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Approach to Fever in Infants and Children

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Approach to Fever in Infants and Children DR. ELIZABETH KE MD, DCH, Ph D, FIAP Infants 3 to 36 months Infant sepsis syndrome: Age 3-36 months Fever39 C ANC10,000 ... – PowerPoint PPT presentation

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Title: Approach to Fever in Infants and Children


1
Approach to Fever in Infants and Children
  • DR. ELIZABETH KE
  • MD, DCH, Ph D, FIAP

2
DEFINITION OF FEVER
  • Fever is an elevation of body temperature that
    exceeds the normal daily variation, in
    conjunction with an increase in hypothalamic set
    point

3
Fever Phobia
  • Fever is the most common pediatric complaint,
    second only to routine care for clinic visits,
    and the most common reason kids are brought to
    the ER.
  • Some feel true fever is harmful all thought
    brain damage gt41ºC(106ºF).
  • 5-20 have no localizing signs with no history to
    explain the fever.
  • The majority of kids with fever do not have a
    serious illness, although a small percentage
    harbor or may develop a serious bacterial
    infection.

4
NORMAL BODY TEMPERATURE
  • Maximum normal oral temperature
  • At 6 AM 37.2
  • At 4 PM 37.7
  • Normal circadian rhythm, which is highest (up to
    2ºC, 3ºF) 6pm and lowest at 6am. This accounts
    for increased volume of ER visits that peaks in
    the evening. Most true fevers follow this
    diurnal pattern

5
True Fever
  • Pyrogens
  • Exogenous pyrogens
  • Bacteria, Virus, Fungus, Allergen,
  • Endogenous pyrogen
  • Immune complex, lymphokine,
  • Major EPs IL1, TNF, IL6

6
HYPERTHERMIA
  • Heat production exceeds heat loss, and the
    temperature exceeds the individuals set point,
    Normal causes of temperature elevation include
    physical activity, ovulation, and environmental
    temperature.
  • Heat stroke Exercise, Anticholinergic
  • Drug induced Cocaine, Amphetamine,MAO inh.
  • Neuroleptic malignant syndromePhenothiazine
  • Malignant hyperthermia Inhalational anesthetics
  • Endocrinopathy throtoxicosis, pheochromocytoma

7
Reliable Temperature Measurement
  • All measurements are estimates of the bodys true
    core tempcentral circulationaorta and pulmonary
    artery.
  • RECTALgold standard
  • Esophagealaccurate but impractical
  • Tactile and axillaryinaccurate, varies
    considerably with environmental temperature
  • Tympanicinaccurate in age lt3 years
  • Newborns- same as axillary temp.

8
Benefits of fever
  • The hypothalamus will not allow the temp to rise
    above 41.5ºC(107ºF).
  • WBCs work best and kill the most bacteria at
    38-40ºC(100.4-104ºF).
  • Neutrophils make more superoxide anion, and there
    is more and increased activity of interferon.
  • Coxsackie and polio virus replication is directly
    inhibited.

9
FEVER
  • Associated Symptoms
  • Shaking chills
  • Ear pain Ear drainage, Hearing loss
  • Visual and Eye Symptoms
  • Sore Throat
  • Chest and Pulmonary Symptoms
  • Abdominal Symptoms
  • Back pain, Joint or Skeletal pain

10
Fever Patterns
  • Sustained (Continuous) Fever
  • Intermittent Fever (Hectic Fever)
  • Remittent Fever
  • Relapsing Fever
  • Tertian Fever
  • Quartan Fever
  • Days of Fever Followed by a Several Days Afebrile
  • Pel Ebstein Fever
  • Fever Every 21 Day

11
Approach to Fever
  • Physical Examination
  • Vital Signs
  • Neurological Exam.
  • Skin Lesions, Mucous Membrane, Petichiae
  • Eyes
  • ENT
  • Lymphadenopathy
  • Lungs and Heart
  • Abdominal Region (Hepatomegaly, Splenomegaly)
  • Musculoskeletal

12
Approach to Fever
  • Assess the extent and severity of the
    inflammatory response to infection
  • Determine the site(s) and complications of organ
    involvement by the process
  • Determine the etiology of the infectious disease

13
Fever without a source/ focus (FWS/ FWF)
  • 5 to 20 of febrile children have no localizing
    signs on PE and nothing in the history to explain
    the fever. By definition, less than 7 days.
  • FWS (like fever) is most common in children
    younger than age 5, with a peak prevalence
    between 6 and 24 months of age.
  • Those lt6 months retain protective maternal
    antibodies against common organisms, while those
    18-24 months old are more immune competent, and
    are at a lower risk of developing bacteremia

14
PUO/FUO
  • Classic FUO
  • Nosocomial FUO
  • Neutropenic FUO
  • HIV-Associated FUO

15
Classic FUO
  • Definition
  • Fever of 38.3 C or higher on several occasions
  • Fever of more than 3 weeks duration
  • Diagnosis uncertain, despite appropriate
    investigations after at least 3 outpatient visits
    or at least 3 days in hospital

