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Hot Stuff:
The Febrile Child
Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head
Pediatric Emergency Medicine. IWK Health Centre. Dalhousie University
November 2017
Know when to suspect a serious bacterial
infection as the cause of fever in the
otherwise healthy child
Fever myths
Fevers with rashes
I have no actual or potential conflict of interest in relation to this program.
I also assume responsibility for ensuring the scientific validity, objectivity, and completeness of the content of my presentation.
Re-setting of hypothalamic temperature setpoint
Controlled physiologic process within benign limits
When body is below the setpoint, body will generate internal heat through shivering and minimize heat loss through vasoconstriction
WBC activity
Activation of T
lymphocytes
Interferon
MAY inhibit viral
or bacterial
function
30% of all pediatric acute care visits are for
fever
Fever with localizing symptoms
Fever of unknown origin (Fever > 2wks)
Higher incidence of noninfectious causes
Very different infectious differential
Fever without focus/source (FWS)
Temperature was high on the “fever bug”
How do you define fever? What is the best method to
take temperature?
Rectal 36.6°C to 38°C
Tympanic 35.8°C to 38°C
Oral 35.5°C to 37.5°C
Axillary 34.7°C to 37.3°C
Age Recommended technique
0-2
years
RECTAL (definitive)
Axillary (screening)
2-5
years
Axillary or tympanic
Rectal used for definitive
only
>5 years Axillary or tympanic
Oral for definitive
Definitive measurements are only needed in select
circumstances – e.g. neonate or immunosuppression
CPS Position Statement:
Temperature Measurement in Pediatrics, 2013
Rectal temperatures traditionally gold
standard
Affected by depth of measurement and
presence of stool
Rectal perforation in less than 1 in 2 million
measurements (Arch Dis Child, 1992)
18 month old previously healthy child should
have an axillary temperature.
Although rectal is likely safe, it is unnecessary
in this scenario to obtain a gold standard
temperature.
14 day old baby girl brought to the ED with a
fever
Feeding well
Healthy full term baby.
Normal pregnancy and birth.
Group B Strep test was negative.
Well looking baby
T39.9R,HR146,RR 46,BP 80/40,Sats 99%
Normal exam
The baby looks ok so we could send her
home………
BUT…
12% of febrile infants less than 1 month old
without source will have Serious Bacterial
Infection (SBI)
Most common bugs:
Group B Strep
Eschericia coli
Listeria monocytogenes
Enterococcus
Serious Bacterial Infection in 12% Urinary Tract Infection 8.6%
Bacteremia 3.2%
Meningitis 1.3%
Cellulitis 0.8%
Bacterial gastroenteritis, septic arthritis and pneumonia 0.3%
Kadish, Clinical Pediatrics, 2000
Neonates have immature
immune systems and
infections are not
contained the way they
are are in adults.
An infection in the urine
can quickly spread to the
blood and the spinal fluid,
for example.
Even for very experienced pediatricians, we
can’t pick the sick child out of a line
up…and the screening bloodwork and urine
tests don’t help either.
All babies who are less than one month old with a fever need cultures of the blood, urine and cerebrospinal fluid culture
All babies with a fever less than one month of age are admitted with intravenous antibiotics (Ampicillin and Cefotaxime)
Herz et al Pediatric Infectious Disease Journal 2006
37,133 blood cultures on children 3-36 months
0.95% positive
Kids older than 3 months rarely get a
bloodstream infection
Blood work not
indicated for
previously healthy,
vaccinated and well
appearing 3-36
month old children
unless fever > 5 days
The presence of another clinically obvious source of infection reduces risk of UTI by one-half.
Overall rate of UTI in febrile kids under 2 is 5%
Highest risk groups: Girls (especially under 12 months)
Uncircumcised boys
Fever for more than 2 days
Temperature >39 C
White race
Gorelick, PEC, 2003Gorelick, Arch Dis Child, 2000
Baraff, Annals of Emerg Med, 2000
Get a urine test if :
2 days of fever in a girl, an uncircumcised boy who
has no other source of infection.
Pediatric Urine Collector (PUC) or Bag Urine is a
screening tool
We measure signs of the body fighting off
infection and would expect to see white cells
and nitrites in a urine sample.
Trouble is – we have white cells all over our
body. So this is only good if it’s negative.
Helps you relax and most importantly helps you
forget the experience.
Options include: Cefixime, Cephalexin, Clavulin,
Trimethoprim-sulfamethoxazole, Cefprozil
Long list of antibiotics that will work – we choose
the one that is the narrowest in spectrum, the
cheapest in cost and the easiest to give based on
taste and dosing interval)
¹American Academy of Pediatrics Clinical Practice Guideline: Urinary Tract Infections Diagnosis and Management PEDIATRICS Volume
128, Number 3, September 2011
7 months old
Chicken pox x 3 days
Today
Crying constantly
Fever
Area of redness around one of the spots
Taken to after hours clinic
Prescribed antibiotics and sent home
“The doctor did not even take her out of the stroller to examine her”
On arrival home was limp and unresponsive
Taken to ED
On arrival in ED:
T 39.4, HR 168, RR 44, Sat 94%
Difficult to arouse
Mottled, cap refill 5 sec
Area of erythema on chest
Further information?? BP 70/35
What is her diagnosis? Septic Shock
Next steps?
Fluid Resuscitation
Antibiotics
Sepsis protocol
Emergency Management
Fluids, fluids, fluids: received Normal Saline 20
ml/kg x 3, no improvement
Pressors started (tighten the blood vessels
and increase the blood pressure).
Pressors started were epinephrine and
dopamine.
Intubated (to protect airway)
Admitted to intensive care unit
Thea had Group A Strep Sepsis.
