Febrile Child Flashcards
(36 cards)
1
Q
What constitutes fever?
A
- Temperature> 38C (axillary)
- Do not disregard parental perception that “child felt hot” or fevers recorded at home
- Most accurate way to measure is axillary temperature with digital thermometer (<3 months)
- Can use tympanic thermometer >3 months (retract pinna)
2
Q
Infectious causes of fever in children?
A
- Viral
- Most common cause in well, fully vaccinated children (10-12 episodes per year in toddlers)
- Bacterial
- Occult bacteraemia (rare if fully vaccinated)
- UTI: 7% of infants with fever without clinical focus
- Pneumonia
- Meningitis
- Otitis media
- Septic arthritis and osteomyelitis Cellulitis
- Abscess
3
Q
Viral causes of acute fever in children?
A
Influenza, RSV, adenovirus, para-influenza, parechovirus, enterovirus, EBV, HSV, VZV etc
4
Q
Bacterial causes of acute fever in children?
A
– Neonates:
• Group B Strep, E.Coli, Pneumococcus, Staph spp, Salmonella, Listeria
– Older children:
• Pneumococcus, Staph spp, E.Coli, Salmonella
5
Q
Risk factors for serious bacterial infections?
A
- Age
– <3 months (especially <4 weeks) = 10-15% of fever caused by bacterial infections
– UTI most common
– also think about pneumonia, sepsis, meningitis, osteomyelitis - Higher fever
– T>40 increased risk bacterial infection <3 months compared to T38 BUT can be afebrile and septic - Not immunised:
– Up to 7% risk serious bacterial infection vs <1% if immunised - Prematurity:
– Correct for gestational age (3 month old ex- 28 week infant has sepsis risk of term newborn) - Maternal factors for neonates:
– Group B strep, HSV, prolonged rupture of membranes - Recent antibiotics (last 3-7 days):
– Can mask signs and symptoms of sepsis / meningitis especially in young infants <3months - Appears ill / signs of toxicity
6
Q
What are the signs of toxicity in fever?
A
- Alertness/activity/arousal (decreased)
- Breathing difficulties
- Tachypnoea, grunting, respiratory distress, or shallow irregular respiration
- Circulation (colour, capillary refill <3 seconds)
- Decreased fluids in (< 50% normal/24hrs) or fluids out (< 4 wet nappies/24hrs), skin turgor, mucous membranes
• Vital signs:
– heart rate
– respiratory rate
– blood pressure
– pulse oximetry
– repeated temperature measurement
• A septic child may be hypothermic
7
Q
What are normal paediatric ranges for heart rate?
A
8
Q
How do you determine if there is a serious infection?
A
- Clinically identifiable source of fever
- Resuscitate if necessary
- Treat infection
- Fever without clinical source
- How do we identify which children need further investigation and treatment?
- Age of child
- Immunisation status of child
- History of illness
- Examination and vital signs
- Appearance: sick or well?
- Signs of toxicity
- Specific risk factors
9
Q
What difficulties are there in assessing young children & infants with fever without a clinical focus?
A
- Often lack localising signs: meningitis,UTI, sepsis, pneumonia
- Signs may be difficult to elicit especially in an irritable infant
- Signs may be nonspecific:
- – diarrhoea & vomiting: gastroenteritis, UTI, or meningitis
- – abdominal pain: appendicitis, lower lobe pneumonia
- Upper respiratory tract infection does not rule out coexisting serious bacterial illness in young children
10
Q
What do you ask on history for a febrile child?
A
- Age
- Fever duration and pattern
- Height of fever
- Activity, alertness, playfulness
- Intake
- Output (urine, diarrhoea, vomiting)
- Systemic complaints (cough, breathing, rhinitis, ear discharge, pain, dysuria, limp…
- Premorbid (underlying illnesses, prematurity, development
- Immunization, travel, infectious contacts Specific parental concerns
- In neonates- antenatal and intra-partum events
11
Q
What examination do you perform in a febrile child?
A
- Head to toe, back to front!
- Walk
- Fontanelle
- ENT
- Lymph nodes
- Rash/petechiae/bruise/lumps/external genitalia
- Chest, CVS, abdomen
- Neurological meningeal irritation, cranial nerves, subtle seizures
- Musculoskeletal joints, bones, limb movements- relative paucity/asymmetry, weight bearing, limp
12
Q
Causes of fever in neonates and infants <3 months old?
