An Approach to Fever in Infants & Children Pediatric Fever Evaluation and Management Clinical Practice Why Is The Topic Important? • 20-35% of urban pediatric ED visits: – “Fever Phobia” • 65% of children visit their pediatrician with complaint of fever before their 2nd birthday • Diagnoses range from minor to life-threatening • Multiple conflicting recommendations, guidelines, and algorithms To Work Up or Not to Work Up? Specific Questions: – Blood tests – Lumbar Puncture – Urinalysis / Urine Culture – CXR – Antibiotic use – Observation – Hospital admission Significant Fever: Defined Temperature of 38.0 ̊ rectally at rest: – 0-2 months risks increase at 38.0 ̊ (the occurrence of Serious Bacterial Infection (SBI) increases from < 1% to 5% at 38.0° C) – 3-36 months risks increase at 39.0 ̊ Fever Without Source: “Fever without source is an acute febrile illness in which the etiology of the fever is not apparent after a careful history and physical exam.” Pediatric Fever Evaluation and Management Clinical Practice Reduce unnecessary testing Shorten time to initiation of antibiotics Goal: to evaluate and manage fever in infants and young children based on best available clinical evidence Lessen length of ED stay Reduce unnecessary antibiotics Sample Case #1 21 day old uncircumcised male presents with: – Fever of 38.3° – Has a runny nose – Cough – Alert and well appearing child – No wheezing or retractions – Previously healthy What is Your Work Up? Neonates (0-28 days) • CBC with manual diff, blood culture • Cath urinalysis, C&S • Lumbar puncture • Antibiotic therapy • Consider CXR if white count > 20,000, tachypnea, or respiratory symptoms • Admit Prevalence of Serious Bacterial Infection (SBI) Infants 0-2 Months Old • Febrile neonates: SBI = 13% • Febrile infants 1 to 2 months of age: SBI = 10% • Febrile infants younger than 3 months of age Urinary Tract Infections account for 1/3 all bacterial diseases Management of Fever In Infants and Children Jeffrey R. Avner MD, M. Douglas Baker MD Emergency Medicine Clinics of North America Volume 20 • Number 1 • February 2002 SBI in Infants 1-2 Months Old With Temperature > 38.0 ̊ • Meningitis: – Bacterial (1.2%) • Bacteremia (2.1%): – Group B Streptococci 30% – Other Bacteria: • • • • • S. Pneumoniae E. Coli N. Meningitidis Salmonella H. Flu • Urinary Tract Infection ( 4% ) The Efficacy Of Routine Outpatient Management Without Antibiotics Of Fever In Selected Infants. Pediatrics 103:660–665,1999 : Baker MD, Bell LM, Avner JR Sample Case #2 6 week (42 day) old male presents with: – – – – – – Temperature of 38.3° Runny nose Sneezing Taking fluids well Has no retractions Parents are reliable What is Your Work Up? Young infants (29-60 days) • Cath urinalysis, C&S • LP • CBC with manual diff, blood culture • If all labs normal, then outpatient management with antimicrobial therapy Rocephin 50 mg/kg IV/IM (one time dose) • If UA, CBC, or LP abnormal, then start antibiotics and admit Sample Case #3 10 week (70 day) old male presents with: – Temperature of 38.5° – Alert and well appearing child – No cough, wheezing or retractions – Previously healthy What is Your Work Up? Young infants (61-90 days) • Cath urinalysis, C&S • CBC with manual diff, blood culture • LP if toxic appearing or significant risk factors • If CBC abnormal, may consider LP. Otherwise, give Rocephin 50mg/kg IM/IV for outpatient management Sample Case #4 4 month old male presents with: – Fever of 39.1° – Some nasal congestion – Cough for 2 days – Feeding poorly – Difficult to arouse What is Your Work Up? Infants (3-5 months) • Cath urinalysis, C&S • CBC with manual diff, blood culture • LP • Start antibiotics and admit Sample Case #5 13 month old female presents with: – Fever of 40.1° for 2 days – Some nasal congestion – One episode of non-bloody diarrhea – She received first 2 immunizations to date – On exam, she is alert and well hydrated What is Your Work Up? Children (6-36 months) • Cath urinalysis, C&S • CBC, Blood Culture • Empiric antibiotic treatment with Rocephin 50mg/kg IV/IM • Disposition per clinical judgment Fever Pitfalls • Bundling: – Bundling can lead to a rise in skin temperature and eventually rectal temperature. (Study 1: Cheng, 1993, Study 2: Grover, 1994) • Route of Measurement: – Tympanic/axillary don’t correlate