1. Dr. Osama Kentab, MD, FAAP, FACEP
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. Implications of body temperature
Is 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
Although laboratory research suggests that fever has antimicrobial actions, clinical evidence to support the hypothesis that fever is beneficial during infection and that fever reduction is harmful remains elusive
Fever rarely goes unnoticed and consistently causes alarm in parents and generates discussion among physicians

4. 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

5. 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)

6. 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

7. 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

8. Protocols for Identification of Low Risk Infants
Management of fever in young children
Protocols for Identification of Low Risk Infants
Rochester
Boston
Philadelphia
Pittsburgh
Age(days)
0-60
28-89
29-56
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.
Temp C
38.0
Infant Obs.score no
Yes
WBC
5-15,000
<20,000
<15,000
<5>15
Bands/BNR
<1.5x10/L
<0.2 BNR LP No
Yes <8 wbc
Yes  5
urine
10WBC/hpf
EUA  9
Stool(if diarrhea)
5 wbc/hpf
< 5
CXR
Neg if sx
ATB(Ceftrx)
34.7%??
SBI in low risk Pts (%)
1.1
5.4
NPV(%)
98.9
94.6
100
Sens (%)
92.4
Not stated

9. Age < 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)
Management of fever in young children

10. Age < 29 days Cont’d Supportive care Antibiotics: Ampicillin AND
Gentamycin OR Ceftriaxone/Cefotaxime
Consider Acyclovir
Admit
Management of fever in young children

11. 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)
Management of fever in young children

12. 29-60 days Low risk Past history Born >37 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
Management of fever in young children

13. 29-60 days Low risk P/E Appears generally well (non-toxic)
No evidence of skin,soft tissue,bone,
joint,or ear infection
Management of fever in young children

14. 29-60 days Low risk WBC >5k <15k
Laboratory
WBC >5k <15k
ANC <10K or band/neutrophil ratio < 0.2
Urine <10 WBC/hpf, spun and negative Gram stain
CSF: 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
Cxr:a conservative approach to evaluation and management requires chest films in all circumstances,some data suggest that this is optional if infants present without specific signs and sx of resp. disease
Management of fever in young children

15. 29-60 days Low Risk Option II Option I 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
Management of fever in young children

16. 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
Management of fever in young children

17. 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
Dexa for >6 weeks
Management of fever in young children

18. 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
All consensus papers agree that any child between the ages of 0-36 months who have a fever and is toxic looking should be admitted to hospital, have a septic work-up including CBC, blood cultures, LP, and urine cultures, and stared on parenteral antibiotics. Controversy arises when making decisions about a well looking febrile child: who are at risk for bacteremia and SBI, who should receive empiric antibiotic treatment, should the child be treated as an outpatient or inpatient, and what follow-up should be arranged. Two decision analysis reports published in 1991 that investigated the utility of diagnosis and treatment strategies of children at risk for bacteremia (temp greater than 39C, no significant source of infection, and clinically looks well) concluded that the strategy of combining routine blood cultures and empiric antibiotics treatment has the greatest clinical utility. The two reports came from Lieu et al and Down et al. Their decision strategies included any well looking child with a temp greater than 39 degrees C and a WBC greater than 15,000 received blood cultures and parenteral or oral antibiotics. Since this time, several changes have occurred in the clinical assumptions made in these analyses. First, h. flu vaccine is now widespread reducing the probability of encountering this most virulent organism and reducing the prevalence of OB and SBI. Second, the emergence of Streptococcus pneumoniae as the number one organism to cause OB and the emerging resistant S. pneumococcus potentially affect the clinical decision to use empiric antibiotics. Third, the previous use of WBC of 15,000 as a cut point has not found to be highly sensitive or specific in detecting all OB. Finally, most child with S. pneumococcal bacteremia will spontaneously resolve without antibiotic treatment.
Management of fever in young children

19. 3-36 months High risk/toxic Admit Supportive care Septic work-up
IV antibiotics
Meningitis---->Vanco + Ceftriaxone
Non-meningitis ----> Ceftriaxone
Management of fever in young children

20. 3-36 months Non-toxic If <3 yrs,temp >39 :
Obtain CBC,Blood culture,Urinalysis & culture
Stool culture,CXR as indicated
If WBC>15k --->Empiric antibiotics
(Ceftriaxone,Clavulin,Biaxin, omnicef or Suprax )
If urine is positive treat as UTI
If WBC normal ,urine is negative no therapy needed
or 2-3 yrs temp >39.5
Management of fever in young children

21. 3-36 months Cont’d IF Temp < 39, Non-toxic, No focus of infection
NO INVESTIGATIONS ARE REQUIRED
Follow up all in 24 hours
Management of fever in young children

22. Management of fever in children with underlying illness
Management of fever in young children

23. 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
; combination of tobramycin and ceftazidime
Indwelling IV devices add vancomycin to tobramycin and ceftazidime
Management of fever in young children

24. 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
(TB, AI), lymphoma and other malignancies
Management of fever in young children

25. 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
Management of fever in young children

26. 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
Management of fever in young children

27. 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
Management of fever in young children

28. 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
Management of fever in young children

29. 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
Management of fever in young children

30. 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)
Royal college of physicians
Complex fs
Partially rx mening
Abnorm exam
Probably 12-18
Certainly <12
Management of fever in young children

31. 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
Management of fever in young children

32. DDx Fever with rash Viral exanthems Streptococcal infection
Staphylococcal scalded skin syndrome / Toxic shock syndrome
Kawasaki disease
Meningococcal disease
Henoch Schonlein purpura (HSP)
Measles virus (paramyxo RNA virus)
Rubella virus (RNA)
Varicella zoster virus (DNA)
Roseola infantum – human herpes virus 6 & 7 (DNA)
Fifth disease (erythemea infectiosum) – Parvo virus 19 (DNA)
Glandular fever (Infectious mononuclesis) – EBV/ DNA
Hand foot & mouth disease (cox sackie A16, A19 – RNA and entero virus 71 – RNA)

34. 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

36. Chicken pox (Varicella)
varicella zoster DNA virus
Incubation 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

38. 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

39. Roseola infantum (Human herpes virus type 6)

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

41. Fifth Disease

42. Erythema infectiosum (Fifth ds/ Slapped cheek ds)
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

44. 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

45. 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

46. 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

47. UTI (2)
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 > 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

49. 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 <1 year, better if evolution of ds slower; overall mortality approx. 30%

51. 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 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

53. 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 hrs
High dose Aspirin 30mg/Kg/day until fever resolves then 3-5mg/Kg/day
Cardiac echo for coronary aneurysm

56. 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 <2 years where S&S of UTI is non specific and diagnosis has implication for future management
With urinary symptoms
Before starting antibiotics

57. 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
WBC >15,000 has a sensitivity of 86% & PPV = 5.1%
86% of children with bacteraemia had elevated WBC but only 5.1% of those children with elevated WBC actually had bacteraemia (Baker et al, 1990)
WBC > 20,000/ mm improved the positive predictive value to 8.1% (Lee et al, 1998)
Quantitative CRP is a valuable test in the evaluation of febrile young children who are at risk of occult bacteraemia and SBI with a better predictive value than WBC count & absolute neutrophil count (Pulliam et al, Paediatrics)

58. 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 > 14 days (PUO)