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Dr. Osama Kentab, MD, FAAP, FACEP

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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)

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