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Pediatric Fever in the ED

Pediatric Fever in the ED. Marc Francis FRCPC R4 PEM Fellow year 1 Consultant Level Physician: Dr Jeff Grant. Objectives. Determination of a fever Case based look at fever in the ED A rational and evidence based approach to the 3 major groups of kids with fever 0-30days

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Pediatric Fever in the ED

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  1. Pediatric Fever in the ED Marc Francis FRCPC R4 PEM Fellow year 1 Consultant Level Physician: Dr Jeff Grant

  2. Objectives • Determination of a fever • Case based look at fever in the ED • A rational and evidence based approach to the 3 major groups of kids with fever • 0-30days • 1 month to 3 months • 3 months to 3 years • Determining the significance of fever in the era of new vaccinations • Evaluation of the work-up for fever and the utility of each variable • Treating Fever in the ED

  3. Why do we care? • Febrile infant can be a challenging situation in the ED • Fever is the CC in up to 20% of visits to the ED • Fever is commonly misunderstood • While the vast majority of kids will have self-limiting viral illnesses a few will have serious bacterial infections • 300+ articles have been written about the evaluation and management of the febrile child

  4. Useful stuff when working with Dr. Bryan Young • Fever • Host response mediated by cytokines • Endogenous pyrogens • IL-1, IL-6, TNF, interferon-alpha • It is IL-6 which triggers the hypothalamic centers to increase body temp set point • Increased metabolic rate, muscle tone and activity and ↓ heat loss through ↓ skin perfusion • PGE2 is likely responsible for the myalgis and arthralgias

  5. Friend Integral part of inflammatory response Role in fighting infection? Decreased length of symptomatology? Growth or survival of some pathogenic bacteria is impaired in range of 40°C Foe Like many defense mechanisms it can go awry Metabolic changes detrimental in the context of shock or significant illness Can aggravate cerebral injury Makes pts uncomfortable Febrile convulsions Fever: Friend of Foe?

  6. Case #1 • 5 month old Male • Previously Healthy • No medications, Vaccines UTD • HPI • 2 day history of tactile fever at home • This AM axillary temp of 38.8 °C by mom • Child more lethargic and decreased PO intake • URTI symptoms of rhinorrhea and unproductive cough

  7. Case #1 con’t • P/E • Well appearing child • given tylenol 15mg/kg at triage • T 37.5 °C, HR 120, RR 24, BP 71/52, Sat 98% • Exam normal • ENT • Rhinorrhea • oralpharynx injected, no exudate • TMs clear x 2

  8. Questions • Does this child even have a fever? • What is the definition of a fever? • What is the best method to measure a temperature in this child? • Should the measured fever at home factor into your decision making at all?

  9. Determination of a fever • What constitutes a fever is debatable • Studies by Wunderlich • 1 Million measurements in 25,000 pts • Determined the upper limits of normal • For infants a rectal temp > 38.0 °C > 100.4 °F

  10. Determination of a fever • Tactile Fever is useless • Otic thermometers • Not used under 6 months of age • Axillary temp • Unreliable • Elevated temp is indicative of a fever • Low or normal is not useful • An infant determined to be febrile at home by a reliable method must be presumed to have been febrile even if the temp later in the ED is normal

  11. What about this thing?

  12. Temporal Artery Thermometer • Computes temporal arterial temperature by a heat balance method • infrared sensor • Uses rapidly repeated measurements (1,000/second) of ambient and temple skin surface temperatures • Painless and rapid measurement • Appealing for use in children

  13. Assessed agreement between rectal and noninvasive temporal artery temperature in infants and children • 275 subjects • average age was 11.2 months • range from 0 to 24 months

  14. Results

  15. Results

  16. Conclusions • Temple temperatures do not reliably predict rectal temperatures • Can be used as an effective screen for clinically important rectal fever in children 3-24 months old • Findings do not support use of temple temperatures to screen young infants for rectal fever >38.0°C

  17. Approach to the Febrile Child

  18. Caveats • The toxic child always mandates aggressive work-up, abx and admission • Studies of febrile infants exclude pts with complicating risk factors • Immunocompromised • Indwelling medical devices • Currently on abx • Prolonged fevers >5days • In kids < 3 mths with a temp ≥40°C, 38% will have a serious bacterial infection • Stanley R, Pagon Z, Bachur R. Hyperpyrexia among infants younger than 3 months. Pediatr Emerg Care 2005;21(5):291 –4.

