Fever in pediatric practice

BY DR M OSAMA HUSSEIN MD

International Neonatology Training Program" INTP

FEVER IN PEDIATRIC PRACICE

Term DefinitionFever Rectal temperature of 38°C (100.4°F)*

Fever without source

Acute febrile illness in which the etiology of the fever is not apparent after a careful history and physical examination

Serious bacterial infection

Meningitis, sepsis, bone and joint infections, urinary tract infections, pneumonia, enteritis

Toxic appearance

Clinical presentation characterized by lethargy, evidence of poor perfusion, cyanosis, hypoventilation or hyperventilation

Lethargy Poor or absent eye contact; failure of child to recognize parents or to interact with persons or objects in the environment

DEFINITIONS OF TERMS IN PRACTICE GUIDELINE ON THE MANAGEMENT OF FEVER IN INFANTS AND YOUNG CHILDREN

Infant appears generally well

Infant has been previously healthy:

Born at term (≥37 weeks of gestation)No perinatal antimicrobial therapyNo treatment for unexplained hyperbilirubinemiaNo previous antimicrobial therapyNo previous hospitalizationNo chronic or underlying illnessNot hospitalized longer than mother

Infant has no evidence of skin, soft tissue, bone, joint or ear infection

Infant has these laboratory values:

White blood cell count of 5,000 to 15,000 per mm3 (5 to 15 × 109 per L)

Absolute band cell count of ≤1,500 per mm3 (≤1.5 × 109 per L)

Ten or fewer white blood cells / high-power field on microscopic examination of urine

Five or fewer white blood cells per high-power field on microscopic examination of stool in infant with diarrhea

ROCHESTER CRITERIA FOR IDENTIFYING FEBRILE INFANTS

AT LOW RISK FOR SERIOUS BACTERIAL INFECTION

Why we pay special attention to fever ?

• Parental concern• “fever phobia”

• Clinician concern• we don’t want to miss a life threatening infection

• Most common complaint in pediatric visits

• Some of these kids are sick• most do well without intervention• need an approach to sort them out

BY DR M OSAMA HUSSEIN MD

Fever Without a Source

• Fever without a source “FWS”= fever with no apparent cause

• “Fever of Unknown Origin”= a febrile illness of at least three weeks' duration, at least 38.3°C on at least three occasions and failure to establish a diagnosis in spite of intensive evaluation.

BY DR M OSAMA HUSSEIN MD

Pediatric Fever AlgorithmNon toxic appearing, 28 – 90 days and “Low Risk”

No

Blood Culture, Urine Culture, CSF Cx, antibx +/-CXR

Yes

ADMITOutpatient Management

Option 1Blood Cx, Urine Cx, CSF Cx, ceftriaxone 50 mg/kg IV/IM, re-eval in 24 hours

Option 2Blood Cx, Urine Cx, Re-eval in 24 hours

Fever 38°C

BY DR M OSAMA HUSSEIN MD

Child 3 to 36 months with FWS: Occult Bacteremia

• S. pneumoniae>>H. influenzae>N. meningitidis– conjugate vaccine for H influenzae virtually

eliminated this type of bacteremia

BY DR M OSAMA HUSSEIN MD

Child 3 to 36 months with FWS: Practice Guidelines

• Toxic - Admit with full work up• Non-toxic – Consider workup when fever is

39°C

BY DR M OSAMA HUSSEIN MD

Pediatric Fever Algorithm

Appears toxic?

Yes

Full sepsis work up and antibiotics and admit

No

Temperature ≥ 39

No Yes

No testing, assure follow up in 48

hrs

Selective workup

Child 3 to 36 months with FWS

BY DR M OSAMA HUSSEIN MD

Child 3 to 36 months with FWS: Practice Guidelines

• Toxic - Admit with full work up• Non-toxic – Consider workup when fever is

39°C (102.2°F)

BY DR M OSAMA HUSSEIN MD

Child 3 to 36 months with FWS: Occult Pneumonia

• Children with high fever and leukocytosis are more likely to have occult bacterial pneumonia– some suggest getting CXR with no resp symptoms

and WBC>20,000 and temp39.5°C (103.1°F)

BY DR M OSAMA HUSSEIN MD

Pediatric Fever Algorithm

Appears toxic?