A
- Higher risk of serious bacterial illness (UTI, pneumonia, bacteraemia, meningitis) because:
- Developing immune system
- Incomplete vaccination at this age
- Causative organisms:
- Group B Streptococcus
- Listeria monocytogenes
- E.Coli
- 9-19% febrile neonates presenting to ED have SBI (population selection – look sicker or sent in by GP)
13
Q
Evaluation of fever in neonates and infants <3 months old?
A
- Neonate (<28 days corrected age)
- FBC and blood cultures
- Urine microscopy and culture (catheter or supra-pubic aspirate)
- LP (unless contra-indicated)
- +/- CXR (tachypnoea, saturations, work of breathing)
- Admit for empiric antibiotics and paediatric review
- DEFG! (Don’t ever forget glucose!)
- Poor ability to localise infection – do not present with classic signs of meningitis
- May not appear that unwell
- Deteriorate rapidly, high morbidity and mortality
- Presence of a viral illness (URTI) does not rule out coexisting bacterial infection, and may increase risk of meningitis in neonate!
14
Q
Evaluation of fever in neonates and infants <3 months old?
A
15
Q
Which antibiotics for fever < 3months?
A
Refer to local protocols
- Meningitis:
- Ampicillin and Cefotaxime (plus Acyclovir)
- UTI or fever with no focus (meningitis excluded):
- Ampicillin and Gentamicin
- Severe sepsis / septic shock:
- Gentamicin,Cefotaxime,Vancomycin,Acyclovir
16
Q
Summary: febrile infant <3 months age?
A
- Neonates
- Serious bacterial infection until proven otherwise:
- Need a full septic work up including LP, and treatment with parenteral antibiotics.
- Neonate with a focus of UTI will often have generalised sepsis as well (bacteraemia and meningitis), and should therefore have LP if look unwell or if blood cultures positive.
- Serious bacterial infection until proven otherwise:
- 1-3 months
- If septic / toxic should collect urine and blood, start parenteral antibiotics, LP once stable
- Bronchiolitis: supportive care
- Bacterial focus egUTI or pneumonia: treat with antibiotics
- LP if blood cultures are positive
17
Q
Causes for occult bacteraemia - Fever in older infants (>3months) and young children (< 3years)?
A
Causative organisms:
- Haemophilus influenzae,
- Neisseria meningitidis,
- Escherichia coli,
- Staphylococcus aureus,
- Streptocccus pyogenes,
- Salmonella sp.
18
Q
Approach to febrile child? (NSW Health Guideline)
A
19
Q
Approach to febrile child (3month-3year)?
A
20
Q
Investigations for a febrile neonate?
A
- FBC
- CRP (and pro-calcitonin)
- Urine collection
- Urinalysis and urine microscopy and culture
- CSF microscopy, culture and PCR
- Chest x-ray
21
Q
Is a normal FBC (WCC) helpful in evaluating a febrile child/neonate?
A
- A normal WBC count (5X109/L to 15 x 109/L) does not rule out SBI
- In fully vaccinated children a high WBC count (>20x109/L) increases possibility of SBI: especially pneumonia or bacteraemia
- Incomplete immunisation:
- Pre-test risk of bacteraemia 5%
- Treating febrile children with WBC>15x109 with parenteral antibiotics reduces chance SBI by 75%
- Do not use WBC alone to guide treatment
22
Q
How do you interpret CRP and procalcitonin in a febrile child?
A
- • C-Reactive Protein rises 12 hours after onset fever
- – >80mg/L may indicate SBI (Sn 40-50%, Sp 90%)
- – <20mg/L may indicate SBI less likely (Sn 80%, Sp 70%)
- • Pro-calcitonin rises earlier than CRP.
- – >2ng/mL may indicate SBI (Sn 40-50%, Sp 90%)
- – <0.5ng/mL may indicate SBI less likely (Sn80%, Sp 70%)
- • Single values not as useful as serial values
23
Q
How common is UTI in children <12months?
A
- ▪ 7% of febrile infants <12 months of age with fever without identifiable source have UTI1. Untreated may cause pyelonephritis, renal scarring.
- ▪ UTI may be associated with sepsis in young infants.
