1. Fever in Children Roger M. Barkin, MD

2. Measurement Definition of fever: 38 C or 100.4 Definition of fever: 38 C or 100.4 Sites Sites –Rectal –Tympanic membrane –Oral –Axillary –Age dependent reliability (<6 mo old)

3. Causes of Fever ( 40 o C) Otitis Media36.9% Non-specific illness 25.5% Pneumonia15.5% Recognizable viral syndrome12.7% (exanthem, encephalitis, gastroenteritis, croup) Recognizable bacterial synd. 9.4%

4. Antipyretic Therapy is Imperative Early Acetaminophen10-15 mg/kg Acetaminophen10-15 mg/kg Ibuprofen10 mg/kg Ibuprofen10 mg/kg Tepid sponging Tepid sponging Facilitates evaluation Facilitates evaluation

5. General Assessment Child looks and focuses on clinician, spontaneously explores room Child looks and focuses on clinician, spontaneously explores room Child spontaneously makes sounds or talks in a playful manner Child spontaneously makes sounds or talks in a playful manner Child plays, reaches for objects Child plays, reaches for objects Child smiles, interacts with parents or practitioner Child smiles, interacts with parents or practitioner Child quiets easily when held by parents Child quiets easily when held by parents

6. History Non-specific and by report Non-specific and by report Exposure Exposure Preexisting medical conditions Preexisting medical conditions Prematurity Prematurity

7. Physical Examination Often non specific findings

8. Ancillary Data WBC WBC Urinalysis Urinalysis Lumbar puncture Lumbar puncture Cultures - blood, urine, CSF Cultures - blood, urine, CSF Chest x-ray Chest x-ray Stool polys Stool polys

9. Urine Evaluation Specimen Specimen –Bag63% contamination –Catheter 9% contamination –Suprapubic with ultrasound

10. Urine Evaluation Gram stain and dipstick analysis for nitrite and leukocyte esterase are similar in sensitivity and specificity Gram stain and dipstick analysis for nitrite and leukocyte esterase are similar in sensitivity and specificity Both superior to microscopic analysis for pyuria Both superior to microscopic analysis for pyuria Enhanced UA (microscopy + gram stain) Enhanced UA (microscopy + gram stain) –most sensitive but had 16% false + –would have missed 4-6% positives

11. Urinalysis unremarkable in up to 80% of newborns with UTI

12. Urine Evaluation- Cost Effectiveness Culture all infants Culture all infants Rx if + LE or nitrite Rx if + LE or nitrite Detected all infants with UTI Detected all infants with UTI

13. Chest X-ray Respiratory symptoms Respiratory symptoms –Tachypnea >59 ( 59 (<6 mo) >52 (6-11 mo) >52 (6-11 mo) >42 (1-2 yr) >42 (1-2 yr) –Coughing, wheezing, dyspnea, retractions, grunting No focus No focus

14. Key Questions 1.What is child’s risk of bacteremia? - Does the history & clinical exam help? 2.Which diagnostic tests are helpful, if any? 3.Should empiric antibiotics be prescribed? - If prescribed which one & by what route? 4.What follow-up is appropriate?

15. Occult Bacteremia 1-3% of febrile patients without a defined focus 1-3% of febrile patients without a defined focus Etiology Etiology –S. pneumoniae, H. influenzea type B, N. meningitidis Risk Factors Risk Factors –<24 months –Temp > 39.4 o C –WBC > 15-20,000

16. Prevalence of Bacteremia Pre-H.influenzae vaccine(n = 7899) 3.1%Bacteremia(n=244) 0.2%SBI(n=17) 0.1%Meningitis(n=7) 70-80% occult bacteremia resolve spontaneously Post H.influenzae vaccine(n = 9465) 1.6% Bacteremia

17. Risk of Developing SBI Incidence bacteremia 1.5% Incidence bacteremia 1.5% –90% strep pneumo – 5% salmonella – 1% n. meningitidis Likelihood of development SBI 0.1% Likelihood of development SBI 0.1%

18. Cost Effective Analysis Model (Lee, 2001) CBC + selective BC and Rx CBC + selective BC and Rx –WBC > 15,000 If bacteremia rate dips to 0.5% If bacteremia rate dips to 0.5% –clinical judgement may be most cost effective

19. Infants Under 2 Months of Age No laboratory, historical or physical exam- ination factor can prospectively exclude underlying bacterial infection No laboratory, historical or physical exam- ination factor can prospectively exclude underlying bacterial infection Clinical judgement alone is not consistently useful in assessing the young febrile infant Clinical judgement alone is not consistently useful in assessing the young febrile infant Children under 3 mos. with temp >38.5 o C have a greater than 20-fold risk of having serious infection than do older children with a similar temperature Children under 3 mos. with temp >38.5 o C have a greater than 20-fold risk of having serious infection than do older children with a similar temperature

