1. Fever in Pediatrics 林口急診醫學科 吳孟書 醫師 出處 : Emergency medicine, APLS

2. PATHOPHYSIOLOGY Defined as a rise in deep body temperature associated with a resetting of the body’s thermostat. Exogenous pyrogens Endogenous pyrogens Peripheral vasoconstriction Shivering Central pooling Behavioral activity

3. CLINICAL FEATURES Temperature more than 38 ℃ The higher temperature is, the higher incidence of bacteremia is. Variation with the body’s circadian rhythm. Rectal temperature is 0.6 ℃ higher than oral temperature. Oral temperature is 0.6 ℃ higher than axillary temperature Infrared thermometer scan tympanic membrane is mimic with oral tempertrature.

4. NEWBORN FEVER (1-3Mo) High risk for life-threatening infection was considered before Serious bacterial infection : 3-4% noted recently Review of birth history: 1.Length of gestation 2.Use of antibiotics in the mother or infant 3.Any neonatal complication Organ-specific list of inquiries may be nonspecific in young infants

5. NEW BORN FEVER (1-3Mo) Physical Examination: 1.PAT (Pediatric assessment triangle) + ABCDEs 2.Inconsolable crying or increased irritability when handled 3.Fullness of anterior frontanelle 4.Meningeal sings are often absent 5.A complete head-to-toe examination 6.Extensive laboratory septic work-up to detect occult infection 7.UTI is the single most common bacterial infection in this group.

6. NEWBORN FEVER (1-3Mo) Rochester criteria for low risk for serious bacterial infection: 1.Nontoxic appearance 2.No soft tissue infection 3.WBCs between 5000-15000/mm 3 4.Bands <1500/mm 3 5.Normal urinalysis 6.Stool with less than 5 WBCs/hpf if infants with diarrhea

7. NEWBORN FEVER (1-3Mo) Management: 1.Hospitalize febrile infants, especially for infants younger than age one month 2.Ceftriaxone 50mg/kg for low risk infants with caretaker telephone in outpatient management 3.Infants could be discharged if cultures were negative after 24 h observation.

8. INFANTS OF 3-24 MONTHS At high risk for occult bacteremia Clinical judgment appears to be more reliable: PAT + ABCDEs Eye contact Playfulness and positive response to interaction Negative response to noxious stimuli Alertness and consolability

9. PAT Configurations and emergency etiologies AppearanceWork of BreathingCirculation to SkinGeneral Consideration of Physiologic Stat Examples of etiologies AbnormalNormal Primary brain dysfunction; Systemic problems Shaken baby; Brain injury; Sepsis; Hypoglycemia; Intoxication NormalAbnormalNormalRespiratory distressMild asthma; Bronchiolitis;Croup; CAP; F-B as[iration Abnormal NormalRespiratory failureSevere asthma; Pulmonary contusion; Penetrating chest injury Normal AbnormalCompensated shockDiarrhea; External blood loss AbnormalNormalAbnormalDecompensated shock Severe AGE; Major burn; Major blunt injury; Penetrating abdominal injury Abnormal Cardiopulmonary failure Arrest

10. INFANTS OF 3-24 MONTHS Viral illnesses (e.g. URI,AGE) account the majority of febrile illness and usually have system-specific symptoms. Bacterial infections : S. pneumoniae; H. influenzae  antibiotics use Meningeal signs may be inapparant in children up to 2 years old Petechiae with high fever WBCs > 15000/mm 3 Bands > 500/mm 3 Total PMNs > 10000/mm 3 Bands + total PMNs > 10500/mm 3 It is important to perform a blood culture to detect occult bacteremia.