16
Causes of Classic FUO
  • Infections 22-58
  • Neoplasms up to 30
  • Noninfectious inflammatory diseases up to
    25
  • Miscellaneous causes up to 25
  • Undiagnosed up to 30

17
FUO
  • Localized pyogenic infections
  • Intravascular infections
  • Systemic bacterial infections (Tuberculosis,
    Brucellosis,)
  • Fungal infections
  • Viral infections
  • Parasitic infections

18
Non Infectious Causes
  • Collagen vascular/ hypersensitivity diseases
  • Lupus
  • Stills disease
  • Temporal arteritis (Giant cell arteritis)
  • Granulomatouse diseases
  • Crohns disease
  • Sarcoidosis
  • Idiopathic granulomatouse disease

19
Drug Fever
  • PATHOGENEGIS
  • Contamination of the drug with a pyrogen or
    microorganism
  • Pharmacologic action of the drug itself
  • Allergic (hypersensitivity) reaction to the drug

20
Factitious fever
  • Diagnosis should be considered in any FUO,
    especially in
  • Young women
  • Persons with medical training
  • If the patients clinically well
  • Disparity between temperature and pulse
  • Absence of the normal diurnal pattern

21
Work up of Fever
  • Blood , Urine,
  • Cultures
  • Serology
  • Imaging
  • Biopsies

22
Investigations
  • 1-3 days Routine Blood Urine tests
  • 4-6 days Cultures, Imaging
  • 7-14 days Serology
  • gt 14 days - Biopsies
  • Well child may wait up to 5 days for viral
    fevers and exanthems to evolve
  • Sick child Empiric antibiotic therapy

23
Acute Phase Reactants
  • Altered hepatocyte function (Acute phase
    reactants)
  • C reactive protein(increased)
  • Serum amyloid A(increased)
  • Fibrinogen(increased)
  • Fibronectin(increased)
  • Haptoglobin(increased)
  • Ceruloplasmin(increased)
  • Ferritin(increased)
  • Albumin(decreased)
  • Transferrin(decreased)
  • Metabolic changes
  • Negative nitrogene balance
  • Loss of body weight
  • Altered synthesis of hormones
  • Hematologic alterations
  • Leukocytosis
  • Thrombocytosis
  • Decreased erythrocytosis

24
Altered Fever Response
  • Fever may not be present despite infection in
  • Newborn
  • Elderly
  • Uremia
  • Significant malnourished individual
  • Taking corticosteroids

25
Neonatal
  • PE is felt to be unreliable in detecting many
    serious bacterial infections. Meningitis should
    always be consideredup to 10 appear well, only
    15 have a bulging fontanelle, and 10-15 have
    nuchal rigidity. So, a high index of suspicion
    is important!!! 20 will not have fever
    initially.
  • Hyperthermia or hypothermia
  • Lethargy or irritability
  • Poor feeding or vomiting
  • Apnea, Dyspnea
  • Jaundice
  • Hypotension
  • Diarrhea or abdominal distension
  • Bulging fontanelle
  • Seizures
  • Bleeding manifestations, DIC

26
Case study
  • 2 month old infant fever 5 days
  • Febrile
  • Poor feeding
  • Rash over the body
  • So what ?

27
Infants 1 to 3 months
  • Infants who are toxic and febrile have a much
    higher risk of serious bacterial infection. They
    should be admitted, have a full sepsis workup,
    and given antibiotics/antivirals?Ampicillin and
    Cefotaxime.
  • Infants who are nontoxic and febrile who meet all
    Rochester criteria can safely be treated as an
    outpatient. Generally, 1-2.9 of children
    meeting these criteria will develop a serious
    bacterial infection, 0.7 bacteremia, 0.14
    meningitis.

28
Infants 1 to 3 months
  • Rochester Criteria/Low Risk Criteria
  • Nontoxicmost critical and difficult
  • Previously healthy, not low birth weight
  • No focal bacterial infection on PE except Otitis
    Media
  • WBC 5,000-15,000/mm3 (normal)
  • Bandslt1500/mm3 (normal)
  • Normal urinalysis, including gram stain
  • If diarrhea, must be non-bloody and WBClt5/hpf.
  • If respiratory symptoms present, normal CXR
  • Negative predictive value 98.9

29
Infants 1 to 3 months
  • If all of the criteria are met, then there are 2
    options for outpatient management
  • 1) Blood, Urine Cultures, LP, Ceftriaxone
    50mg/kg IM (to 1g), and return for reevaluation
    within 24 hours.
  • 2) Blood, Urine Cultures and careful
    observation.
  • Parents should have mature judgement, can return
    within 30 minutes and have a thermometer and a
    phone.
  • IF NO LP IS DONE, DO NOT GIVE CEFTRIAXONE AS IT
    WILL COMPROMISE F/U IF THE PATIENT IS STILL
    FEBRILE