20. Rochester Criteria Well appearing infant - normal vital signs, good hydration, perfusion Well appearing infant - normal vital signs, good hydration, perfusion Healthy infant Healthy infant –Term (>37 week gestation) –No antibiotic therapy - antenatal or post natal –No underlying illness –No previous hospitalizations; discharged with mother as newborn

21. Rochester Criteria (continued) No focal infection (skin, soft tissue, bone/joint) No focal infection (skin, soft tissue, bone/joint) Good social situation Good social situation Laboratory criteria Laboratory criteria –WBC 5 - 15,000/mm 3 –Band form count <1500/mm 3 –Normal urinalysis (<5 WBC/HPF) –Normal stool (<5 WBC/HPF, if done)

22. Hyperpyrexia (Temp >41 o C [105.8 o F]) 20% of children will have a seizure 20% of children will have a seizure 10% of children < 2 yr will have bacterial meningitis 10% of children < 2 yr will have bacterial meningitis 53% of children will have serious disease 53% of children will have serious disease –meningitis, bacterial pneumonia, pericarditis, Kawasaki ‘s disease Temp >42 o C often have non-infectious etiology Temp >42 o C often have non-infectious etiology

23. Management Antibiotics Antibiotics –IV, or –Oral

24. Management 0 - 30 days of life 0 - 30 days of life 30-60 days of life 30-60 days of life Children under 3 years of age Children under 3 years of age

25. Work-up and Management CBC,UA/UC, blood culture; consider LP CBC,UA/UC, blood culture; consider LP Supportive care,antipyretics Supportive care,antipyretics <1 mo: assess, treat (ampicillin and <1 mo: assess, treat (ampicillin and gentamicin/cefotaxime), admit gentamicin/cefotaxime), admit 2-3 mo: assess, consider empirical treatment, 2-3 mo: assess, consider empirical treatment, reassess reassess

26. Non-toxic Child >90 days, T > 39 o C Urine dip/Culture Urine dip/Culture –Males < 6 mos. –Males 6-12 mos. If uncircumcised –Females < 12 mos. Urine dip/Hold Urine dip/Hold –Males 6-12 mos. If circumcised –Females 12-24 mos. Culture if positive dip/gram stain Culture if positive dip/gram stain

27. Non-toxic Child >90 days, T > 39 o C Pneumococcal vaccine YES YES –CXR if respiratory findings and WBC > 20,000 NO NO –if WBC > 15,000 BC Ceftriaxone Recheck

28. Febrile Seizure Meningitis associated with seizure in 23% cases (115/503) Meningitis associated with seizure in 23% cases (115/503) –10 “relatively normal” Rate SBI in patient with first-time febrile seizure same as those with fever without seizure Rate SBI in patient with first-time febrile seizure same as those with fever without seizure

29. Febrile Seizure Strongly recommend LP if < 12 months Strongly recommend LP if < 12 months Not routinely recommend LP if >18 months Not routinely recommend LP if >18 months Low threshold if on antibiotics Low threshold if on antibiotics Fever evaluation Fever evaluation

30. Immunocompromised Children Chemotherapy Chemotherapy Asplenia - congenital, trauma Asplenia - congenital, trauma Sickle Cell disease Sickle Cell disease

31. Fever and Petechiae 15/90 had bacterial disease 15/90 had bacterial disease –13 - N. meningitidis Decreased risk if normal LP, WBC, ANC and bands, and temp <40 o C Decreased risk if normal LP, WBC, ANC and bands, and temp <40 o C

32. DISCHARGE INSTRUCTIONS AND FOLLOW-UP IS ESSENTIAL. DISCHARGE INSTRUCTIONS AND FOLLOW-UP IS ESSENTIAL.

33. KEY POINTS TO REMEMBER FEVER IS A COMMON COMPLAINT IN THE ED FEVER IS A COMMON COMPLAINT IN THE ED NEWBORN: GBS IS MOST COMMON BACTERIAL PATHOGEN. ALSO E. COLI AND LISTERIA MONOCYTOGENES NEWBORN: GBS IS MOST COMMON BACTERIAL PATHOGEN. ALSO E. COLI AND LISTERIA MONOCYTOGENES APPROACH TO FEBRILE CHILD SOULD BE AGE SPECIFIC APPROACH TO FEBRILE CHILD SOULD BE AGE SPECIFIC HISTORY AND PHYSICAL ARE OFTEN NON- SPECIFIC HISTORY AND PHYSICAL ARE OFTEN NON- SPECIFIC

34. KEY POINTS TO REMEMBER EXPECTANT MANAGEMENT IS OFTEN APPROPRIATE EXPECTANT MANAGEMENT IS OFTEN APPROPRIATE ANTIPYRETICS MAY ASSIST IN ASSESSMENT BUT ARE NOT PREDICTIVE OF THE ETIOLOGY ANTIPYRETICS MAY ASSIST IN ASSESSMENT BUT ARE NOT PREDICTIVE OF THE ETIOLOGY