  19. Case #2 • 22 day old F • PMHx • Term baby of uncomplicated pregnancy • Vaginal delivery • GBS negative mother • No prolonged ROM • Discharged home less than 48hrs • HPI • Public health nurse saw the child and temp of 38.4 rectally recorded – sent in to ED

  20. Case #2 cont • HPI • Child doing well at home • Gaining weight appropriately • No lethargy or irritability • Feeding well, BMs normal, good u/o • Exam • T 38.6, HR 155, RR 35, Sat 99% RA • Child examines very well • Tone normal, good strong suck • No focus for fever found

  21. Questions • Could this be a serious bacterial infection? • How do you want to manage this child?

  22. Issues in the <30d old • High risk • Exposure to pathogens in birth canal without passively transferred maternal antibodies • Immature immune system • Exhibit few if any classic signs of sepsis • Limited behavioral repertoire • may deteriorate rapidly • May not even be able to mount a fever • Children born premature are at even greater risk

  23. Issues in the <30d old • Immature immune system • Decreased opsonin activity • Decreased macrophage activity • Neonatal neutrophils have reduced ability to migrate from blood to sites of infection

  24. Issues in the <30d old • The majority will go on to a diagnosis of nonspecific viral illness • 12% of all febrile neonates presenting to a peds ED will have serious bacterial illness* • Typically more virulent bacteria • More likely to develop significant sequelae *Baker MD, Bell LM. Unpredictability of serious bacterial illness in febrile infants from birth to 1 month of age. Arch Pediatr Adolesc Med 1999;153(5):508–11 *Kadish HA, Loveridge B, Tobey J, et al. Applying outpatient protocols in febrile infants 1–28 days of age: can the threshold be lowered? Clin Pediatr (Phila) 2000;39(2):81 – 8.

  25. Full Septic W/U CBC with Diff Blood culture Urinalysis and culture LP Stool culture and fecal leukocyte count if diarrhea present +/- Chest radiograph Admission IV Abx Management

  26. Pathogens: First few weeks GBS E. coli Listeria Monocytogenes Community Strep Pneumo H flu Neisseria Meningitidis Rarely Staph aureus Salmonella Antibiotics: Ampicillin 3rd generation cephalosporin +/- Acyclovir ? Ceftriaxone Antibiotics

  27. ACEP Clinical guidelines: • Level A recommendations • Infants between 1 and 28d with a fever should be presumed to have a serious bacterial infection

  28. Case #3 • 2 month old Male • Previously healthy, no medications and vaccines are UTD • HPI • 48hr history of fever • Decreased PO intake and occasional vomiting • Some lethargy noted at the breast • Otherwise well • No diarrhea, no rash, no cough, no URTI symptoms

  29. Exam T 38.9 tympanic, HR 136, RR 38, Sat 98% RA Generally looks well and appropriate CVS – normal Resp – no distress, clear bilaterally Abd – soft and nontender no HSM Derm – no rash Neuro – good tone, strong suck, interacting well ENT – throat clear, TM’s normal, no adenopathy Case #3 cont

  30. Questions? • Does this child need a full septic work-up too? • Is this child high or low risk? • How can you risk stratify him? • What degree of work-up does this child need for his fever without a source? • How would you manage this child

  31. Issues in the 1mth to 3mth old • Significant amount of research in this area • Give more clinical clues to their degree of wellness than the <30d olds • Clinical criteria alone do not give adequate accuracy to detect a significant infection • Determination requires clinical and laboratory investigations

  32. Lab evaluation of FWS • CBC with diff • Urinalysis • Boys <6mths • Girls <2yrs • Stool for leukocytes if diarrhea • Chest radiograph if respiratory symptoms

  33. Approaches

  34. Need to identify the high risk pt • Criteria for same are well documented • Pick one and stick to it • The Rochester Criteria are well recognized • Advantage of no CSF criteria!!! • Use your clinical judgment if you are experienced • Good research to show that experienced clinicians are good predictors

  35. Rochester Criteria • Dagan and colleagues • Stratifies children less than 60d old into High or low risk categories • Clinical and lab criteria • Low-risk group were unlikely to have serious bacterial infection • NPV of 98.9% Jaskiewicz JA, McCarthy CA, Richardson AC, et al for the Febrile Infant Collaborative Study Group. Febrile infants at low risk for serious bacterial infection–an appraisal of the Rochester criteria and implications for management. Pediatrics 1994;94(3):390– 6.