Rates of Group A Strep sepsis have decreased
since have chicken pox vaccination, but this is
a well known complication.
Sepsis is a leading cause of
death in infants and children
6 million deaths per year
worldwide in infants and
children
60-80% of deaths in children
in developing countries is from
sepsis
Sepsis occurs when chemicals released into
the bloodstream to fight infection trigger
inflammatory responses throughout the body.
This inflammation can result in a number of
physical responses that can damage multiple
organ systems causing them to fail.
If sepsis progresses to septic shock, blood
pressure drops dramatically, which may lead to
death.
US National database
28.2 million ED visits < 18 yrs annually
95,055 severe sepsis
0.34% of pediatric ED visits
Bimodal age distribution
32% < 1 yr
24% 13-18 yrs
National estimates of emergency department visits for pediatric
severe sepsis in the United States. Singhal et al. 2013
Mortality 9%
Causative Organism found in ~40% Staph 7%
Gram neg 5%
Strep 3%
Meningococcus 0.5%
Trends in the Epidemiology of Pediatric Severe
Sepsis. Watson et al. Ped Crit Care Med 2013
HR
TIME
BP
Compensated
Decompensated
Partnerships:
• 4 year old boy
• Non immunized
• Recent trip to the UK
• Returns to Halifax
• Fever, cough, red eyes, runny nose for 4 days
• Miserable
• Taken to chiropractor x 2
• Comes to ED on a busy night…and you finally see him after
he has been in the ED for 6 hours.
Public Health
Image Library,
CDC
60
• Incubation: 6-19days• Starts with fever, cough, coryza
and conjuctivitis• Koplik spots (Day 2)• Morbilliform rash-confluent face (Day
4) spread from head down-takes 3-4 d
Nature Reviews Micro2006
Public Health Image
Library, CDC
8 million deaths per year worldwide (Sem Ped
Neur 2012)
Vaccine preventable
Most deaths due to complications:
Pneumonia
Encephalitis
Higher case fatality for < 5 years, poverty,
outbreaks, secondary case in household
Wolfson, 2009
Paramyxo virus
Spreads through aerosolized droplets
Infectious droplets in your waiting room for 2
hour period
One of most communicable infectious disease
>90% household attack rate
Not spread by those who are immune
R0: basic reproduction number i.e. average
number 20 infectious cases produced by a single
index case in completely susceptible pop
From Dr.
Noni
MacDonald
, ID
Primary measles encephalitis Fever, headache, altered mental
status, seizures, ataxia and weakness
10-15% death rate
25% serious disability
Acute postinfectious measles encephalomyelitis Sensory loss, Ataxia, back pain
Autoimmune demyelination
Weeks to months after measles infection or vaccination
Measles inclusion body encephalitis Altered mental status, medically
refractory seizures, motor deficits
75% death rate in 2-3 weeks
Immunocompromised kids Subacute sclerosing
panencephalitis Behaviour problems, dementia,
myoclonus, cerebellar ataxia, necrotizing retinitis, cortical blindness
Diffuse cortical atrophy
Fatal
2-20 years post measles
2 year old girl with fever for 3 days and mild nasal congestion.
Parents already called 811 twice, been to a walk-in clinic, and visited the IWK ED
Records show a negative urinalysis and microscopy from 0200h this morning at ED
Mom’s main concern is that the fever is not responding to acetaminophen or ibuprofen.
She is worried her child will get “brain damage”.
Your thorough physical exam reveals a well
appearing child with no signs of meningitis.
She looks well and there is no focus on exam
aside from mild rhinorrhea. She attends day
care.
Poirier, Clinical Pediatrics, 2010
230 caregivers, Pediatric ED settings
Median temperature to cause harm 40.6 C
% “Very concerned” about potential harmful
consequences of fever
73%
%”Very concerned” when fever not reduced by
antipyretics
88%
% who wake children from sleep to administer
antipyretics
77%
% who administer ibuprofen more than every 6
hours
40%
Seizure 32%
Death 18%
Brain damage 15%
Passing out 6%
Infections 3%
Shock 2.2%
Blindness 1.9%
Meta-analysis
11 articles
Majority of published research indicates that
response to antipyretics cannot be used as a
predictor of significant bacterial illness
Is this helpful? Could it be harmful?
Heterogeneity of studies
Reduction of temperature :no statistical or clinical significance.
Comfort: Unclear effect
Side effects : not sufficiently powered to detect toxicities or side effects
Not recommended in light of possible dosing errors and lack of harm due to pyrexia
Inquire about parents concerns and address specific fears directly
Fever is a “symptom” and not a “disease” Antipyretic treatment is optional. Routine temperature checking and night
waking for antipyretics is unnecessary Recommend against alternating agents of
antipyretics
Unwell looking febrile child – if they are lethargic, confused or irritable, if their
skin is cool or mottled, or if they have breathing troubles or specific symptoms
such as a stiff neck. Fever with a rash that doesn’t blanch…needs to go to the ED
Fever that has no explanation after 2-3 days even if they look ok
Special populations:
Any baby less than 3 months
Any child who has had recent surgery
Immunocompromised child with fever. Common conditions include:
▪ Chronic steroid / immunosuppressant therapy
▪ Chemotherapy related immune suppression
▪ Sickle Cell Disease / Asplenia
▪ Known B or T cell immune deficiency
▪ Any children with a central line or other medical devices
Fever is a normal physiological response
Fever phobia is common
No need for alternating doses of antipyretics.
You’re likely to need a urine sample if you are under 36 months and have a fever with no obvious source.
Sepsis is a dysregulated body response to infection that damages organs and can lead to death.
Immunization prevents against serious diseases in children.