1. Case 1 You are volunteering in the tent for Grandma’s Marathon and the first wave of runners are finishing. The first patient of the day is a 27 year old male (5 th place finisher) who is ashen, mumbling, and stumbles in supported by two friends. His vital signs are taken. Pulse= 168, RR= 42, pulse ox= 85%, BP= 85/ 54, Temp=107.2 degrees.

2. Case 2 You are working in the emergency room and go on to see the next patient- a 20 month old female with three days of elevated temps at home. Parents measured a temperature of 104.6 degrees and have brought her in at 11 PM. She has no URI symptoms, no rash, but has had some vomiting today. Her vital signs are taken. Pulse= 168, RR= 42, pulse ox= 98%, BP= 85/54, Temp= 105.4 degrees.

4. Physiologic Responses to Increase Body Temperature (Heat Production/ Reduce Loss): Peripheral vasoconstriction Shivering Behavioral (seeking clothing, blankets, Warmth) (Accompanied by tachycardia and tachypnea)

5. Physiologic Responses to Reduce Body Temperature (Heat Loss) Sweating Peripheral vasodilation

7. To treat (fever)….or not to treat….that is the question

8. Many parents believe that fever is injurious. This table measures parent beliefs around harmful causes of fever:

9. Physicians May Suffer From the Same Contextual Problems As Parents: May and Bauchner ((1992) performed a survey of Pediatricians and found: - 65% believed that fever alone could cause bodily injury - 60% cited a temperature above 40 degrees (C) as a critical point - 21% listed brain damage as the most serious complication of fever - 26% listed death as the most serious complication

10. Reasons Not to Treat Fever: Fever enhances immune function Fever is physiologic Limited research suggests that it may shorten duration of illness

11. Reasons to Treat Fever: Comfort ??? Metabolic preservation in certain chronic disease (i.e., cardiac)

12. Effective Treatments for Fever Reduction: Acetaminophen (15 mg/kg/dose q 4 hours up to standard adult dosage) Ibuprofen (10 mg/kg/dose q 6 hours up to standard adult dosage) Aspirin (not recommended under age 16)

13. Ineffective Treatments for Fever Reduction: Sponging Bathing Electric fans Alternating acetaminophen/ ibuprofen (no more effective than one agent)

14. Causes of Fever: Infectious: viral, bacterial, fungal, and parasitic Inflammatory: Kawasaki Syndrome, Juvenile Rheumatoid Arthritis Cancer: Acute Lymphocytic Leukemia Pharmacologic: Aspirin overdose (fictitious)

15. Considerations in Evaluating Febrile Children Pattern of fever reported by parents (reliable?) Age of Child (newborn to age 3 months more at risk) Risk factors by age, chronic disease, immunization status, travel, etc. Known patterns of disease entities- i.e., Kawasaki Syndrome Exam findings: vital signs, “sick appearance”, focal abnormalities

16. Occult Bacteremia: Bacteria Recovered From Blood of Nonseptic Individual More common in children under 3 than older ages Generally: pneumococcus, Hemophilus, meningococcus Vaccines licensed for all three typical bacterial pathogens (above) Less than 3% of febrile children under age 3 with temp > 103

17. Urinary Tract Infection Is More Common Than Bacteremia Equal male : female ratio under age 6 months Caucasian female under age 3 years with T> 39 degrees= 16% UTI UTI in uncircumcised : circumcised male (under age 1)= 10:1 Diagnosis by culture of urine

18. Interpretation of CBC: WBC> 15K predicts bacteremia with 80% sensitivity, 69% specificity, and positive predictive value of 6% WBC< 5K with ANC < 1500 is worrisome ANC > 10K gives sensitivity of 76%, specificity of 78% and positive predictive value of 8% Thrombocytopenia is exceptionally worrisome development Thrombocytosis is a frequent consequence of inflammation after 10- 21 days Total Band Count: ANC > 0.16 highly predictive of neonatal sepsis

19. ESR and CRP: CRP> 4.0 suggest increased chance of bacterial disease CRP> 10 have been associated with 85% chance of bacterial infection ESR is an indirect measure of plasma acute phase reactants ESR can be affected by fibrinogen, RBC morphology, sex ESR fluctuates at a slower pace than CRP

20. Fever Under the Age of 30 Days: one study of 254 neonates presenting to an urban ER with temp >38 (C) identified 32 infants with serious bacterial illness (SBI) No screening protocols for identifying young infants at “low risk” have been validated. Evaluation must be individualized and strong consideration must be given to “full sepsis work up”- CXR, blood culture, urine culture, CSF studies and empiric antibiotics

21. Fever From 30- 90 Days of Age (Am. Coll. Of ER Physicians): Full exam (are they “well appearing”?) Screening CBC CXR in children with respiratory symptoms Screen all infants for UTI (UA and urine culture) Infants who have positive screening receive blood culture, CSF studies, and empiric antibiotics.