11. INFANTS OF 3-24 MONTHS Admit any child who appears ill or toxic. Expectant Ceftriaxone for well-appearing infants with no focus of infection, and fever greater than or equal to 39.5 ℃ and WBCs over 15000/mm 3 or a temperature more than 40.0 ℃, regardless of WBCs. Out-patient management with frequent follow up

12. Positive blood culture On antibiotics Well Afebrile (<38 ℃ ) Finish course of antibioticss “Sick” Febrile (>38 ℃ ) Septic W/U Hospitalize; Parenteral antibiotics Recall for repeat exam Not on antibiotics Well Afebrile (<38 ℃ ) No focus of infection Observe as outpatient Focus of infection Institute antibiotics; Hospitalize if indicated “Sick” Febrile (>38 ℃ ) Septic W/U; Hospitalize; Parenteral antibiotics

13. OLDER FEBRILE CHILDREN Easier to evaluate Lower risk of bacteremia, but higher incidence of streptococcal pharyngitis in 5- 10 years aged cildren Infectious mononucleosis: fever, tonsillar hypertrophy with exudate, LAP, and hepatosplenomegaly. Mycoplasma pneumoniae  marcrolid

14. Managing the Fever Aside from febrile convulsion, fever is not known to produce any harmful effects in children. 1.Unwrapping a bundled child 2.Rehydrating a dehydratded child 3.Sponging with tepid water slowly 4.Acetaminophen :10-15 mg/kg, po, q4-6h 5.Ibuprofen :5-10 mg/kg, po, q6-8h 6.Aspirin :10-15 mg/kg, po, q4-6h Equally effective in reducing fever between antipyretics Sponging and antipyretics used together are more effective. Administration of these antipyretics simultaneously produce a longer duration of reducing fever Avoid aspirin in children with chicken pox or influenza-like illness – Reye syndrome Antibiotics for system-specific infection

15. Fever in Children at Risk for Sepsis Fever in the immunosuppressed children Fever in very young infants Fever with petechiae

16. Fever in the immunosuppressed children Often benign illness, but 20% of SBI Absolute neutrophil count (ANC) ＜ 500 Low lymphocyte count, especially a low CD4 lymphocyte count in children with HIV Acute deterioration Catheter infection Other infection site as normal children Several viral infection may disseminate

17. Fever in the immunosuppressed children CBC/DC – compared with previous data Blood culture – from catheter and other peripheral site U/A and U/C Other laboratory test and radiologic studies as indicate

18. Fever in the immunosuppressed children Gram positive bacteria 1.Coagulase-negative staphylococcus 2.Staphylococcus aureus 3.Streptococcus viridans Gram negative bacteria 1.E coli 2.Klebsiella 3.Pseudomonas aeruginosas Typhlitis – chemotherapy Children with HIV 1.Pneumococcus 2.Salmonella 3.Pneumocystis carinii

19. Fever in the immunosuppressed children Access and treat respiratory distress and failure Obtain IV access and begin fluid resuscitation for signs of shock Obtain laboratory studies as indicated Begin empiric antibiotics treatment including ceftazidime (antipseudomonal antibiotics) and gentamicin, plus vancomycin if there are catheter-related infections or a severe infection. Admit for inpatient care.

20. Fever in very young infants As above at page 4-7

21. Fever With Petechiae Red flag for invasive illness, especially due to meningococcus (Neisseria meningitidis) – 20% mortality rate Fever Headache Fatigue Myalgias Arthralgias Lethargy Rigors Tachypnea Tachycardia Skin signs of shock Petechiae/purpura

22. Fever With Petechiae Viral etiologies; influenza, enterovirus, infectious mononucleosis, adenovirus… Bacterial etiologies; meningococcus, pneumococcus, HIB, group A streptococcus Rocky mountain spotted fever Leukemia Bacterial endocarditis, ARF Fever with petechiae above the nipple line – SBI unlikely

23. Fever With Petechiae Early resuscitation of ill appearing children and empiric antibiotics and hospitalization. Age less than 12 mo : hospitalization and empiric antibiotics Older children : observe in ED then discharge if --- WBC between 5000 and 15000 ‚Band count < 500 ƒNormal ANC „Normal PT …Normal CSF studies (if obtained) †Antibiotics if indicated

24. Thanks for your attention!!