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Paediatrics - SCHP Oral Viva > Febrile Child > Flashcards

Febrile Child Flashcards

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)
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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
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3
Q

Viral causes of acute fever in children?

A

Influenza, RSV, adenovirus, para-influenza, parechovirus, enterovirus, EBV, HSV, VZV etc

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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

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5
Q

Risk factors for serious bacterial infections?

A
  1. Age
    – <3 months (especially <4 weeks) = 10-15% of fever caused by bacterial infections
    – UTI most common
    – also think about pneumonia, sepsis, meningitis, osteomyelitis
  2. Higher fever
    – T>40 increased risk bacterial infection <3 months compared to T38 BUT can be afebrile and septic
  3. Not immunised:
    – Up to 7% risk serious bacterial infection vs <1% if immunised
  4. Prematurity:
    – Correct for gestational age (3 month old ex- 28 week infant has sepsis risk of term newborn)
  5. Maternal factors for neonates:
    – Group B strep, HSV, prolonged rupture of membranes
  6. Recent antibiotics (last 3-7 days):
    – Can mask signs and symptoms of sepsis / meningitis especially in young infants <3months
  7. Appears ill / signs of toxicity
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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

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7
Q

What are normal paediatric ranges for heart rate?

A
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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
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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
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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
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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
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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)
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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!
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14
Q

Evaluation of fever in neonates and infants <3 months old?

A
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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
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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.
  • 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
Q

How reliable are urinalysis results?

A
  • 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
Q

How do you interpret urine microscopy and culture?

A
  • • 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
Q

What are normal values for CSF?

A
28
Q

What indicates, on CSF:

  • Bacterial meningitis
  • Viral meningitis
  • TB meningitis
A
29
Q

How do you interpret CSF culture and PCR? What organisms are PCR of CSF fluid available for?

A
  • • 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
Q

What are some contraindications to lumbar puncture in a child?

A
  • 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
Q

When to consider obtaining a CXR in a child?

A
  • 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
Q

When would you start empiric antibiotics and what would you use?

A
  • 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
Q

Where can you find information for antibiotic choice?

A
  • • Australia: Antibiotic guidelines (e-Therapeutic Guidelines)
  • • RCH guidelines
  • • Children’s Hospital Westmead antibiotic cards
  • • Local hospital guidelines
34
Q

How would you counsel parents regarding a febrile child?

A
  • 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
Q

Parental counselling: when to seek early review?

A

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
Q

Parental counselling: when to seek urgent review?

A

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

Paediatrics - SCHP Oral Viva (14 decks)

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