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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

Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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Page 1: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

Hot Stuff:

The Febrile Child

Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head

Pediatric Emergency Medicine. IWK Health Centre. Dalhousie University

November 2017

Page 2: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

Know when to suspect a serious bacterial

infection as the cause of fever in the

otherwise healthy child

Fever myths

Fevers with rashes

Page 3: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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.

Page 4: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 5: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

WBC activity

Activation of T

lymphocytes

Interferon

MAY inhibit viral

or bacterial

function

Page 6: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

30% of all pediatric acute care visits are for

fever

Page 7: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

Fever with localizing symptoms

Fever of unknown origin (Fever > 2wks)

Higher incidence of noninfectious causes

Very different infectious differential

Fever without focus/source (FWS)

Page 8: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

Temperature was high on the “fever bug”

How do you define fever? What is the best method to

take temperature?

Page 9: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 10: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 11: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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)

Page 12: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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.

Page 13: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 14: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

The baby looks ok so we could send her

home………

BUT…

Page 15: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 16: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 17: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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.

Page 18: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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.

Page 19: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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)

Page 20: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 21: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 22: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 23: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 24: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 25: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 26: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

Blood work not

indicated for

previously healthy,

vaccinated and well

appearing 3-36

month old children

unless fever > 5 days

Page 27: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 28: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

Get a urine test if :

2 days of fever in a girl, an uncircumcised boy who

has no other source of infection.

Page 29: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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.

Page 30: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 31: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 32: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 33: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

Helps you relax and most importantly helps you

forget the experience.

Page 34: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 35: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 36: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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”

Page 37: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 38: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

Further information?? BP 70/35

What is her diagnosis? Septic Shock

Next steps?

Fluid Resuscitation

Antibiotics

Sepsis protocol

Page 39: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 40: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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.

Page 41: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 42: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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.

Page 43: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 44: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 45: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 46: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

HR

TIME

BP

Compensated

Decompensated

Page 47: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 48: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

Partnerships:

Page 49: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 50: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 51: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 52: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 53: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 54: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 55: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 56: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 57: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 58: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

• 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.

Page 59: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

Public Health

Image Library,

CDC

Page 60: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 61: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

Public Health Image

Library, CDC

Page 62: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 63: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 64: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 65: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 66: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 67: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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”.

Page 68: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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.

Page 69: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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%

Page 70: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

Seizure 32%

Death 18%

Brain damage 15%

Passing out 6%

Infections 3%

Shock 2.2%

Blindness 1.9%

Page 71: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine
Page 72: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

Meta-analysis

11 articles

Majority of published research indicates that

response to antipyretics cannot be used as a

predictor of significant bacterial illness

Page 73: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

Is this helpful? Could it be harmful?

Page 74: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 75: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 76: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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

Page 77: Hot Stuff: The Febrile Child - Dalhousie University...Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine

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.