  36. Rochester Criteria 1) previously healthy term infant with uncomplicated nursery stay 2) well appearance 3) No focal infection (except OM) 4) WBC 5,000-15,000/mm3 5) Band count <=1,500/mm3 6) U/A normal (<=10 WBC/hpf) 7) stool <=5WBC/hpf (if diarrhea)

  37. Rochester Criteria • Low risk if none • High risk if look toxic or fail the criteria • Numerous studies have shown an increase in serious bacterial infections missed when applied to infants age 1 – 28 days -Ferrera PC et al Neonatal fever: utility of the Rochester criteria in determining low risk for serious bacterial infections. Am J Emerg Med. 1997;15:299-302 -Kadish et al. Applying outpatient protocols in febrile infants 1-28 days of age: can the threshold be lowered? Clin Pediatr. 2000;39:81-88 -Baker MD, Bell LM. Unpredictability of serious bacterial illness in febrile infants from birth to 1 month of age. Arch Pediatr Adolesc Med. 1999;153:508-511

  38. High risk management? • Look toxic or fail the criteria • Full septic work up • Hospital admission • Empiric antibiotics • Clear CSF: 24hr empiric ceftriaxone • Urine positive: amp/gent pending cultures • CSF pleocytosis: 48hrs on amp/ceftriaxone and consider Vanco

  39. 2 management strategies: 1) blood, urine and CSF cultures single dose of IM ceftriaxone re-evaluation within 24hrs 2) Urine culture obtained No abx therapy Careful observation Low risk infants 30d to 90d

  40. Should you LP? • Prevalence of bacterial meningitis in febrile infants < 3 months is 4.1/1000 pts • Neither the clinical exam or WBC is reliable in diagnosis • The LP should be strongly considered • If you forego the LP do not give antibiotics • Confounds the evaluation for meningitis if still febrile on follow-up exam

  41. Disposition is Key • Outpatient • Reliable follow-up within 24hrs • Immediate access to health care if required • Good parents • Careful plan derived with parents

  42. Do these clinical guidelines actually help the experienced clinician?

  43. Prospective cohort study • Aim to characterize the management and clinical outcomes of febrile infants • N= 3066 infants ≤ 3mths with temp >38°C • Office based practice of 573 practitioners in 44 states (PROS) • Outcome measures assessed: • Management strategies • Illness frequency • Rates and accuracy of treating bacteremia

  44. Results: • Hospitalized 36% of infants • Lab testing in 75% • Bacteremia detected in 1.8% and bacterial meningitis in 0.5% • In the initial visit physicians treated 61/63 cases of bacteremia/bacterial meningitis with abx

  45. Conclusions: • Peds clinicians in the US use individualized clinical judgment • Neither current guidelines or any other clinical model performed with greater accuracy than observed practitioner management • Current guidelines would not have resulted in improved care with more hospitalizations and lab testing

  46. Case #4 • 2yo M • Previously well, no meds, vaccines UTD • HPI • 3 day hx of fever responsive to advil prn • Decreased activity level as per parents • poor po intake of solids, but drinking • Good u/o, no diarrhea or vomiting • No URTI symptoms

  47. Case #4 con’t • Exam • Well appearing child • T39.1°C, HR 115, RR 24, BP 80/48, Sat 98% • CVS – normal • Resp – Clear and no distress • Abd – soft and nontender • Derm – no rash • ENT - normal

  48. Questions • What is the concern in this age group? • What defines a significant fever in this age group? • What diagnostic test are indicated in this scenario? • How would you manage this child?

  49. Issues in the 3mth to 3yo child • Remains controversial (surprised?) • Have been considered at risk for occult bacteremia • This age group where widespread vaccination has had its greatest effect • Important to obtain a detailed vaccination history to assess risk

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