Pediatric Fever

Pediatric Fever

Emergency Medicine ClerkshipIndiana University

Objectives

• Review the approach to pediatric fever • Examine the work up for pediatric fever

without a source (FWS) in stratified age groups• Discuss the impact of current vaccines on our

approach

Fever

• 20% of Pediatric Emergency Department visits

• 35% of Ambulatory visits

• 20% have fever without a source after H&P

• “Fever Phobia”

“Fever Phobia”

• Study of 340 caregivers– 56% very worried about potential harm of fever– 7% thought temp could rise >110 F if left untreated– 91% believed fever could cause harmful effects

• 21% brain damage• 14% death

– 46% perceived their doctors to be very concerned about fever

– 14% gave acetaminophen and 44% gave ibuprofen at too frequent dosing intervals

Pediatrics. 2001;107 (6): 1241-1246.

“Fever Phobia”

• “Pediatric health care providers have a unique opportunity to make an impact on parental understanding of fever and its role in illness”

Pediatrics. 2001;107 (6): 1241-1246.

What is the definition of fever?

• Generally fever defined as at least 100.4°F

– < 3 months fever is ≥100.4°F (38°C)

– > 3 months still has same lower limit of 100.4°F (but diagnostic testing usually begins at 102.2°F or 39°C)

Defining Fever: How do we take the temperature?

• Axillary and tympanic temps are unreliable in young children (sensitivity 50-65%)– rectal temperature is the “gold” standard

• Expert panel concluded 100.4°F(38°C) by rectal thermometer should be used as the lower limit of the definition of fever

Defining Fever

• Fever documented at home by similar means should be considered the same as that documented in the ED

• 92% of the infants who had rectal fever at home had subsequent fever in next 48 hours. So, even if they are afebrile on presentation you can trust the rectal temperature at home.

Pediatric Infect Dis J. 1990 Mar;9(3):158-60

Defining Fever

• Be sure to communicate with the parents– ask how it was taken and if they added degrees– i.e. make sure 103°F was not 100.3°F

Why is fever so important?

• Your Goal is to rule out Serious Bacterial Infection (SBI)– UTI– Meningitis– Septicemia– Bone and joint infections– Pneumonia– Bacterial gastroenteritis

“Sick or Not Sick?”

History

• Birth history? Specifically for neonates-maternal infection or fever at delivery

• Eating?• Urine output?• Irritability?• Excessive sleepiness?• Immunized?

Physical

• Hypo- or Hyperthermic• Vitals• Rash• Fontanel• Respiratory• Circ or no Circ?

“Sick or Not Sick?”

• All febrile children less than 36 months [or for that matter any age] that appear toxic should be hospitalized for evaluation and treatment of possible serious bacterial infection (SBI)– What is a “toxic” appearance?• Lethargy• Signs of poor perfusion• Hypoventilation/hyperventilation• Cyanosis

The Dilemma

• What do you do with the well appearing child with fever?–What diagnostics need to be done?–Antibiotics or no antibiotics?–What is the availability and reliability of

follow up? How does that affect your management?

The Dilemma

• Lots of literature– No definitive rules for the treatment of pediatric

fever– “Guidelines” available• Mostly opinion papers over last 15 years despite

changes in epidemiology

• Art versus science– each patient is different– each staff is different– workups may change during community epidemics

Pediatric Fever

• Stratification into different risk groups:–Neonates: 0 to 28 days– Young infants: 29 to 90 days–Older infants and young children: 3 to 36

months

Let’s see some patients!

Case 1

• 3 week old white female• CC: congestion and fever. • Unremarkable PMHx/BHx. • ROS neg. • Initial temp at triage was 100.1° F. • PE is non-toxic alert infant with no abnormal

findings.

Do you want additional information about the fever?

• How was it taken at triage?• Were there any antipyretics given?• What was the fever at home?– fever in this case at home was 101.2°F

Infant 0 to 28 days

• Risk of SBI is as high as 20%• All of these patients require: – Full sepsis workup including CBC, Blood Cx, UA,

Urine Cx, CSF studies and CSF Cx– Consider CXR and stool studies– Empiric antibiotics– Admission

Antibiotics

• Ampicillin and gentamicin– covers GBBS, E. coli, Listeria monocytogenes– Ampicillin specifically for Listeria and provides

some synergy with gentamicin for GBBS• Ampicillin and cefotaxime– covers the < 1 month etiologic agents and also S.

pneumoniae– with cefotaxime you don’t have to worry about

oto/renal toxicity associated with gentamicin

Antibiotics

• Ceftriaxone is not used in neonates

• Why?

