management of febrile infants and young children

8/13/2019 Management of Febrile Infants and Young Children

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Management of the Febrile Infant

and Young Child

Benjamin P. Harrison, MD, LTC, MC, USA

Program Director, Madigan-University of WashingtonEmergency Medicine Residency

*Revised from previous edition by Ann Egland, MD and Kim Forman, MD

Government Services Chapter

American College of Emergency Physicians


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Scope of the Problem

Fever = Temp > 100.4 F or 38.0 C (some

use 100.5 or greater)

10-20% of all pediatric visits to the ER.

20% will have fever without source


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GSACEP 2005

Approach to the

Febrile Infant / Child

The Great Debate

Approaches in the 1 month36 month old

febrile infant/child vary greatly

Guidelines change as disease prevalence

fluctuates; data/studies conflict at times

Grey Areas are abundant; be open to change!One-size-fits-all approach discouraged


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GSACEP 2005

Occult Bacteremia

Transient bacteremia is a daily occurrence

(tooth brushing, dental or bowel

procedures)

Identifying occult bacteremia increases with

increasing fever, WBC, and ANC.

Vast majority of infants/children with fever

are viral, even if hyperpyrexic


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GSACEP 2005

Occult Bacteremia

2-3% of febrile children < 3 y.o. had occult

bacteremia in past (H. influenza B and S

pneumoniae predominately)

Numbers much lower now

OPB = occur pneumococcal bacteremia

SBI = serious bacterial infection


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Occult Bacteremia

By definition, a well-appearing child with

bacteria in his/her blood.

Initially bacteremia occult or hidden

May progress to toxicity, septic shock or

produce focal infections


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Incidence of Occult Bacteremia (Post HiBand Pre Pneumococcal Vaccine Era)

1.9% incidence of bacteremia

82.9% S. pneumoniae13 times more likely to be pathogen (vs.

contaminant) if grew in less than 18 hrs.

95.7% resolved without parenteralantibiotics


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Predictors of Occult Bacteremia

Age Dependent

Premature InfantsInfants and children

Birth to 28 days

28-60 days 2 to 36 months

Above 3 years


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OPB pts younger, ill-appearing, with

higher temperatures, WBC, ANC, and ABC

Occult bacteremia in 8.1% with ANC

>10,000 vs. 0.8% if ANC


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When a recognizable viral syndrome

present, low risk for occult bacteremia.

i.e. Croup, varicella, bronchiolitis,

stomatitis

0.2% rate of occult bacteremiaBlood cultures are not indicated in these

cases


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GSACEP 2005

Occult Urinary Tract Infections

Occult UTIs 4% of boys < 12 mos and 9% of

girls < 24 mos (Not immunized against E. coli !)

Uncircumcised males more at risk

UA & urine culture < 6 months for circumcised

and < 12 months old in uncircumcised

Get UA in hyperpyrexia even if other sourcespresent (AOM, AGE, etc)


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Occult UTI Diagnosis

Urine Culture > 103-105 cfus = gold std

Tr. LE, > 10 WBC/hpf and neg- Gm stain or

no bacteria are all highly senstitive

Nit +, >Mod LE, + Gm Stain, > 10

WBC/hpf and bacteruria are all very

specific for UTI on cath UA


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GSACEP 2005

Occult Urinary Tract Infection

75% of febrile UTIs are pyelonephritis

Consequences of missed pyelonephritis in

childhood

Renal scarring in 27-64% (with risk of HTN,

renal failure and pre-eclampsia as an adult)

13-15% of end-stage renal disease is thought tobe related to under-treated childhood UTI.


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Occult Pneumonia

40% of children suspected of pneumonia

confirmed with CXR

26% without pneumonia clinically had

positive CXR in subgroup with WBC >

20,000

Strongly consider CXR in children < 5 y.o.

with WBC > 15K even if normal RR, pulse Ox

and lung exam!


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Consequences of Missing OPB

10-25% of children with OPB will

develop cellulitis, pneumonia, or sepsis

if not treated

3-6% will develop meningitis (Pre

Prevnar) Much lower numbers now


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GSACEP 2005

Why Not Treat All Highly Febrile

Children with Antibiotics?

Indiscriminate use of antibioticscontributes to emerging resistance of S.

pneumoniae

Adverse drug reactions

Decreases patient discomfort and EDcosts


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GSACEP 2005

The Febrile Child

Rectal temperature is the gold standard

Age > 36 months much less at risk

Definition of fever for selective protocols to

be discussed are as follows:

Birth to 28 days

29-90 days

3-36 months


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GSACEP 2005

What about the Temperature?

Recent immunization history

Overbundling is not the cause of a fever

Accept the T-max at home

Parents good at identifying fever (tactile)

Normal/low temp doesnt preclude SBI


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Toxic Appearing?

Eval toxic-appearing children immediately

Septic workup and admit, regardless of age

Toxicity is defined as:

Lethargy

Signs of poor perfusion

Hypoventilation, hyperventilation, or cyanosis

I.E. Shock / sepsis / meningitis / encephalitis


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GSACEP 2005

Approach to the Toxic Patient

Fever alone may make a child appear ill

Ask about childs behavior when not febrile

and observe in ED if afebrile

Normal?

Still ill appearing?

Eating/drinking?


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Vital Signs

Fifth Vital Sign

Pulse Ox mandatory with abnormal lung

exam, resp rate or respiratory symptoms

RR will increase with fever

Pulse oximetry more reliable predictor infection

than respiratory rate


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Vital signs

Address Abnormal Vital Signs

Get accurate weight for treatment

Elevated pulse may be from fever or crying

Repeat pulse after antipyretics or hydration

Try to document vitals when patient is calm


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Physical Exam Findings

Petechial / purpuric rashes (invasive

bacteremia)

Toxic appearance and WBC >15,000 are

100% sensitivity for identification these

rashes

Meningococcemia associated with purpura

more than petechiae alone.


