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Dr. Osama Kentab, MD, FAAP, FACEP
Assistant Professor of Paediatrics and emergency Medicine
King Saud Bin Abdulaziz university for Health sciences
Riyadh
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Epidemiology
Very common sign and symptom of illness in childhood
May be indicative of an infection that is local or systemic; benign or invasive & life threatening
Normal body physiological reaction to pyrogen ( infective, inflammatory)
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Implications of body temperatureIs it beneficial?Rate of bacteraemia is 2-3% in all febrile
infants < 2months (Baker 1999; Kadesh et al 1998)
Infants < 2 months differ are less immunocompetent unique group of bacteria (GBS, Gram. Neg bacteria & listeria)
Young infants show relative inability to demonstrate clinical evidence of illness
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Assessment: Relevant historyDuration of feverPattern of fever: intermittent or
continuousHx of contact: family members, friends,
school matesHx travel abroad: country visited
Malaria endemic regions, enteric fever (Africa, Asia) Travel immunization, malaria prophylaxis
Travel to mountainous region, camping in forest (Rickettsial infection, Lyme disease)
Hx of Immunization
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Relevant symptomsSystemic symptoms: Resp, ENT, Renal, GIRash: Pattern/type (macular, papular,
ulcerative, erythematous, blanching)Distribution (mucosal involvement-
conjuctivitis, mucositis, buttocks and extremities(HSP) Oral ulcers (aphthous, herpes gingivostomatitis)
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Relevant clinical signs Unwell – ToxicHaemodynamic instabilityRashLower Respiratory signsJoint involvement: Arthritis/ Athralgia:
Reactive viral arthritis, Septic arthritis, HSP, Rheumatic fever, Chronic arthritis of childhood
Organomegaly: Hepatomegaly, Splenomegaly, +/- Anaemia: Systemic illness, Septicaemia, Lymphoproliferative disorders
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Causes of febrile illnesses in childhood
Common causesURTI (viral or bact.)LRTIGastroenteritisUTIOral (dental abscess,
hyperangina, herpetic gingivitis, mumps)
MSS (septic arthritis, osteomyelitis, cellulitis
Serious causesURTI (epiglottitis,
croup, retropharyngeal abscess)
LRTIGI (appendicitis)CNS (Meningitis,
encephalitis)Systemic
(meningococcaemia, toxic shock syndrome
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Protocols for Identification of Low Risk Infants
Rochester
1985-1988
Boston 1992
Philadelphia 1993-1999
Pittsburgh
1999-2000
Age(days) 0-60 28-89 29-56 0-60
Past health >37 wk,home with or before mom,no susequent hosp,no prenatal, post,or current ATB,no treatment for unexplained
hyperbole,no chronic diseases
- No known immundef. Rochester
Temp C 38.0 38.0 38.0 38.0
Infant Obs.score no Yes Yes no
WBC 5-15,000 <20,000 <15,000 <5>15
Bands/BNR - <1.5x10/L <0.2 BNR no
LP No Yes Yes <8 wbc Yes 5
urine 10WBC/hpf - 10WBC/hpf EUA 9
Stool(if diarrhea) 5 wbc/hpf - - < 5
CXR - - Yes Neg if sx
ATB(Ceftrx) No Yes No 34.7%??
