Fever

Question 1

T/F: Fever is a very common problem in children

Answer 1

true - esp in under 2s Fever is 2nd most common cause of hospital admission in children (next to breathing difficulty)

Question 2

T/F: Fever in a child is most often a sign of serious bacterial infection.

Answer 2

false - Most fevers in children are caused by mild viral infections, which get better by themselves. Average of 8 illnesses with a temperature by 18 months

Question 3

why are serious bacterial infections are more likely in children under two years old?

Answer 3

because it takes until roughly two years old for their immune system to become mature enough to handle infections well. Changes in the thymus organ and the spleen are happening through these early years.

Question 4

The highest risk age group for serious infection is babies under what age

Answer 4

3 months old

Question 5

Name some of the most common causes of serious feverish illnesses in children in developed countries

Answer 5

Question 6

can think of the potential sources of fever in children in a top-to-toe fashion.

Answer 6

Question 7

T/F: a key differentiating factor between mild viruses and serious bacterial infections is a high temperature, lethary and not wanting to eat or drink very much

Answer 7

false - can happen in either mild viruses or serious bacterial infections, making them hard to differentiate

Question 8

what sort of parameters to look at when considering whether a child has a serious bacterial infection?

Answer 8

colour, activity, RR, circulation and hydration

(Table from NICE: Fever in under 5s)

Question 9

How would you explain the following to a parent

‘the localised infection has spread and is starting to cause septicaemia’

Answer 9

‘it has entered into the bloodstream and all the tissues, not just the area affected by the infection’

Question 10

When bacteria multiply in the bloodstream they release “poisons”, such as endotoxin, into the circulation.

State an example of an infection in children this occurs in, and what sign it causes

Answer 10

the endotoxin released in meningococcal septicaemia > purpuric rash

Question 11

why does sepsis cause circulatory shock?

Answer 11

body’s inflammatory response causes leaky blood vessels, poor contraction of the heart and can cause the lungs or other organs to fail > pt loses fluid from the blood stream > circulatory failure and shock.

Children may need fluid replacement of 20-40 ml per kg

Question 12

T/F: children compensate well in the early stages of infection

Answer 12

true - by an autonomic response, which shrinks the blood vessels in the peripheries making sure that the vital organs, such as the brain and kidneys, still receive an adequate blood supply.

(causes peripheral shutdown > why we test CRT and feel temp of hands and feet)

Question 13

what blood tests will help in the acute setting for identifying infection?

Answer 13

VBG: metabolic acidosis and high lactate (lactic acid released into circulation through anaerobic metabolism where periphereal tissues are underperfused). Base excess more than -3/ lactate >3 are significant. The acidosis causes a child to breath faster in order to normalise the blood pH > high RR.

WBC: raised

CRP: often doesn’t help in acute setting as hasn’t had time to rise

Question 14

some children are just prone to fevers

in general, a temperature greater than ___ degrees is more worrying

Answer 14

39.5

Except babies (0-3 months), when a fever of >38 is considered significant.

Question 15

what duration of fever is worrying?

Answer 15

5 days or more (more likely something serious e.g. UTI or Kawasaki)

Most only last a day or two

Question 16

It is also important to find out if the child has had any problems which may make them more vulnerable e.g.?

Answer 16

CP or prematurity, or a child on steroids, or who has had leukaemia in the past.

Question 17

Questions to ask in a Hx of a child presenting with fever?

Answer 17

• how long?
• rash?
• comorbidities e.g. CP, prematurity, on steroids, PMH of leukaemia
• does it come down with antipyretics e.g. paracetamol/ ibuprofen?
• behaviour: drowsy? irritable? miserable? clingy?
• colour: compare to normal
• eating and drinking
• vaccinations

Question 18

A temperature in itself will increase the heart rate. How to tell therefore if they have a tachycardia due to temperature or illness?

Answer 18

May be able to spot an inappropriately high HR > degree of fever adds about 10 to the heart rate.

Give an antipyretic and review in half an hour.

If the RR is high w/o signs of resp distress, consider septicaemia.

Question 19

T/F: low BP is an early sign of shock in children

Answer 19

False - their highly efficient peripheral shut down keeps the blood pressure normal until very late in the disease process.

If peripheral shut down detected > start IV fluids asap

Question 20

What to look for in particular in a child with a temperature?

Answer 20

‘ABCDENTT’

• general behaviour (drowsy, irritable etc.). Appearance: colour, mottled?
• B: RR, work of breathing
• C: HR, CRT
• E: rash (check all over), BM Stix (hypoglycaemia can occur in sepsis)
• T: temperature of hands and feet
• T: abdo exam

urine sample if no source of infection identified by this point. Next steps depend on traffic light system.

Question 21

what in examination may make you consider meningitis

Answer 21

• non-blanching purpuric rash
• temperature
• bulging fontanelle
• photophobia
• NB: neck stifness is a late/ unreliable sign

Question 22

The eardrums are often pink, just because of a temperature, just like cheeks become flushed.

Therefore only diagnose otitis media when?

Answer 22

if the eardrum has a fluid level behind it, or is very dull and non-reflective, or looks significantly different from the oppostite eardrum.

Question 23

children with amber and red features tend to have further tests done to seek out the cause e.g. ?

Answer 23

• FBC
• blood cultures
• CRP
• CXR
• VBG
• LP if >1yr/ meningitis suspected

Question 24

T/F: degree of fever is a strong predictor of seriousness of illness.

Answer 24

false - there is a correlation between incidence of serious bacterial infection and degree of fever but it is weak.

Individual variation of the way a child’s temperature reacts when they’re ill has a lot of bearing on the degree of fever.