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GSACEP 2005

Birth to 28 Days Old

Documented temperature above 100.4

degrees F requires a full septic work-

up and admission


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Septic work-up includes:

CBC with manual differential

Blood culture

Urinalysis and urine culture

CXR

LP for CSF analysis and culture; Herpes PCRTesting

Stool culture and fecal WBCs for diarrhea


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If ill-appearing, give parenteral antibiotics

once urine/blood obtained ( < 30 mins &

before LP !)

Ampicillin 50-100 mg/kg/dose IV +

Cefotaxime 50 mg/kg/dose IV up to 2g

OR Ampicillin + Gentamicin 2.5 mg/kg IV


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GSACEP 2005

Nontoxic 28 to 90 Days Old

Various approaches and debatable area

10% will have aseptic meningitis if LP done

Management also depends on risk factors

Low Risk Group may be discharged home

High Risk Group requires more extensive

workup and admission


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28 to 90 Days Old

Low Risk Patients

No bacterial focus on PE (excluding OM)

Non-toxic, previously healthy

Not hospitalized, term infant , no antibiotics

Reliable parents with car/phone, close F/U


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28 to 90 Days Old

Low Risk Patients

WBC 5-15k (


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Most conservative approach

Full Septic Workup

Antibiotics within 30 minutes of arrival

Ceftriaxone 100 mg/kg o.k. after 6 weeks age

Admit pending culture results

Consider Acyclovir treatment if Herpes

PCR testing not returned yet and CSF

results not clearly bacterial in etiology


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The Minimalist approach

UA, Blood and Urine cultures

1 in 1,000 missed meningitis (most viral) if

no LPparents/provider o.k. with that risk?

No antibiotics

Follow up visit in 24 hours


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My Approach

Lab/CXR work-up for fever >38 degrees C /100.4 degrees F, observe patient in ED

No antibiotics if no LP and Close F/Uensured

LP added if:

Younger patient (2860 days) with high feverIll, but non-toxic, appearing or any other

concern while observing


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Toxic 3 to 36 Months Old

Toxic appearing? Concern for sepsis or

meningitis?

Treat empirically

Ceftriaxone 100 mg/kg IV up to 4G OR

Vancomycin 15 mg/kg IV up to 500 mg AND

Cefotaxime 50 mg/kg IV up to 2G


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GSACEP 2005

3 to 36 Months Old

Well appearing with clear source of fever:

Treat and send home with follow-up

Patient has a source but appears toxic:

LP, antibiotics and admit

Well appearing but no clear source of fever;

Debatable approachdepends on

immunization status


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Why Treat in

Pre-HiB and Pre-Prevnar Era?

Patients who received oral antibiotics later

identified with OPB had fewer serious

bacterial infections (3.3% vs. 9.7%).

Meningitis developed in 0.8% vs. 2.7%,

respectively.

h ld


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GSACEP 2005

Nontoxic 3 to 36 Months Old

Not Immunized

< 24 months old with 39 C (102.2 F) fever

without a identifiable source needs further

work-up

24-36 months old, 39.5 C (103 F) used

because risk of bacteremia increases to2.1% from 0.7% with fever 39 C to 39.4 C.

d


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Nontoxic Un-immunized

3 to 36 Months Old

Labs recommended in those without a

source:

Blood culture

CBC

Cath U/A and urine culture (as indicated)

CXR for tachypnea, retractions, focalabnormalities, room air SaO2 < 95%


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N i U i i d


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Nontoxic Un-immunized

3 to 36 Months Old

If urine or CXR is positive, treat with appropriate

antibiotics for UTI or pneumonia

If ANC > 10k (or WBC > 15k), send blood culturethen give ceftriaxone 50 mg/kg IV/IM

Follow-up with ED or PCM in 24 hours to check

culture results, reassess the patient and consider

need for further antibiotic treatment.


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N i I i d*


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GSACEP 2005

Nontoxic Immunized*

3 to 36 Months Old

> 95% infants with serotype specific

antibodies after 2 doses Prevnar

Herd immunity / lower invasive disease

After 2 doses HiB and Prevnar vaccines,

UTI alone is primary concern if no source

* At least 2 doses each of HiB and

Pneumococcal vaccines


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3 to 36 Months Old

Advise parents/caretakers to return

immediately if the child is worse

Follow-up in the appropriate clinic/PCM

office if not improving or for culture results


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GSACEP 2005

3 Years Old and Up

After a careful history and physical to

identify possible fever causes, treatment

should be tailored to specific causes only.

In the well-appearing child without a

source, no further evaluation is indicated.

Occult serious bacterial infection in childrenover 3 years is extremely low.


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3 Years Old and Up

Treat fever with anti-pyretics:

Acetaminophen 15- 20 mg/kg every 4 hours

and/or Ibuprofen 10 mg/kg every 6-8 hours

Advise parents to return immediately if the

child is worse and to follow-up with his/her

PCM if not improving.


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Special Cases

Any child with a complicated or significant

medical history should be treated

conservatively.

Clinical judgment must be used.

Febrile children with sickle cell disease

under age 4 are usually admitted.


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Summary

Treatment of the febrile infant and young

child depends on:

Appearance

Fever

Age

Past Medical History

Immunization Status


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Summary

Bloodwork rarely helpful

Do complete History and PE

Ensure appropriate admission

Arrange close F/U or return to ED

Always tell the parents to return if the childis getting worse!

management of febrile infants and young children

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