• because it competes for bilirubin binding sites and may lead to hyperbilirubinemia

Acyclovir?

• Consider acyclovir– Maternal history of Herpes (especially if primary

outbreak with vaginal delivery) or any noted skin or mucosal lesions

• BUT in the majority of patients with neonatal HSV, there is no maternal history of HSV.

• Definitely give if ill-appearing, pleocytosis with negative gram stain, vesicles, or seizures

Case 2

• 6 week old white male • Presents to the ED with fever to 101 • PMHx/BHx unremarkable • No source of infection on the exam• Looks non-toxic

Protocols

• We may not be able to determine sick vs not sick by H&P alone in this age group

• Several studies have attempted to develop a protocol for infants < 90 days of age– Rochester– Philadelphia

Rochester Criteria & Philadelphia Criteria

• Attempt to develop more sensitive ways to detect serious illness in febrile pediatric patients using:– History– Physical– Laboratory Evaluation

Rochester Criteria & Philadelphia Criteria

• Clinical Criteria:– Previously healthy, term infant with

uncomplicated nursery stay

– Non-toxic clinical appearance

– No focal bacterial infection on exam

Rochester Criteria & Philadelphia Criteria

Lab criteria for “low risk infant”• CBC:

– WBC count 5-15,000/mm3

– <1500 bands/mm3

– Band/neutrophil ratio <0.2• Urine:

– <5 WBC/hpf– Negative gram stain of

unspun urine (preferred)– Or negative urine leukocyte

esterase and nitrite

• CSF:– <8 WBCs/mm3 – Negative Gram stain

• Stool (when diarrhea):– <5 WBC/hpf

Back to your patient

• Labs are all negative– Normal Urine, LP, CBC

• What is the disposition?– Admit or send home

• Empiric Antibiotics?

Low Risk Febrile Infants 28 to 90 Days

Option 1• Full Sepsis work up:

Blood, Urine, CSF• Ceftriaxone (50

mg/kg)• Follow up in 24

hours

Option 2• Partial sepsis work

up: Blood and Urine• NO Antibiotics• Follow up in 24

hours

Low Risk Febrile Infants 28 to 90 Days

• Parents must be reliable– Phones– Ability to understand instructions

• Close follow up must be ensured– May need to wake up the primary care physician

Non-Low Risk Febrile Infants 28 to 90 Days

• In other words: Failed Rochester Criteria• Full Sepsis work up• Empiric antibiotics• Admit

Antibiotics

• Ceftriaxone– covers S. pneumoniae, H. influenzae, and N.

meningitidis• Add vancomycin if any concern for S.

pneumoniae on LP in any age range (resistant strains have been appearing in CSF)

Special ConsiderationsCase 3

• 2 month old asian male• Fever at home to 101• Immunizations given today at PMD clinic• PMHx/BHx negative• Well appearing

Fever after immunizations

• 2.8% of infants < 12 weeks who presented to the ED with fever within 24 hours of immunizations still had a UTI.

• There were not any other serious bacterial infections noted in the first 24 hours.

• After the first 24 hours, rates of serious bacterial infection (including UTI) increased to 8.9%.

Acad Emerg Med. 2009 Dec; 16(12):1284-9

Fever after immunization

• If less than 24 hours since immunizations– Consider UA, Urine Cx– May not need further work up

• If more than 24 hours since immunizations– Consider full vs partial sepsis work up

Special ConsiderationCase 4

• 2 month old hispanic female• Nasal congestion, cough• PMHx/BHx negative• Tachypneic, mild retractions and wheezing on

exam• Clinical dx: Bronchiolitis

Bronchiolitis with fever

• Significantly lower risk of most SBIs

• However, the rate of UTI remains significant (2.4-5.4%)

• 1.1% of infants with bronchiolitis had bacteremia compared to 2.3% of febrile infants without bronchiolitis

Pediatrics 2004 Jun; 113(6):1728-34Pediatrics 2009 Jul; 124(1):30-9

Bronchiolitis with fever

• 0-28 days: Full sepsis work up• >29 days: UA and Urine Cx

Case 5

• 7 month old male • Fever to 103 for 2 days• PMHx/BHx negative • Immunizations are UTD• Exam is unremarkable• What is your work up?

