceftriaxone at second visit

Option INo antibioticsAdmit for observation

ORRe-evaluate in 24 & 48

hours


Discharge only if:

Reliable caregiver

Has nearby telephone

Adequate transportation

Discharge only if:

Reliable caregiver



61-90 days Low RiskOption INo LP No antibiotics Admit for observation

ORRe-evaluate in 24

hours

Option IILP & if normal:Ceftriaxone 50 mg/kg

(IV or IM) ORNO antibioticsAdmit for observation.

ORRe-evaluate in 24

hours


Discharge only if:

Reliable caregiver



Discharge only if:

Reliable caregiver



29-90 days High riskToxicPositive labsConcerning

history /social factors

AdmitSupportive careMeningitis Ceftriaxone and

VancomycinNon-meningitis Ampicillin and Ceftriaxone OR

Gentamycin


3-36 months Toxic looking Fever, meningeal signs, lethargic, limb, mottled

Admit, septic work-up, parenteral antibioticsFocal bacterial infection

OM, pharyngitis, sinusitis, etc (excluding SBI).Oral/parenteral antibiotics, outpatient care

Well looking Risk for occult bacteremia and serious bacterial

infectionPrevious decision analysis( Pre-H. flu

immunization)Current decision analysis


3-36 months High risk/toxicAdmitSupportive care Septic work-upIV antibiotics Meningitis---->Vanco + Ceftriaxone Non-meningitis ----> Ceftriaxone


3-36 months Non-toxicIf <3 yrs,temp >39 :Obtain CBC,Blood culture,Urinalysis & cultureStool culture,CXR as indicatedIf WBC>15k --->Empiric antibiotics (Ceftriaxone,Clavulin,Biaxin, omnicef or

Suprax )If urine is positive treat as UTIIf WBC normal ,urine is negative no therapy

needed


3-36 months Cont’dIF Temp < 39, Non-toxic, No focus of

infectionNO INVESTIGATIONS ARE REQUIREDFollow up all in 24 hours



Oncology patientsAt risk of overwhelming sepsisCBC, CXR, blood culture, urine culture, and

LP when clinically indicatedNeutropenic patients at risk for Pseudomonas

and other gram negativeBroad spectrum antibiotics


Acquired Immunodeficiency SyndromeRepeated 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


Sickle Cell AnemiaFunctional asplenia susceptible to

overwhelming infection esp. encapsulated organisms such as pneumococci and H. flu

Parvovirus can cause aplastic crisisOsteomyelitis should be suspected in

fever and bone painCBC, retics,blood culture, stool culture,

and urine culture recommendedCeftriaxone Hospitalization recommended


Congenital Heart DiseasesChildren with valvular heart disease are

at risk for endocarditisFever 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


Ventriculoperitoneal shuntsMust 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. epidermidisCT head also warranted


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


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 rigidityGreen SM, et al: Pediatrics 1993


Febrile SeizuresSynopsis 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)


Febrile SeizuresRoutine 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


DDx Fever with rash

Viral exanthems Streptococcal infectionStaphylococcal scalded skin syndrome /

Toxic shock syndromeKawasaki diseaseMeningococcal disease Henoch Schonlein purpura (HSP)

Measlesparamyxo virusSpread by respiratory dropletsIncubation period: 7 – 12 daysCF: 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 serumComplications: OM, pneumonia, encephalitis,

subacute sclerosing pan encephalitis

Chicken pox (Varicella)varicella zoster DNA virusIncubation period 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

Rubella (german measles)RNA rubella virusIncubation period: 14 – 21 days Fever, rash, posterior cervical lymph nodeComplications: Deafness,encephalitus,

Congenital rubella syndromeRx: Symptomatic

Roseola infantum (Human herpes virus type 6)

Roseola infantum Caused by Human herpes DNA virus type 6 &

7Many children already infected by 2 years Incubation period: 5- 15 daysCF: short febrile illness x 3- 5 days and an

erythematous rashComplication: Meningoencephalitis & Sz

Fifth Disease

Erythema infectiosum (Fifth ds/ Slapped cheek ds)

Human parvo virus B19Incubation period: 7 – 17 daysHead 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

Hand, Foot & Mouth diseaseCaused by coxsackie A16, A19 and

Enterovirus 71 RNA virusesIncubation period: 4 – 7 daysCF: 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

Infectious mononucleosis (Glandular fever)

Ebstein Barr (DNA) virusCF: fever, lymphadenopathy, tonsillitis,

headache, malaise, myalgia, splenomegaly, petechiae on soft palate, rash (macular, maculopapular, urticarial or erythema multiforme)

DX: EBV specific IgM; Paul Bunnell testComplication: Splenic rupture, ataxia,

facial nerve palsy, aplastic anaemia, interstitial pneumonia

Rx: Symptomatic

UTI in childhoodUTI is commonVUR is assoc with renal scarring

particularly in the 1st year pf lifechronic 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

UTI (2)Inv: Urine m/c/s x 2 (or 1 SPA urine

sample) – mid stream, clean catch, bag, SPA urine samplePyuria, organism on microscopySignificant bacteruria > 10 5 org/ml or and

growth from SPATreatment: Antibiotics PO or ivCommence low dose prophylactic antibiotic

Refer to the Paediatrician for further investigations

Meningococcal diseaseGram neg. diplococciNasopharyngeal carriage in 25%Invasive disease in 1% carriers15% meningitis; 60% Septicaemia +

endotoxaemia; fulminant septicaemic shock with circulatory

failure & wide spread purpuraRx: Antibiotics; management of shock,

anticipate ventilatory failureTransfer to PICU and contact public health deptPrognosis: Poor if <1 year, better if evolution of

ds slower; overall mortality approx. 30%

Kawasaki disease Systemic vasculitis of early childhood 80% cases < 4 years & M:F ratio = 1.5:1

No single diagnostic test; 5/6 clinical criteria fever >5 daysChanges in the mucous membrane of URTChanges in the peripheral extremities (oedema,

desquamationPolymorphous rash (urticarial, maculopapular,

multiforme)Cervical lymph adenopathyExclusion of staphylococcal & streptococcal

infection & others (Measles, drug reaction, JCA)Coronary aneurysm +fever + 3 / 4 criteria

Kawasaki disease (2)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 hrsHigh dose Aspirin 30mg/Kg/day until fever

resolves then 3-5mg/Kg/dayCardiac echo for coronary aneurysm

InvestigationAccording to the differential diagnosisIndicated if child is unwell and or no

cause identified full infection screenUrinalysis & Urine m/c/s

where no focus of infectionAll children <2 years where S&S of UTI is

non specific and diagnosis has implication for future management

With urinary symptomsBefore starting antibiotics

Complete Infection ScreenFBC & blood film; WBC differential, band

neutrophil ratioCRPThroat swab: virology, m/c/sUrine m/c/sBlood c/sBlood for PCR and rapid antigen screen:

meningococcal, pneumococcal,Stool m/c/s & virologyCXR LP for CSF analysis: protein, glucose,

m/c/s

TreatmentTemp control: antipyretics (paracetamol,

Ibuprofen) exposure & avoid dehydrationSick / deteriorating child: supportive mx

with best guess antimicrobial therapySpecific causeIndication for referral to paediatric team

Unwell/ toxicUnknown source or cause of fever particularly

in early childhoodAssociated systemic symptoms & signsFever > 14 days (PUO)

Documents

Fever in children