Fever in childhood

Introduction Commonest reason for admission to hospital in UK Either alone or with associated symptoms Self limiting or life threatening illness Source may not be apparent May have a non infectious origin

Points to consider Is there an accepted definition? Are patterns of fever important? When should children with fever be referred to secondary care? When should we investigate? Do we need to treat fever, and if so with what?

Should be aware of the 2007 NICE guideline and its recommendations “Feverish illness in children” NICE guideline CG47

Aims Look at the key recommendations from the NICE guideline Think about the common infectious causes of fever in childhood Case histories Non infectious fever Slide quiz

Infectious Fever Skin Respiratory tract GI tract infections CNS Musculo-skeletal infections Urinary tract Travel related infections Cardiac

Case1 6 month old infant with a short history of fever Term baby Never previously unwell Immunisations up-to-date

What further history are you going to take? What are you looking for on examination?

What investigations are you going to request? Suggest a management plan?

2 hours after admission to hospital he has a short fit on the ward. How is this going to alter your management?

LP confirms raised white cell count Low glucose Raised protein

What is your management plan in terms of treatment Follow up

Case 2 7 year old boy is admitted with a weeks history of fever He has become increasingly lethargic

What further history are you going to need? What are you looking for on examination? Suggest other important investigations

Hb 9.9 WCC 15 Pls 444 Na 128 K 3.2 CRP 200

He gives a history of recent travel abroad What is going to be your management? What are the most important differentials?

Discuss specific investigations and treatment

Investigations Thick and thin Blood films Rapid Diagnostic tests looking for malarial antigens 3 clear tests exclude diagnosis Blood cultures

Management Faliciparum 1.Oral Quinine +/- clindamycin Non-Falciparum 1.Chloloquine 2.Primaquine Cefotaxime

Case 3 8 year old girl with a 7 day history of swinging fever and sore throat Previously well Maculo-papular Rash

What are you looking for on examination? What investigations do you suggest?

Hb 11 WCC 20 Plts 10 Na 134 Bili 88 ALT 174

What is your differential diagnosis? What further investigations may be indicated?

Case 4 3 year old boy presents to A+E with a short history of fever and vomiting In the department he is noted to have a petichial rash

Differential diagnosis? Management?

Case 5 8 year old girl is admitted to the surgical ward with severe abdominal pain Previously fit and well The GP suspects appendicitis

Hb 15.4 WCC 22 Plts 450 Urea 12 Creat 56

The surgical team ask you to see her the next day as they don’t think she has an appendix What are your differentials? What are you looking for on examination?

Do you want any further investigations? What is your management plan?

What treatment are you going to recommend for a community acquired pneumonia?

Treatment Amoxicillin Co-amoxiclav Cefuroxime Cefotaxime or Ceftriaxone Macrolide.

Case 6 A 5 year old girl is admitted by her G.P. with a history of recurrent temperatures and a skin rash There is no past medical history of note

On examination she is unwell and febrile There is a wide spread skin rash of a maculopapular nature

What other features are you looking for on examination? What investigations are you going to request? How are you going to treat her?

Non infectious Fever Kawasaki’s Disease Systemic onset JCA Other connective tissue diseases IBD Neoplasia Familial Mediterranean Fever

Kawasaki’s disease Persistent fever for >5days Conjunctivitis Oropharyngeal changes Changes in the peripheral extremities Skin rash Cervical lymphadenopathy

Atypical or incomplete cases recognised Pathogenesis unknown Infectious agent suspected Under diagnosed

Investigations Mild anaemia Raised WCC Raised inflammatory markers Raised platelets Cardiac abnormalities

Treatment IV Immunoglobulin 2g/kg within 10 days High dose aspirin 30-50mg/kg/24hrs for 14 days or until fever settles. Then reduced 3-5mg/kg o.d. for 4-6 weeks and until know echo normal

Investigation CXR Sputum Gastric washings Mantoux Quantiferon CT

Treatment A 6-month, four-drug initial regimen (6 months of isoniazid and rifampicin supplemented in the first 2 months with pyrazinamide and ethambutol) should be used to treat active respiratory TB