well with rectal temps (Craig, 2000; Craig, 2002; Jean-Mary, 2002) • Antipyretics: – No correlation between disease etiology/severity and response to antipyretics (Baker, 1987; numerous others) • Tactile temperatures: – Sensitivity 83% – Specificity 76% (Hooker, 1996; Graneto, 1996) • Afebrile on presentation: – 6 of 63 infants 0-3 months with bacteremia/meningitis afebrile in clinic after being febrile at home (pantell, 2004) – * No comment on whether or not antipyretics were given Home Care Instructions • Educate parent about appropriate wt-based med dose with return demonstration • When discharged from ED follow up with primary care provider within 24 hrs • When discharged from inpatient follow up with primary care provider in 1-2 days • Reasons to call provider or return to ED • Provide Fever Instruction sheet with fever dosing chart for ED discharges • Provide Krames sheets: Fever in infants & young children and Kidcare: Fever Putting it into YOUR practice • The following 10 questions will review the clinical practice • Check the rationale for correct answers on the subsequent slide 1. In infants younger than 3 months of age, the most commonly occurring bacterial infection is: A. B. C. D. Group B Streptococcal infection Meningitis Neonatal sepsis Urinary tract infection Answer to question1. In infants younger than 3 months of age, the most commonly occurring bacterial infection is urinary tract infection (D) The Avner & Baker article (slide 9) included 2 related studies: A 1994-1996 study by Baker & Bell, published in 1999, looked at 36 neonates admitted with rectal temperatures of 38° or higher and diagnosed with serious bacterial infection. Another study by Baker, Bell, & Avner completed during the same time period, using the same criteria, and also published in 1999 involved 43 infants between the ages of 29 and 60 days with serious bacterial infection. Group B Streptococcal infection 2 3 Meningitis 4 5 Neonatal sepsis 6 na Urinary tract infection 17 17 2. Which statement about temperature measurement in infants less than 3 months of age is accurate? A. Bundling (swaddling) causes elevation in skin temperature, but not in rectal temperature B. Fever that lowers quickly after antipyretic medication indicates a less severe infection than a fever that is less responsive to medication C. Temperature of 38.0°C (100.4°F) is defined as fever D. Tympanic measurement is closely correlated with rectal measurement Answer to question 2. The accurate statement about temperature measurement in infants less than 3 months of age is: Temperature of 38.0°C (100.4°F) is defined as fever (C) From slide 23: • In a study by Cheng & Partridge published in 1993, 2 of 12 newborns older than 1 day reached rectal temperatures of 38.0°C after being bundled for 2 ½ hrs. A study by Grover & others (1994) of 36 infants aged 11-95 days showed an insignificant 0.06° C increase in rectal temp within1 hr of bundling. Bundling may be a factor and warrants investigation. • Baker & others (1987) investigated the association between severity of disease and response to acetaminophen in 1,559 children between the ages of 8 wks and 6 yrs with temperatures greater than 38.4°C. No correlation was found, and children with some serious bacterial infections actually demonstrated the greatest response. • Jean-Mary & others (2002) compared infrared axillary and aural thermometer readings with digital rectal thermometer readings in 198 children aged 3-36 mos. Axillary and aural measurements were comparable, but significantly different than rectal measurements. • A systematic review of 44 studies with 5,935 children aged birth-18 yrs published in 2002 by Craig & others also revealed insufficient agreement between aural and rectal measurements. In 2000, Craig published a systematic review of 20 studies with 3,201 children aged birth-18 yrs demonstrating wide variation between axillary and rectal measurements using either mercury or electronic thermometers. 