24
Q
How do you collect urine in children?
A
- • <12 months:
- – Supra-pubic aspirate (1% contamination rate, perform with full bladder at level of pubic crease through anterior abdominal wall) or in/out catheter specimen (10% contamination rate)
- – Clean catch (25% contamination rate)
- – If doing clean catch try “quick wee” technique
- • >12 months:
- – Clean catch or mid-stream urine if possible (25% contamination rate)
- • Bag urines:
- – 50% contamination rate so do not send for culture
25
How reliable are urinalysis results?
* Meta-analysis of 95 studies showed dipstick positive (for leukocyte esterase or nitrite) has r sensitivity 88% and specificity 79% for diagnosing urinary tract infections (UTI) in children
* False negative rate especially \<2years (due to urine not staying in bladder very long, therefore white cells do not accumulate)
26
How do you interpret urine microscopy and culture?
* • Microscopy:
* – \>100 WBC suggests infection
* – \>10 epithelial cells suggests contamination
* • Culture positive if:
* – Growth single organism \>108 CFU/L (\>105 CFU/mL) by any collection technique
* – Single organism at \>106-8 CFU/L (\>103-5 CFU/mL) from catheter
* – Single organism any growth from supra-pubic aspirate
27
What are normal values for CSF?
28
What indicates, on CSF:
* Bacterial meningitis
* Viral meningitis
* TB meningitis
29
How do you interpret CSF culture and PCR? What organisms are PCR of CSF fluid available for?
* • Any bacterial growth abnormal, may have no growth if previous antibiotic treatment
* • PCR available for:
* – N.meningitidis,
* – S. Pneumoniae
* – Group B Strep
* – HSV (can have false negative \<72 hours illness)
* – Enterovirus
* – Parechovirus
30
What are some contraindications to lumbar puncture in a child?
* Decreased level of consciousness
* Unstable vitals (shock, impending respiratory failure)
* Focal neurological signs
* Infection at local site
* Bleeding disorder
* If contra-indications exist start antibiotics early. LP can be done later once patient is stable.
31
When to consider obtaining a CXR in a child?
* Consider in case of
* Respiratory abnormality (tachypnoea)
* Low oxygen saturations
* Prolonged fever or cough or high fever (temperature\>39C) with no identifiable source
* Young children may have pneumonia without clinical signs of decreased air entry, bronchial breathing, dullness to percussion e.g. small child with early pneumonia
32
When would you start empiric antibiotics and what would you use?
* Indications for empiric antibiotics:
* – Where possible (without causing treatment delay) after appropriate cultures have been taken
* – Febrile Neonates and infants under three months after a complete septic work up
* – Any toxic/severely unwell child
* Which antibiotic?
* – Use local guidelines
* – If septic 3rd generation cephalosporin (cefotaxime or ceftriaxone) plus aminoglycoside (gentamicin) plus staphylococcal cover (vancomycin) plus consider acyclovir
33
Where can you find information for antibiotic choice?
* • Australia: Antibiotic guidelines (e-Therapeutic Guidelines)
* • RCH guidelines
* • Children’s Hospital Westmead antibiotic cards
* • Local hospital guidelines
34
How would you counsel parents regarding a febrile child?
* Common parental concerns: fever causing harm, specific aetiological fears
* Parents seek information (cause for the fever, management, prevention) and reassurance
* Some general advice for parents:
* ▪ A fever is the body’s way of fighting infection
* ▪ Know about the warning signs of serious illness
* ▪ Risks of overmedicating and over the counter cold, flu & cough preparations
* ▪ Anti-pyretics do not prevent febrile convulsions
35
Parental counselling: when to seek early review?
Seek early review if:
* ▪ Child’s condition appears to be worsening
* ▪ Reduced fluid intake-output
* ▪ Fever prolonged beyond five days
* ▪ Parental anxiety/gut feeling “Something is not right with my child...”
36
Parental counselling: when to seek urgent review?
Urgent review in case of (warning signs of serious illness):
* ▪ Lethargy/irritability, reduced alertness
* ▪ Feed refusal/intolerance or excessive ongoing fluid loss
* ▪ Respiratory distress
* ▪ Pallor (very reliable), reduced urine output
* ▪ Worsening symptoms
* ▪ Non blanching rash
