The Sick Infant: Five Deadly Misconceptions Todd Wylie, MD University of Florida Department of Emergency Medicine June , 2009

Case 1 6 month female with fever to 103.6

Misconception Immunizations have eliminated the need to perform any laboratory studies on febrile infants!

Febrile Infant Protocol

Febrile Infant Immunization Status?

Case 2 4 month male with 1 day history of high fever and lethargy

Misconception 1)Kids are just small adults! 2)Kids are a totally different species!

Sepsis What’s different?

Sepsis What’s similar?

Case 3 3 month female –3 days of fever, cough, rash, conjunctivitis

Misconception Kids will read the textbook prior to presenting with a myriad of signs and symptoms!!

Kawasaki Disease Five or more days of fever

Kawasaki Disease 4 out of 5 –Conjunctivitis –Rash –Extremity changes –Cervical adenopathy –Mucositis

Incomplete (“Atypical”) Kawasaki Disease Lack sufficient clinical signs to fulfill the classic criteria

Incomplete (“Atypical”) Kawasaki Disease Age Newburger JW, Takahashi M, Gerber MA, et al. Diagnosis, Treatment, and Long- Term Management of Kawasaki Disease: A Statement for Health Professionals…Pediatrics 2004; 114: Prevalence

Incomplete (“Atypical”) Kawasaki Disease Age Genizi J, Miron D, Spiegel R, Fink D, Horowitz Y. Kawasaki Disease in Very Young Infants: High Prevalence of Atypical Presentation and Coronary Arteritis. Clin Pediatr 2003; 42: Coronary artery abnormalities

Case 4 8-day old female with poor feeding, fever, and grunting respirations

Misconception The sick neonate has been adequately treated with antibiotics alone

Neonatal HSV Skin-Eye-MouthCNSDisseminated Onset (days)5-11 days8-17 days5-11 days Clinical findings VesiclesIrritable, Lethargy Seizures Jaundice Resp. distress Irritable Mortality untreated Up to 70% progress 50%90% Mortality treated 015%54%

Neonatal HSV

The Prevalence of Neonatal Herpes Simplex Virus Infection Compared with Serious Bacterial Illness in Hospitalized Neonates Caviness AC, Demmler GJ, Almendarez Y, Selwyn BJ. J Pediatr 2008;153:164-9

Neonatal HSV When should we start empiric acyclovir treatment in sick neonates? Clear index of suspicion for HSV –Skin vesicles –Seizures –Elevated hepatic transaminases

Neonatal HSV When should we start empiric acyclovir treatment in sick neonates? Sepsis-like picture –Respiratory distress –Hypothermia –Lethargy –Appears more ill than would be expected

Neonatal HSV When should we start empiric acyclovir treatment in sick neonates? CSF pleocytosis –Mononuclear cell predominance

Neonatal HSV When should we start empiric acyclovir treatment in sick neonates? Age < 21 days and fever?

Case 5 9 month male presents following a generalized seizure…noted to have fever to 103.4

Misconception 1)You don’t have to do a spinal tap anymore! 2)You always have to do a spinal tap!

Febrile Seizure and Meningitis What is the risk of meningitis in patients with a febrile seizure?

Febrile Seizure and Meningitis Indications for a spinal tap