Yes

Full sepsis work up and antibiotics and admit

No

Temperature ≥ 39

No Yes

No testing, assure follow up in 48 hrs

Selective workup

Child 3 to 36 months with FWS

BY DR M OSAMA HUSSEIN MD

Summary of Testing: 3 to 36 months and FWS, non-toxic, temp ≥39 C

• Urine– All females < 2 years– Males

• Uncircumcised <12 months• Circumcised < 6 months

• Stool culture– If bloody diarrhea or >5 wbc’s/hpf

• CXR– If respiratory symptoms or hypoxic

• LP– Signs of meningitis

• Blood cultures and Antibiotics– Option 1: All with fever ≥ 102.2– Option2 : All with fever ≥ 102.2 and WBC ≥ 15,000– Option3: Practitioner/immunization dependent

BY DR M OSAMA HUSSEIN MD

Fever with a Source

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

BY DR M OSAMA HUSSEIN MD

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

BY DR M OSAMA HUSSEIN MD

Fever with a Source: Viral

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

B19)→

BY DR M OSAMA HUSSEIN MD

Fever with a Source: Bacterial

• Clinically evident bacterial infections– Readily diagnosed from H&P• Pneumonia• Meningitis• Septic arthritis• Osteomyelitis• Lymphadenitis• Cellulitis/Abscess• Bacterial enteritis

BY DR M OSAMA HUSSEIN MD

Antipyretics

• Triage protocols– acetaminophen by protocol

• Acetaminophen dose– 15 mg/kg q 4 hr prn

• Ibuprofen dose (for greater than 6 months old)– 10 mg/kg q 6 hr prn

BY DR M OSAMA HUSSEIN MD

Bug Drugs: <1 month

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

some synergy with gentamycin for GBBS• Consider acyclovir– Maternal history of Herpes (especially if primary

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

BY DR M OSAMA HUSSEIN MD

Bug Drugs: 1-2 months

• 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 gentamycin

BY DR M OSAMA HUSSEIN MD

Bug Drugs: >2 months

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

meningitidis– theoretically shouldn’t give < 1 month because of

biliary sludging • Add vancomycin if any concern for S.

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

BY DR M OSAMA HUSSEIN MD

Kawasaki’s Disease

• Fever for at least 5 days' duration and the presence of 4 of the following – Extremities changes (erythema, edema, and

desquamation) – Conjunctivitis (no exudate).– Polymorphous rash (not vesicular) is usually generalized – Cervical lymphadenopathy usually unilateral and greater

than 1.5 cm– Lip or oral cavity changes (erythema, dry/fissured or

swollen lips, and strawberry tongue)

BY DR M OSAMA HUSSEIN MD

Febrile Seizures

• Simple Febrile Seizure– 1 event in a 24 hour period– Non-focal

• Complex– Whenever it is not simple– Consider larger work-up

• 30% chance of recurrence

BY DR M OSAMA HUSSEIN MD

Febrile Seizures

• Work up for the source of the fever• “Strongly consider LP” for under 12 months –

AAP guidelines• Brain imaging not often necessary• Need to explain to parents why you aren’t

worried about the seizure

BY DR M OSAMA HUSSEIN MD

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 immunizationsBY DR M OSAMA HUSSEIN MD

Fever with xanthem Infectious causes

Virus: Classic viral exanthem: Measles, Rubella, VZV, Parvovirus,

Roseola Others:, HSV, EBV, HBV, Enterovirus, Dengue

Bacteria: Scarlet fever, Staph infection (sepsis, 4S,toxic shock syndrome), Meningococcemia, typhoid

Mycoplasma Rickettsial infection

Noninfectious cause Allergy: Food, drug, toxin, serum sickness Uncertain cause: Kawasaki disease

BY DR M OSAMA HUSSEIN MD

Clinical Manifestation Incubation: 8-12 days, the average interval between

appearance of rash in the source case and subsequent cases is 14 days, with a range of 7-18 days.

Prodromal period: fever 2-4 day + 3C cough coryza conjunctivitis Koplik spot

Rash: erythematous maculopapular rash facesole in 72 hr. face and trunk: mostly distributed pneumonia

Convalescence cough may persist for 1 week

BY DR M OSAMA HUSSEIN MD

BY DR M OSAMA HUSSEIN MD

BY DR M OSAMA HUSSEIN MD

Complication Pneumonia Otitis media Diarrhea Meningoencephalitis Croup Subacute sclerosing panencephalitis (SSPE)

BY DR M OSAMA HUSSEIN MD

Treatment and Care Supportive and Symptomatic Vit A supplementation

6 mo-2 yr hospitalized with measles and complication

> 6 mo who have risk for severe measles and vit A deficiency:

immunodef, vitamin A def, impaired intestinal absorption, malnutrition, recent immigration from high mortality rated due to measles

Antibiotic for superimposed bacterial infection

BY DR M OSAMA HUSSEIN MD

Treatment and Care Isolation: Airborne Precaution

1-2 day before onset of symptom or 3-5 days before onset of rash

4 days after onset of rash in healthy children

For the duration of illness in immunocompromised pt.

Isolated room (negative pressure ventilation)

Prevention: immunization 9-15 months 4-6 years

BY DR M OSAMA HUSSEIN MD

Rubella RNA virus: Family Togaviridae, genus

Rubivirus IP: 14-21 days Infectivity: 7 days before – 5 days after onset

of rash

BY DR M OSAMA HUSSEIN MD

Clinical Manifestation Prodromal period 1-5 days MP rash for < 3 days LN at postauricular and cervical area CBC: normal range Dx: viral isolation

Serologic test: CF, HI, IgM ELISA

BY DR M OSAMA HUSSEIN MD

BY DR M OSAMA HUSSEIN MD

Rubella Complication

arthritis thrombocytopenia meningoencephalitis

Treatment: supportive Isolation:

droplet precaution for 7 days after onset of rash, contact precaution for congenital rubella until >

1 yr-old Prevention: immunization

BY DR M OSAMA HUSSEIN MD

Chickenpox VZV, HHV-3: Transmission

airborne contact vesicular fluid vertical transmission

Incubation period: 14-16 days, (10-21days)

Infectivity: winter season Most contagious: 1-2 days before onset of rash

until crusting of lesion.

