The Febrile Infant

1. The Febrile Infant BY: DRA.Fatma .s.al zahrani

2. The Febrile Infant Definition: • Temperature >/= 38 C (100.4 F ) • Rectal temp closely correlates with core body temperature • Ear/Axillary/Sticker temps are unreliable. • Temps vary depending upon time of day

3. The Febrile Infant Fever Without A Source (FWLF) Acute febrile illness in which the etiology of the fever is not localized after the history and physical examination.

4. The Febrile Infant Pathogenesisof fever: Pathogens → cytokine release →resets thermoregulation of hypothalamus→ maintains a higher body temperatur Infants < 3 months less likely to have fever

5. The Febrile Infant What to do? Obtaining detailed History • Age • Parents report of wellbeing • Parents report of specific symptoms • Height and presence of fever • Risk Factors (Prematurity,Immunocompromised) • Epidemiologic Factors (Sick contacts)

6. The Febrile Infant Physical Exam • Give anti pyretic to relax the child if irritable or in pain • Perform throughu physical examination. • Look for evidence of serious illness • Meningeal signs may not be apparent < 18mo

7. The Febrile Infant Approach 1)The high risk age is: • 0 – 28 days • 28 – 90 days • 3 – 36 months

8. The Febrile Infant 2)Toxic Appearing • A clinical picture consistent with the sepsis syndrome: • Lethargy • Poor Perfusion • Hypoventilation • Hyperventilation • Cyanosis

9. The Febrile Infant 3)Lethargy: Poor eye contact &poor interaction with parents and people arround

10. The Febrile Infant Assessing Risk  Rochester Fever Criteria  Yale Observation Scale (Clinical)

11. The Febrile Infant Rochester Criteria for Febrile Infants Ages 60 – 90 Days Criteria • Well appearing/Full term • No skeletal, soft tissue, skin, or ear infections • Previously healthy • WBC 5000 – 15,000 • Bands <1500 • UA: WBC’s < 10/hpf • If diarrhea: fecal Leukocytes <5/hpf Interpretation • Well appearing febrile infant risk: 7-9% • All Rochester Criteria present: < 1%

12. The Febrile Infant Yale Observation Scale 3 - 36 Months • Quantifies “Toxic Appearance” • Quality of Cry • Reaction to parents • Arousability • Color • Hydration • Social Response Interpretation: Risk increases with higher scores

13. The Febrile Infant Low Risk Infants • Previously Healthy/Full term • No focal Bacterial Infection on PE • Good social situation • Nontoxic clinical appearance • Negative lab screening: • WBC 5000 – 15,000 • < 1500 Bands • Normal UA • < 5 WBCs/hpf in stool if diarrhea present

14. The Febrile Infant Management: • Infants 0 – 28 Days • ALL infants should be admitted , with full sepsis workup (Blood, Urine, CSF) • Empiric parenteral antibiotic therapy pending negative cultures.

15. The Febrile Infant Management: Infants 0 – 28 Days Most common bacterial organisms (Group B Strep,E. Coli,Listeria) Antibiotic coverage • Ampicillin and Gentamicin OR • Ampicillin and Cefotaxime

16. The Febrile Infant Management: Infants 28 – 90 Days Febrile Infant • Toxic OR Nontoxic • High Risk OR Low Risk • Inpatient OR outpatient

17. The Febrile Infant Management: a)Infants 28 – 90 Days Low Risk Outpatient • Full sepsis work up and empiric parenteral • antibiotic coverage (Ceftriaxone IV/IM) Follow up within 24 hours If CSF cx (+), admit for IV Abx treatment If Blood cx (+) i) febrile/ill for IV Abx ii) afebrile/well, may consider oral Abx outpt Rx If Urine cx (+), i)febrile/ill for IV Abx, ii) afebrile/well, consider oral Abx outpt Rx

18. The Febrile Infant Management: Infants 28 – 90 Days Admit Low Risk if: • Immature/Unreliable Parents • Unsure of follow up • No home telephone • Lack of Transportation

19. The Febrile Infant Management: Infants 28 – 90 Days Nontoxic High Risk • Admit • Full sepsis work up • +/- empiric parenteral antibiotics Most Common Organisms • Late onset Group B Strep • Strep. Pneumoniae • H. Flu • N. Meningitidis

20. The Febrile Infant Management: Children 3 – 36 Months • Fever without source accounts for 14% of outpatient visits • Mean probability of occult bacteremia 4% • Higher risk of bacteremia with temps >39C • Sensitivity of clinical evaluation greater (89-92%) in this age group

21. The Febrile Infant Management: Children 3 – 36 Months Nontoxic, Temp > 39 C (102.2 F) Lab work not indicated if presumptive diagnosis is URI, or sick contacts with URI - CBC w Diff, Blood Cx -CXR indicated if signs of LRI, WBC > 15, Temp > 104 • urine culture (catheter or suprapubic) is gold standard UA/Urine cx if males < 6 months and females < 2years

22. The Febrile Infant Management: Children 3 – 36 Months Most Common Organisms • Strep. Pneumoniae • H. Flu • N. Meningitidis • Strep. Pyogenes • Staph • Salmonella

23. The Febrile Infant AntibioticTreatment: -Children 3 – 36 Months Nontoxic, Temp > 39 C (102.2 F) • WBC > 15,000 • UA (+) • Can treat with Abx without LP in this age • Group optional)

24. The Febrile Infant Treatment: Children 3 – 36 Months • Ensure follow up • If Blood cx (+) i) febrile/ill f0r admission & IV Abx ii) a febrile/well, consider outpt oral Abx Most studies indicate that treatment with parenteral Abx associated with least risk of further sequelae • If Urine cx (+) i) admit if febrile/ill for IV Abx ii) a febrile/well, consider outpt oral Abx

25. The Febrile Infant Summary Guidelines is one way to assist physicians in managing infants and children with fever without a source .They are flexible and management may be individualized according to the case.