SBI in low risk Pts (%)
1.1 5.4 0 0
NPV(%) 98.9 94.6 100 100
Sens (%) 92.4 Not stated 100 100
Management of fever in young children
8
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Age < 29 days CBCD,glucose,BUN,Creat,lytes, +/-
cap.gassesBlood cultureUrine cath (microscopy and culture)LP (if infant unstable defer)CXR (suspected respiratory disease)NPW (suspected viral respiratory disease)Stool for WBC, culture and heme test
(suspected eneteric infection)Management of fever in young children 9
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Age < 29 days
Cont’dSupportive careAntibiotics: Ampicillin AND Gentamycin OR Ceftriaxone/Cefotaxime Consider AcyclovirAdmit
Management of fever in young children 10
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29 to 60 days CBCD, BNRBlood culture LP (if infant unstable defer)Urine cath (microscopy and culture)CXR (suspected respiratory disease)Stool for WBC, heme test and culture
(suspected enteric infection)
Management of fever in young children 11
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29-60 days Low riskPast historyBorn >37 wksHome with or before the motherNo subsequent admissionNo prenatal,postnatal,or current
antibioticsNo treatment for unexplained
hyperbilirubinemiaNo known immune deficiency
Management of fever in young children 12
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29-60 days Low riskP/EAppears generally well (non-toxic)No evidence of skin,soft tissue,bone, joint,or ear infection
Management of fever in young children 13
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29-60 days Low riskLaboratoryWBC >5k <15kANC <10K or band/neutrophil ratio < 0.2Urine <10 WBC/hpf, spun and negative Gram
stainCSF: Non-bloody ,< 8 WBC , normal glucose,
protein, negative Gram stain and latex agg.test
Normal CXR (if it was done)Stool (if diarrhea) <5 wbc/hpf
Management of fever in young children 14
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29-60 days Low Risk
Option IICeftriaxone 50
mg/kg IV or IMRe-evaluate in 24
hours and 48 hoursOptional second
dose of ceftriaxone at second visit
Option INo antibioticsAdmit for observation
ORRe-evaluate in 24 & 48
hours
Management of fever in young children 15
Discharge only if:
Reliable caregiver
Has nearby telephone
Adequate transportation
Discharge only if:
Reliable caregiver
Has nearby telephone
Adequate transportation
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61-90 days Low RiskOption INo LP No antibiotics Admit for observation
ORRe-evaluate in 24
hours
Option IILP & if normal:Ceftriaxone 50 mg/kg
(IV or IM) ORNO antibioticsAdmit for observation.
ORRe-evaluate in 24
hours
Management of fever in young children 16
Discharge only if:
Reliable caregiver
Has nearby telephone
Adequate transportation
Discharge only if:
Reliable caregiver
Has nearby telephone
Adequate transportation
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29-90 days High riskToxicPositive labsConcerning
history /social factors
AdmitSupportive careMeningitis Ceftriaxone and
VancomycinNon-meningitis Ampicillin and Ceftriaxone OR
Gentamycin
Management of fever in young children 17
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3-36 months Toxic looking Fever, meningeal signs, lethargic, limb, mottled
Admit, septic work-up, parenteral antibioticsFocal bacterial infection
OM, pharyngitis, sinusitis, etc (excluding SBI).Oral/parenteral antibiotics, outpatient care
Well looking Risk for occult bacteremia and serious bacterial
infectionPrevious decision analysis( Pre-H. flu
immunization)Current decision analysis
Management of fever in young children 18
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3-36 months High risk/toxicAdmitSupportive care Septic work-upIV antibiotics Meningitis---->Vanco + Ceftriaxone Non-meningitis ----> Ceftriaxone
Management of fever in young children 19
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3-36 months Non-toxicIf <3 yrs,temp >39 :Obtain CBC,Blood culture,Urinalysis & cultureStool culture,CXR as indicatedIf WBC>15k --->Empiric antibiotics (Ceftriaxone,Clavulin,Biaxin, omnicef or
Suprax )If urine is positive treat as UTIIf WBC normal ,urine is negative no therapy
needed
Management of fever in young children 20
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3-36 months Cont’dIF Temp < 39, Non-toxic, No focus of
infectionNO INVESTIGATIONS ARE REQUIREDFollow up all in 24 hours
Management of fever in young children 21
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Management of fever in young children 22
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Oncology patientsAt risk of overwhelming sepsisCBC, CXR, blood culture, urine culture, and
LP when clinically indicatedNeutropenic patients at risk for Pseudomonas
and other gram negativeBroad spectrum antibiotics
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Acquired Immunodeficiency SyndromeRepeated risk of infection with common
bacterial pathogens, risk of Pneumocytsis carinii, mycobacterial infections, cryptococcosis, CMV, Ebstein-Barr virus.