22. Fever From 3 – 36 Months of Age - Nigrovic, Et Al, (Clinical Pediatric Emergency Medicine- March 2004) Pre- 1987 causes of bacteremia- Hemophilus and Pneumococcus Hib vaccination eliminated Hemophilus (1987) Pneumococcal vaccination (Prevnar) is about 85- 93% effective at prevention of invasive pneumococcal disease Febrile children- 2.5% rate of pneumococcal bacteremia (80% spontaneous resolution?) 1998 to 2001 surveillance- 69% drop in invasive pneumococcal disease “Well-appearing”, febrile child > 6 mos + hx 3 doses Prevnar= no screening CBC, blood culture at Boston Children’s Hospital

24. Febrile Seizures Occur in about 4% of children 6 mos of age to 6 years Associated with temp > 38 degrees Absence of CNS infection/ inflammation Absence of systemic metabolic disturbance Absent hx of prior afebrile seizure

25. Febrile Seizure Classification: Simple: duration less than 15 minutes, nonfocal (>90%) Complex: longer than 15 minutes, may have focal component, post ictal paresis

26. Etiology of Febrile Seizures: Genetic susceptibility: several chromosomal loci have been identified in various extended families Siblings and parents of children with febrile seizures show 4-10% rate of epilepsy 10-20% of parents/ siblings will have a hx of febrile seizures MRI studies suggest hippocampal abnormality may have role

27. Differential Dx Involuntary myoclonic release movements Shivering Metabolic disorder Bacterial meningitis Viral encephalitis

28. Diagnostic Evaluation: Conflicted opinion regarding necessity of examining CSF in children < 12 mos Consider LP in questions of meningitis or if seizure occurs after first day of fever Routine metabolic studies rarely yield etiology Neuroimaging and EEG should be considered in “complex” variety

29. Treatment of Febrile Seizures: Supportive care If duration exceeds five minutes consider emergent anticonvulsant Tx (IV lorazepam @ 0.05 to 0.1 mg/ kg) IV fosphenytoin (15-20 mg/ kg) can be used if refractory Diazepam rectal gel (0.5 mg/kg) if IV access unavailable Fever reduction is unlikely to be accomplished by “external” means (sponging, bathing)- best to use acetaminophen or ibuprofen

30. Recurrent Febrile Seizure Treatment Home use of rectal Diazepam gel can be used by parents if seizure is longer than 5 minutes Focal seizures are more likely to be prolonged

31. Prevention of Febrile Seizures AAP does not recommend intermittent or continuous anticonvulsant use Evidence supporting aggressive antipyretic use likewise has no evidence

32. Prognosis for Febrile Seizures Recurrence rate is 50-65% if first seizure occurs below age 12 months Recurrence rate is 20% in older children Majority of recurrences are within one year of the first seizure No evidence for developmental, neurologic, cognitive sequelae “Normal child” with simple febrile seizure= “slightly” increased risk epilepsy Risk factors for later epilepsy= focal sz, prolonged sz, multiple sz< 24 hrs

33. Next to Last Word 30% of office visits to Pediatricians have fever as the primary concern. More than 50% of after hours phone calls involve fever concerns. Fever is a significant factor in primary care of children. Fever is not a diagnosis (though, there is an ICD9 code for it) but rather a sign of an underlying disorder. Fever by itself is not harmful and there is increasing recognition of its role in enhanced body response to infection.

34. Last Word Fever as the sole manifestation of serious illness is unusual. Urinary tract infection is the most common of these obscure etiologies- generally in the preverbal child (under age 3). Hence, of all potential lab studies in the hunt for isolated fever, a UA is more productive than a CBC. Febrile seizures are not rare. All parents will go into “panic mode” in the face of this dramatic event. The health professional’s role is first to assess and treat the needs of the child- and, second, to interpret this event for the parents.