1. SDMH EMC 2015
Paediatric Fever

2. Objectives Define fever Recognise risks with the febrile child
Identify the ‘toxic’ child
Learn the approach to management of febrile children in the ED

3. What is fever?
NSW guidelines defines axillary T >38 degrees = fever.(Rectal T ‘gold standard’ but not advised)
Axillary T < rectal by ~ degrees.
Oral may vary from rectal ~0.5 degrees.
Therefore axillary T ~ may still represent fever, particularly older children.
Fever = immune mediated; not harmful of itself, potentially beneficial.

4. Why the concern?
Younger children relatively immunosuppressed (reduced IgG primarily)
Paed. sepsis mortality ~10%.
Morbidity associated with Pneumonia, Meningitis, UTI and Septic arthritis
Infants and neonates less likely to demonstrate clear signs
Majority of febrile children however have benign illness
Therefore need to identify those with Serious Bacterial Infection (SBI)

5. How common is SBI?
Historical data  SBI of 10-30% in children < 3mths with ‘toxic appearance’, 5% when ‘well appearing’
‘Occult bacteraemia’ historically 2-3% in 3-36mth even when ‘well appearing’
Post pneumococcal vaccine incidence ~0.5% in 3-36mth
Height of fever ‘correlates’ incidence SBI, but poor bedside predictor
Pre-vaccine data; Age 4-8 weeks T38-39: 3.2%,T39-40: 5.2% ,T>40: 26%. Age 3-36mth rates 3%,5% and 9% respectively

6. What is ‘toxic appearing’
????
A – Alertness/activity level
B – Breathing difficulties (tachypnoea/WOB)
C – Poor Colour, Circulation or Cry
D – Decreased fluid in and out

7. Scoring ‘Toxicity’
Measurable with a good toy in the ED!

8. Paediatric Normal Vitals

9. Approach to management
Based upon varying level of risk of SBI per differing age groups
Differing approach depending upon whether ‘well’ or ‘toxic’
Relies upon child being immunised against Pneumococcus as per Schedule
Consider parental anxiety; significant parental concerns, especially re-presentation, indicates higher risk
HOWEVER – ‘Fever phobia’ very real problem – should be addressed with parents

10. Febrile Neonate Age 1d – 28d (corrected) Background risk of SBI 12-30%
ALL febrile neonates require paediatric consultation, and complete septic screen including LP, regardless of clinical appearance
Unwell neonates - immediate empiric IV antibiotics (cefotaxime 50mg/kg OR ampicillin 50mg/kg + gentamicin 7mg/kg)
‘Well appearing’ can complete septic screen, and then receive either targeted or empiric IV antibiotics depending upon findings
Disposition is Paediatric admission (transfer if seriously unwell)

11. Febrile infant 1 mth - 3 mth
Recent change in guidelines
Previously treated as for Febrile Neonate
Any ‘toxic’ 1-3 mth old should be treated as for Febrile Neonate
Investigation – FBC/Blood + Urine culture. Consider CXR/LP
Paediatric or Senior ED review
Disposition variable, depending upon Ix results; Likely admit, but low risk cohort may be suitable for discharge
‘Well appearing’; Nil significant perinatal hx; Clear Urine+CXR+CSF; WCC <15  SBI risk 0-2%

12. Febrile child 3mth-36mth Background risk SBI 0.5% if immunised
Fever therefore highly likely to be viral
UTI commonest SBI isolated
Any ‘toxic’ child – empiric or targeted IV a/bs + admit
If ‘well appearing’ ; thorough physical exam, with mandatory urinalysis
If clear and remains well; suitable for discharge BUT requires review in 24 hrs to ensure wellbeing. Ensure good parental education re:fever
Nil antibiotics if well and no focus; target oral antibiotics only for foci likely to benefit

13. Questions

14. Summary Fever is normal immune response and probably beneficial
Fever height predicts SBI poorly outside of neonatal period
Child appearance and age of paramount importance
IV a/b’s promptly for all ‘toxic’ children
Paediatric consultation and probable admit for febrile children under 3/12
Thorough physical and urinalysis sufficient for immunised well children over 3/12 (but ensure safe disposition)