Child 3 to 36 months with FWS: Occult Bacteremia

• PCV7 (Prevnar):– Targets 7 capsular serotypes of S. pneumo that

caused 80% of the infections– Licensed in US in 2000– Studies have shown a 90% reduction in invasive

disease in children receiving the vaccine

Child 3 to 36 months with FWS: Occult Bacteremia

• Post Hib and PCV7 vaccines:• Causes of bacteremia have changed: – E.Coli 33%– Non-vaccine serotype S. pneumoniae 33%– S. aureus, Salmonella, N. meningitidis, S.

pyogenes 33%

Pediatr Infect Disease J. 2006; 25:293-300

Child 3 to 36 months with FWS: Occult Bacteremia

• Post Hib and PCV7 era:

• Occult bacteremia rates are now between 0-0.74%!

• So…..do you really need to blood culture??

Child 3 to 36 months with FWS: Occult Bacteremia

• In addition, in the post vaccine era, studies have shown that the rate of contaminated blood cultures equaled the rate of pathogenic blood cultures.

• In one study, children less than 6 months old were more likely to have contaminated blood cultures than true bacteremia.

Pediatric Adolescent Medicine. 1998; July; 152; 624-628

Child 3 to 36 months with FWS: Occult Bacteremia

• “For countries with widespread vaccination with Hib and PCV7, the data indicates that rates of occult bacteremia and subsequent SBI are extremely rare”

• So, in the non toxic appearing child, age 3-36 months with FWS. The blood culture and CBC are not a necessary part of the work up.

Minerva Pediatr 2009;61: 489-501.

Child 3 to 36 months with FWS: Urinary Tract Infection

• Most common SBI

Child 3 to 36 months with FWS: Urinary Tract Infection

• UTI’s almost always occult < 2 years of age

• Most common occult bacterial infection

• UTI occur in 7% of males < 6 months and 8% of females < 12 months with fever without a source

Child 3 to 36 months with FWS: Urinary Tract Infection

• Who needs a UA and Urine Cx– All females <24 mo– All males <6 mo– Uncircumcised males <12 mo

Child 3 to 36 months with FWS: UA/Urine Culture

• Get cath specimens– supra-pubic or trans-urethral– clean catch impossible– bags are usually not helpful (unless retrospectively

the culture is negative)• If you get urine, SEND for culture– up to 20% of negative UA’s will grow pathogen

Child 3 to 36 months with FWS: Meningitis

• In this age group, children will start showing signs of meningitis (clinical evaluation is more useful)

• LP is not mandatory – use clinical discretion

Child 3 to 36 months with FWS:Chest X-ray

• Usually negative in children with fever without a source and no signs and symptoms of lower respiratory infections

Child 3 to 36 months with FWS: Empiric Antibiotic Therapy

Don’t Do IT!

Pediatric Fever Algorithm

Appears toxic?

Yes

Full sepsis work up and antibiotics and admit

No

Temperature ≥ 102.2

No Yes

No testing, assure follow up in 48 hrs

Selective workup

Child 3 to 36 months with FWS

Summary of Testing: 3 to 36 months and FWS

• Blood cultures– Consider if child is unimmunized or immunocompromised

• Urine– All females < 2 years– Males

• Uncircumcised <12 months• Circumcised < 6 months

• CXR– If respiratory symptoms or hypoxic

• LP– Signs of meningitis

Fever with a Source

• More common than fever without a source• Clinically identifiable viral or bacterial illnesses

Fever with a Source: Viral– Varicella– Measles (recent outbreaks)– Mumps (recent Midwest

outbreaks)– Adenovirus

(pharyngoconjunctival fever)– Coxsackie infections

• Herpangina→• Hand-foot-and-mouth

– Croup– Bronchiolitis (as in our case)– Influenzae

Fever with a Source: Viral

• Pediatric exanthems– Roseola (HHV 6)– Fifths disease (Parvo

B19)→

Fever with a Source

• What is the risk of concurrent serious bacterial infections with identifiable viral syndromes?– Low, in general• Not zero

Special ConsiderationCase 6

• 6 week old female• Red area on leg noticed today• Febrile to 100.8 F• PMHx/BHx negative

Cellulitis in the neonate

• Up to 90% of febrile neonates with cellulitis may have bacteremia. Because of the high rate of systemic infection in these patients, these infants require IV antibiotics and hospitalization initially

Pediatrics. 1998;102(4 pt1):985-986

Cellulitis in the neonate

• What if this infant was afebrile?• One small retrospective cohort study that evaluated the

presence of serious bacterial infection in afebrile infants 0 to 28 days with skin and soft tissue infections.