30
Infants 1 to 3 months
  • Follow-up of low risk infants
  • If all cultures negative afebrile, well
    appearing?Careful observation
  • Blood cultures negative well appearing,
    febrile?Careful observation, may consider second
    dose of Ceftriaxone
  • Blood culture positive?admit for sepsis workup
    and parenteral antibiotics pending results
  • Urine culture positive if persistent
    fever?admit for sepsis workup, parenteral
    antibiotics pending results. If afebrile and
    well?outpatient antibiotics

31
Case Study
  • 3 year old child
  • Treated for fever
  • 3rd day developed rash over legs
  • Thought as drug allergy
  • Collapsed in the evening, hypotension
  • So what ?

32
Case study
  • 2 year old child with fever, cough
  • Developed inconsolable crying in the night
  • Refusal of feed
  • So what ?

33
Infants 3 to 36 months
  • UA with micro, CBC with differential, Blood
    Cultures
  • LP if meningeal signs, not wanting to be held or
    moved, petechiae, purpura or toxic.
  • Antimicrobials
  • OM or pneumonia cover for pneumococcus,
    non-typable H. flu and Moraxella
    amoxicillinaugmentin, ceftriaxone
  • URI or no focus cover for pneumococcus and
    menigococcus amoxicillin(80-100mg/dg/day),
    ceftriaxone
  • Pneumococcemia promptly reassess, if well,
    should at least treat with 1 dose ceftriaxone.
  • PCV-7 gt97 protection, thus all pneumococcal
    sepsis will decrease by 90. So CBC and
    antimicrobials for this age group is becoming
    less critical.

34
Infants 3 to 36 months
  • Infant sepsis syndrome
  • Age 3-36 months
  • Fevergt39ºC
  • ANCgt10,000
  • If a child meets all 3 criteria, he has a 3 risk
    for pneumococcemia. If untreated, 3 will
    progress to meningitis.
  • Bacteremia risk peaks at 8-12 months
  • Pneumococcal sepsis peaks at 1 year, then drops
    off
  • Pneumococcal meningitis peaks at 3-5 months
  • OM, sinusitis, pneumonia, response to
    antipyretics, and social status do not
    significantly alter risk.
  • Other causes HHV6(15), UTI(girls 3, boys
    0.6), menigococcemia(0.1), Salmonella(0.2), H.
    influenza(0.05), Enterovirus(July?October).

35
Occult Bacteremia
  • Empiric antibiotics should be targeted against S.
    pneumoniae, N. meningitidis, and H. influenza
  • Amoxicillin
  • Augmentin, Bactrim, 2nd or 3rd gen Cephalosporins
  • Single dose Ceftriaxone 50-75mg/kg
  • Followup is essential!

36
Risk of Occult Bacteremia
Low Risk Age gt3yr Temp lt39.4ºC WBC gt5000 and lt15,000 High Risk lt2yr gt40ºC(104ºF) lt5000 or gt15,000 Hx of contact with H. Flu or N. meningitidis
  • OB has a low prevalence, so even though WBC is a
    sensitive and specific screening test, it has a
    low PPV. So the test does not discriminate
    between children who have FWS who are bacteremic
    and those who are not.
  • Therefore, blood culture is the gold
    standard?still has a high number of false
    positives, take 24-48hrs, and most cases of
    occult pneumococcal bacteremia clear without
    treatment.

37
Pneumococcal
  • Streptococcus pneumonia is responsible for 2/3 to
    ¾ of all cases.
  • Peak prevalence between 6 and 24 months
  • Association with high fever(39.4ºC or 103ºF)
  • High WBC count(gt15,000)
  • Absence of evident focal soft tissue infection.
  • Neisseria meningitidis, Haemophilus influenzae
    type b, and salmonellae account for most of the
    remaining cases.

38
Antibiotics
  • 5 of children with FWS have OCCULT BACTEREMIA
  • The presence of a positive blood culture in kids
    who look well enough to be treated as outpatients
    and in whom the positive results are not
    anticipated.

39
Antipyretic
  • Acetaminophen is generally a first-line
    antipyretic due to being well tolerated with
    minimal side effects.
  • Pediatric dose 10-15mg/kg q4-6h (2400mg/day)
    adult 650mg q 4 h(4000mg)
  • Can be hepatotoxic in high doses can upset
    stomach

40
Others
  • Aspirin
  • Ibuprofen
  • Mefenamic acid
  • Nimuselide _ NO
  • Combinations - NO

41
CLINICAL PEARLS
  • Dont give aspirin to children under 18 years
    (Reyes Syndrome)
  • Try tepid water sponge bath (80F or 27C)
  • remove blankets and heavy clothing keep room at
    comfortable temp, Avoid ice and alcohol
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