Question 25

measuring temp in babies vs infants and older children?

Answer 25

babies - armpit

infants/ older children - eardrum

Question 26

T/F: babies under 8 weeks of age may have a serious infection but not have a fever

Answer 26

true

In fact, temp may in fact drop. Hypothermic baby = red flag

Question 27

T/F: if you give an antipyretic and the temperature comes down this is a sign that the infection is a mild infection.

Answer 27

false - is purely a pharmacological response and happens in most children, whatever the cause.

Question 28

reason for giving an antipyretic?

Answer 28

• to recheck behaviour and physiology once the temperature is dealt with. By removing the influence of the fever on the respiratory rate and heart rate, you can then judge if the child has a tachypnoea or tachycardia as a sign of serious infection
• to observe behaviour. Remain subdued even when their temperature is down = red flag

Question 29

T/F: a CXR is often needed to diagnose pneumonia in kids

Answer 29

true - as the symptoms are notoriously subtle

e.g. children with bacterial pneumonia will appear more unwell and lethargic than with common viral resp infections, temp >38.5 and often refusing food and drink

Question 30

When examining the respiratory system the most important discriminating sign is what?

Answer 30

raised respiratory rate

<3s who require hospitalisation > raised RR is enough to warrant a CXR

Low sats give another important clue to the presence of pneumonia.

Question 31

If your history and physical examination of the child have revealed no source for the fever, consider what?

Answer 31

a UTI

Young children may not have classic symptoms of pain on passing urine. More likely to be non-specific e.g. fever, vomiting, poor feeding, abdominal pain or irritability.

Question 32

How to collect a urine sample if a child is still in nappies? (that avoids a sample contaminated with faeces or skin germs)

Answer 32

obtain a clean catch urine.

• take off the child’s nappy
• clean the genital area
• give the parents a sterile container, they must remain vigilant for the first sign of passing urine. The urine is caught in the container at that time.

(ply the child with lots of drinks to help)

Question 33

With modern multireagent DipStix it is easy to exclude a urinary tract infection, if all the components are negative - especially the ___ and _____.

What to do if these are positive?

Answer 33

nitrites

leucocytes

If +ve, the urine should be sent to a lab for a full culture, and the child should be treated with antibiotics in the meantime, until the result is available.

Question 34

What signs of bone/ joint infection may be noticed?

Answer 34

• look at elbow, hip or knee.
• Parent may note the child is reluctant to use the limb, or that it seems to hurt when moved.
• Child may be limping or refusing to walk
• May or may not be warmth and redness over the affected area in the early stages.

Question 35

septic arthritis management?

Answer 35

surgical emergency - needs urgent opening out of the joint and washing out of the infection

If you have any suspicion, refer immediately to a senior orthopaedic surgeon.

Question 36

what is this describing: a disease of childhood most common in the under 2s which has serious complications with the heart and coronary arteries.

Answer 36

Kawasaki disease

(with the right drug treatments started early these serious problems can be prevented)

Question 37

Clinical features of kawasaki disease?

Answer 37

NB: work from top to bottom of head to remember symptoms

eyes> conjunctivitis

mouth > red, cracked lips, strawb tongue

throat > injection of oropharngeal mucous membranes. Cervical lymphadenopathy

rash is usually maculopapular

Question 38

symptoms of influenza?

Answer 38

headache, muscle ache, sore throat, fever, general tiredness. There may be a cough.

Younger children will have less specific symptoms and may have vomiting or diarrhoea or a rash

The symptoms overlap with other diagnoses such as bacterial meningits and pneumonia, but also much more minor viral infections. The younger the child, the more you need to keep an open mind.

Question 39

T/F: Mild, viral meningitis occurs with many common infections.

Answer 39

true - mostly just felt as a HA

Question 40

what are the commonest causative organisms for meningitis in the UK?

Answer 40

NB: meningococcus aka Neisseria meningitidis

Question 41

the incidence of meningitis has dropped significantly since widespread vaccination for what pathogens?

Answer 41

Haemophilus B and Meningococcus C

There is also a vaccine available for the Pneumococcus.

Question 42

what does the term ‘meningitis’ mean?

Answer 42

inflammation of the meninges of the brain.

Can become infected by various viruses or bacteria, and when this happens it causes headache, drowsiness, and sometimes fits.

The same bacteria which cause meningitis also cause septicaemia.

Question 43

Children with septicaemia are more likely to die than those with pure meningitis. The mode of death is different, depending on which is the greater problem.

Answer 43

Question 44

signs and symptoms of meningitis?

Answer 44

Question 45

symptoms and signs of meningococcal septicaemia

Answer 45

Question 46

what causes the purpuric rash of meningococcal septicaemia?

Answer 46

due to the endotoxin which the bacterium releases.

Causes leaking of the capillaries, and the red blood cells leak into the skin. Is the basis of the tumbler test (can do the same thing just by pressing on the rash and seeing if that makes it fade)

Question 47

before the classic purpuric rash of meningococcal septicaemia develops, how may it appear?

Answer 47

early stages may start as a pink blanching rash

So don’t assume that a rash is innocent if it is blanching, but the child is unwell.

NB: the purple rash can evolve rapidly, and later on the intensive care unit these areas of skin can break down and need skin grafts or amputation.

Question 48

if referring a child to the hospital for suspected meningitis, what treatment should you administer asap?

Answer 48

IM/ IV Abx - either penicillin or ceftriaxone, as every minute counts.

With modern DNA technology the diagnosis can be made on blood or other samples, after the antibiotics have been given, so there is no reason to not give antibiotics immediately.