Low CD4; septic work up and broad spectrum antibiotic
Management of fever in young children 24
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Sickle Cell AnemiaFunctional asplenia susceptible to
overwhelming infection esp. encapsulated organisms such as pneumococci and H. flu
Parvovirus can cause aplastic crisisOsteomyelitis should be suspected in
fever and bone painCBC, retics,blood culture, stool culture,
and urine culture recommendedCeftriaxone Hospitalization recommended
Management of fever in young children 25
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Congenital Heart DiseasesChildren with valvular heart disease are
at risk for endocarditisFever without obvious source with a new
or changing murmur; hospitalization, serial blood cultures, echo, antibiotics against: S.viridans, S aureus, S. fecalis, S. pneumo, enterococci, H. flu, and other gram neg rods
Suggested antibiotics include Vancomycin and Gentamycin until cultures are known
Management of fever in young children 26
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Ventriculoperitoneal shuntsMust be evaluated for shunt infection esp if
patient displays headache, stiff neck, vomiting, or irritability
Shunt reservoir should be aspirated and examined for pleocytosis and bacteria
Most common pathogen is S. epidermidisCT head also warranted
Management of fever in young children 27
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Febrile Seizures 455 children with simple febrile seizure -1.3% with bacteremia -5.9% UTI - 12.5% with abnormal chest x-ray -Normal CSF in all who had an LP (135)
Trainor J, et al: Clin Pediatr Emerg Med 1999
Management of fever in young children 28
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Febrile Seizures 486 children with bacterial meningitis -complex seizures present in 79% -93% of those with seizures were obtunded -of the few with “normal” LOC, 78% had
nuchal rigidityGreen SM, et al: Pediatrics 1993
Management of fever in young children 29
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Febrile SeizuresSynopsis of the American Academy of Pediatric
practices parameters on the evaluation and treatment of children with febrile seizures
LP strongly considered in the first seizure in infants less than 12 month because signs and symptoms of meningitis may be absent in this age group
12-18 months LP should be considered because sign of meningitis may be subtle in this age group
18+ months LP only if signs and symptoms of meningitis
(Peditrics 1999)
Management of fever in young children 30
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Febrile SeizuresRoutine lab (CBC, lytes, Ca, phos, Mg, or
glucose) should not be performed in simple febrile seizure
Neuro-imaging should not be performed routinely on simple febrile seizure
EEG is not performed in a neurologically healthy child with simple febrile seizure
Anticonvulsant therapy is not recommended in simple febrile seizure
Management of fever in young children 31
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DDx Fever with rash
Viral exanthems Streptococcal infectionStaphylococcal scalded skin syndrome /
Toxic shock syndromeKawasaki diseaseMeningococcal disease Henoch Schonlein purpura (HSP)
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Measlesparamyxo virusSpread by respiratory dropletsIncubation period: 7 – 12 daysCF: prodromal period (fever, conjuctivitis,
coryza, dry cough, koplik spots +/- lymphadenopathy) florid maculopapular rash appearing over head and neck spreading to cover the whole body X 3-4 days
Infectious from the prodromal period until 4 days after rash appeared
Dx: Measles Antibodies in saliva or serumComplications: OM, pneumonia, encephalitis,
subacute sclerosing pan encephalitis
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Chicken pox (Varicella)varicella zoster DNA virusIncubation period 14 – 21 days Fever & malaise X 5-6 days followed by
crops of skin lesions that go through stages of macules, papules, vesicles, and crusting
Infectious 2 days before rash until vesicles dry/crust
Complications: Secondary bact. Infection of lesions, haemorrhagic varicella, pneumonia, encephalitis, ataxia at 7-10 days after rash
Severe illness in immunocompromised adults, preg. Women & neonates
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Rubella (german measles)RNA rubella virusIncubation period: 14 – 21 days Fever, rash, posterior cervical lymph nodeComplications: Deafness,encephalitus,
Congenital rubella syndromeRx: Symptomatic
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Roseola infantum (Human herpes virus type 6)
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Roseola infantum Caused by Human herpes DNA virus type 6 &
7Many children already infected by 2 years Incubation period: 5- 15 daysCF: short febrile illness x 3- 5 days and an
erythematous rashComplication: Meningoencephalitis & Sz
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Fifth Disease
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Erythema infectiosum (Fifth ds/ Slapped cheek ds)
Human parvo virus B19Incubation period: 7 – 17 daysHead ache & malaise rash on face ( slapped cheek app.)