BY DR M OSAMA HUSSEIN MD

Clinical Manifestation Prodromal period: 2-3 days Generalized, pruritic, vesicular rash 250-500

lesions involving skin and oral mucosa Complication

Herpes Zoster, Shingles Congenital varicella: Scar, limb, ocular, CNS

defect Bacterial infection Severe chickenpox CNS: encephalitis, cerebellar ataxia, Reye’s

Syndrome

BY DR M OSAMA HUSSEIN MD

BY DR M OSAMA HUSSEIN MD

BY DR M OSAMA HUSSEIN MD

BY DR M OSAMA HUSSEIN MD

Treatment and care Supportive and symptomatic

antipruritic drug for severe case: ACV, famciclovir,

valacyclovir Isolation:

Airborne and contact isolation 1-2 days before rash until crusting of all lesion.

Prevention Immunization

BY DR M OSAMA HUSSEIN MD

Child Care and School Children may return to school when all lesion

are crusted.

For compromised children with prolonged course should excluded for the duration of the vesicular eruption.

Older children and staff members with zoster should be instructed to wash their hands if they touch potentially infectious lesion

BY DR M OSAMA HUSSEIN MD

Hand-foot-mouth Disease coxackie virus type 16 (A 16) most

common, other include A5, A7, A9, A10, B2, B5(31) and enterovirus 71

Fever, sore throat, drooling DDx from Herpes gingivostomatitis Self-limited, symptomatic treatment

BY DR M OSAMA HUSSEIN MD

HFMD

BY DR M OSAMA HUSSEIN MD

BY DR M OSAMA HUSSEIN MD

Roseola Infantum

Exanthem subitum 3 mo- 3 yr. (6 mo-1 yr) HHV-6,7: DNA virus, Herpesviridae Uncertain incubation period (9-10 days)

BY DR M OSAMA HUSSEIN MD

Clinical Manifestation High fever 39-41 c for 3-4 days

nonspecific symptom bulging AF febrile convulsion

MP Rash after defervescence CBC: normal range of WBC, lymphocyte

predominated

BY DR M OSAMA HUSSEIN MD

BY DR M OSAMA HUSSEIN MD

Erythrema infectiosum (Fifth Dz) Parvovirus (PV) B19 Family Parvoviridae 3-15 year Droplet transmission Incubation period: 4-14 days S/S: lowgrade fever, constitutional symptoms, arthralgia Classical 3 phases

Sunburn-like rash both cheek (classic slapped-cheek appearance) 2-4

Day 1-4 after facial rash macular – to – morbiliform eruption at extremities (extensor surface)

Lacy pattern: some w/o classic slapped-cheek pattern

BY DR M OSAMA HUSSEIN MD

BY DR M OSAMA HUSSEIN MD

BY DR M OSAMA HUSSEIN MD

Meningococcemia N meningitidis: GNDC, bean shape Clinical manifestation

acute febrile illness petechiae, hemorrhagic manifestation:

purpura fulminan rapid progressive with HT or coma meningoencephalitis

Diagnosis: gram stain, antigen detection, buffy coat smear and culture

Treatment: penicillin, CTX, CRO

BY DR M OSAMA HUSSEIN MD

BY DR M OSAMA HUSSEIN MD

Scarlet fever GAS or S aureus: pyrogenic exotoxin (SPE) Acute febrile illness with:

Sore throat Gooseflesh or coarse sand-paper rash within

12-48 hr. Most intense at pressure area: axilla, groin Pastia’s line Strawberry tongue Pustule (Staph scarlet)

Desquamation begins toward the end of the 1st week

BY DR M OSAMA HUSSEIN MD

BY DR M OSAMA HUSSEIN MD

Scarlet fever

BY DR M OSAMA HUSSEIN MD

Scarlet fever

BY DR M OSAMA HUSSEIN MD

Scarlet fever

BY DR M OSAMA HUSSEIN MD

Staphylococcal scalded skin syndrome (SSSS/4S) Staphylococcus toxigenic strain phage

group 2 with epidemolylic toxin A and B Start with local infection e.g. purulent

conjunctivitis, otitis media, nasopharyngeal infection

Fever, MP rash or erythroderma with periorificial and flexural accentuation with Nikolski sign

BY DR M OSAMA HUSSEIN MD

BY DR M OSAMA HUSSEIN MD

Impetigo contagiosa

BY DR M OSAMA HUSSEIN MD

BY DR M OSAMA HUSSEIN MD