• None of the neonates had serious bacterial infections. • Skin and soft tissue infections (SSTI) in the study were

pustulosis, cellulitis, and abscesses.• This was a small study so it is hard to use to guide practice

definitively. However, it may suggest that well appearing infants without fever can be managed without a full evaluation.

Pediatr Emerg Care, 2012. 28(10): p. 1013-6.

Fever with a Source

• Take Home Points– A clear viral illness is a source and portends a low risk of

SBI• However in infants ≤ 28 days, SBI risk is still high enough to

warrant sepsis evaluation– Bronchiolitis/Influenza

• ≤ 28 days = full sepsis evaluation• 29-60 days = at least check urine

– Be careful with nonspecific viral infections (no well defined viral illness)

Pediatric Fever Summary: Golden Rules

• A toxic appearance demands immediate action– Work-up/antibiotics and admit

• Know the age-specific algorithm for FWS• Test the urine (most common SBI)• Look for specific bacterial and viral etiologies• Careful follow up must be assured• Recommendations continue to evolve with

new immunizations

References1. Schwartz, S., et al., A week-by-week analysis of the low-risk criteria for serious bacterial infection in febrile neonates. Arch Dis

Child, 2009. 94(4): p. 287-92.2. Caviness, A.C., et al., The prevalence of neonatal herpes simplex virus infection compared with serious bacterial illness in

hospitalized neonates. J Pediatr, 2008. 153(2): p. 164-9.3. Bonadio, W.A., M. Hegenbarth, and M. Zachariason, Correlating reported fever in young infants with subsequent temperature

patterns and rate of serious bacterial infections. Pediatr Infect Dis J, 1990. 9(3): p. 158-60.4. Albanyan, E.A. and C.J. Baker, Is lumbar puncture necessary to exclude meningitis in neonates and young infants: lessons from

the group B streptococcus cellulitis- adenitis syndrome. Pediatrics, 1998. 102(4 Pt 1): p. 985-6.5. Kharazmi, S.A., et al., Management of afebrile neonates with skin and soft tissue infections in the pediatric emergency

department. Pediatr Emerg Care, 2012. 28(10): p. 1013-6.6. Wolff, M. and R. Bachur, Serious bacterial infection in recently immunized young febrile infants. Acad Emerg Med, 2009.

16(12): p. 1284-9.7. Krief, W.I., et al., Influenza virus infection and the risk of serious bacterial infections in young febrile infants. Pediatrics, 2009.

124(1): p. 30-9.8. Levine, D.A., et al., Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections.

Pediatrics, 2004. 113(6): p. 1728-34.9. Wolff M, Pomeranz E, Carney M. Febrile Young Infant Learning Module. MedEdPORTAL; 2013. Available from: www.mededportal.org/publication/956810. McVey P. Fever Without a Source in Children Less Than 28 Days, 28 to 90 Days, and 3 to 36 Months. MedEdPORTAL; 2006.

Available from: www.mededportal.org/publication/31611. Bandyopadhyay, S; Bergholte, J; Blackwell, CD; Friedlander, JR; Hennes, H. Risk of serious bacterial infection in children with

fever without a source in the post-haemophilus influenzae era when antibiotics are reserved for culture-proven bacteremia . Arch Pediatric Adolescent Medicine. 2002;156; 512-517.

References12. Klein, J. Management of the febrile child without a focus of infection in the era of universal pneumococcal immunization. The Pediatric Infectious Disease Journal. 2002; 21; 584-587. 13. Lee, GM; Harper, MB. Risk of bacteremia for febrile young children in the post-haemophilus influenzae type b era . Arch Pediatric Adolescent Medicine. 1998; July; 152; 624-628.14. Chancey, RJ, Jhaveri, R. Fever without localizing signs in children: a review in the post-Hib and postpneumococcal era. Minerva Pediatr 2009;61:489-501. 15. Herz, AM et al. Changing epidemiologhy of outpatient bacteremia in 3-36 month old children after the introduction of heptavalent-conjugated pneumococcal vaccine. Pediatr Infect Dis J 2006;25:293-300.16. Crocetti, M, Moghbeli, N., Serwint, J. Fever Phobia Revisited: Have Parental Misconceptions About Fever Changed in 20 Years?. Pediatrics. 2001;107 (6): 1241-1246.

QUESTIONS????