spreading to the trunk and limbs with maculopapular lesion evolving to a lace- like reticular pattern
Complications: Aplastic crisis with underlying chronic haemolytic anaemia, Aseptic meningitis, Hydrops fetalis
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Hand, Foot & Mouth diseaseCaused by coxsackie A16, A19 and
Enterovirus 71 RNA virusesIncubation period: 4 – 7 daysCF: fever, malaise , head ache,
pharyngitis, vesicular lesions on the hands and feet including palms & soles
May be complicated by chronic recurrent skin lesions
Rx: Symptomatic
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Infectious mononucleosis (Glandular fever)
Ebstein Barr (DNA) virusCF: fever, lymphadenopathy, tonsillitis,
headache, malaise, myalgia, splenomegaly, petechiae on soft palate, rash (macular, maculopapular, urticarial or erythema multiforme)
DX: EBV specific IgM; Paul Bunnell testComplication: Splenic rupture, ataxia,
facial nerve palsy, aplastic anaemia, interstitial pneumonia
Rx: Symptomatic
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UTI in childhoodUTI is commonVUR is assoc with renal scarring
particularly in the 1st year pf lifechronic renal failure Neonates – irritability, refusal of feeds,
vomiting, FTT, prolonged NNJ, toxic/extremely unwell
Pre-school: vomiting, poor wt. Gain, fever, malaise, freq, dysuria, enuresis, haematuria, loin pain
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UTI (2)Inv: Urine m/c/s x 2 (or 1 SPA urine
sample) – mid stream, clean catch, bag, SPA urine samplePyuria, organism on microscopySignificant bacteruria > 10 5 org/ml or and
growth from SPATreatment: Antibiotics PO or ivCommence low dose prophylactic antibiotic
Refer to the Paediatrician for further investigations
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Meningococcal diseaseGram neg. diplococciNasopharyngeal carriage in 25%Invasive disease in 1% carriers15% meningitis; 60% Septicaemia +
endotoxaemia; fulminant septicaemic shock with circulatory
failure & wide spread purpuraRx: Antibiotics; management of shock,
anticipate ventilatory failureTransfer to PICU and contact public health deptPrognosis: Poor if <1 year, better if evolution of
ds slower; overall mortality approx. 30%
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Kawasaki disease Systemic vasculitis of early childhood 80% cases < 4 years & M:F ratio = 1.5:1
No single diagnostic test; 5/6 clinical criteria fever >5 daysChanges in the mucous membrane of URTChanges in the peripheral extremities (oedema,
desquamationPolymorphous rash (urticarial, maculopapular,
multiforme)Cervical lymph adenopathyExclusion of staphylococcal & streptococcal
infection & others (Measles, drug reaction, JCA)Coronary aneurysm +fever + 3 / 4 criteria
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Kawasaki disease (2)Other features: irritability, arthritis,
aseptic meningitis, hepatitis, hydropic gall bladder
20-30% Myocarditis, pericarditis, arthymia, cardiac failure, coronary aneurysm
Rx: High dose IV Ig 2g/Kg over 12-18 hrsHigh dose Aspirin 30mg/Kg/day until fever
resolves then 3-5mg/Kg/dayCardiac echo for coronary aneurysm
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InvestigationAccording to the differential diagnosisIndicated if child is unwell and or no
cause identified full infection screenUrinalysis & Urine m/c/s
where no focus of infectionAll children <2 years where S&S of UTI is
non specific and diagnosis has implication for future management
With urinary symptomsBefore starting antibiotics
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Complete Infection ScreenFBC & blood film; WBC differential, band
neutrophil ratioCRPThroat swab: virology, m/c/sUrine m/c/sBlood c/sBlood for PCR and rapid antigen screen:
meningococcal, pneumococcal,Stool m/c/s & virologyCXR LP for CSF analysis: protein, glucose,
m/c/s
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TreatmentTemp control: antipyretics (paracetamol,
Ibuprofen) exposure & avoid dehydrationSick / deteriorating child: supportive mx
with best guess antimicrobial therapySpecific causeIndication for referral to paediatric team
Unwell/ toxicUnknown source or cause of fever particularly
in early childhoodAssociated systemic symptoms & signsFever > 14 days (PUO)