3. The following asymptomatic infants come to the emergency department with fever of unknown source. Who will definitely have a lumbar puncture? A. 1 month old B. 5 month old C. 7 month old D. All of them 4. For a young infant with fever of unknown source, the nurse should notify the physician for which abnormal lab finding? A. ANC of 2,000 B. ANC of 9,000 C. WBC of 4,000 D. WBC of 11,000 3. The 1 month old (A) will definitely have a lumbar puncture? • • Following the Fever Clinical Practice, infants under 2 mos of age with fever > 38.0°C will have an LP Neonates 0-28 days of age (slide 7) Infants 29-60 days of age (slide 12) In those between 3 and 36 mos with fever > 39° C, physicians should consider a full septic work up if the child appears toxic or shows signs of meningitis or encephalitis Infants 3-5 mos of age (slide 18) Children 6-36 mos of age (slide 21) 4. For a young infant with fever of unknown source, the nurse should notify the physician for WBC of 4,000 (C) Low risk criteria (slide 12): • • WBC > 5,000, < 15,000 ANC > 1,000, < 10,000 5. A 3 week old infant presents with fever and cough. He has no signs of respiratory distress and has been healthy since birth. Based on the Pediatric Fever Clinical Practice, the nurse anticipates which of the following orders? A. B. C. D. Blood culture Chest x-ray Lumber puncture All of the above 6. A fully immunized 6 month old uncircumcised male infant presents with cough, decreased feeding, temperature of 39.0°C (102.2°F) and a diagnosis of clinical bronchiolitis. Based on the Pediatric Fever Clinical Practice, the nurse anticipates which of the following orders? A. Blood culture B. Cath UA and culture C. Lumbar puncture D. RSV viral study 5. Following the Fever Clinical Practice, the 3 week old infant with fever will have a full septic work-up. Infants with respiratory signs may also warrant a CXR. All of the above (D) • Fever > 38.0°C in Neonates 0-28 days of age (slide 7) 6. The 6 month old uncircumcised male infant will have a cath UA and culture (B) • Fever > 39.0°C in Children 6-36 mos of age (slide 21) These children will have a full septic work-up only if they appear toxic or show signs of meningitis or encephalitis. Those with clear clinical diagnosis of bronchiolitis do not need RSV viral studies. 7. A 2 year old presents with a fever of 39.1°C, is difficult to arouse, and eating poorly. Based on the Pediatric Fever Clinical Practice, the nurse anticipates which of the following orders? A. Blood culture B. Cath UA and culture C. Lumbar puncture D. All of the above 8. A 3 month old is discharged from the ED after work up for fever of unknown source. The nurse’s parent teaching should include the importance of a follow up appointment with the baby’s primary care provider at: A. 24 hours B. 2-3 days C. 1 week D. Next well baby check at 4 months of age 7. Following the Fever Clinical Practice, the 2 year old will have all of the above (D). • Fever > 39.0°C in Children 6-36 mos of age (slide 21) This child warrants full septic workup due to fever, altered level of consciousness, and poor eating. 8. Home care instructions should include the importance of a follow up appointment with the baby’s primary care provider at 24 hours 9. Fever of unknown origin is most dangerous in the following age groups: A. 0-3 years B. 5-7 years C. 10-12 years D. 15-17 years 10. Successful implementation of the Banner Health Fever Clinical Practice will be demonstrated by: A. Extended time between child’s hospital arrival and initiation of antibiotic therapy B. Increased use of antibiotic therapy in treatment of young children with fever C. Longer length of ED stay resulting in fewer hospital admissions D. Reduction in number of diagnostic tests utilized in children younger than 3 years of age 9. Fever of unknown origin is most dangerous in children aged 0-3 years (A) •Evaluation & management of fever of unknown source in infants and young children is challenging •History & physical exam may provide few clues to guide therapy •Findings may be nonspecific •Social interaction skill is limited •Clinical scoring systems identifying those at low risk of SBI have varying degrees of reliability in the very young (Avner & Baker, 2002) 10. Successful implementation of the Banner Health Fever Clinical Practice will be demonstrated by reduction in number of diagnostic tests utilized in children younger than 3 years of age (D) Consistent use of this practice, based on best clinical evidence, will result in: • reduction in unnecessary testing • reduction in length of ED stay • reduction in unnecessary antibiotics • reduction in time to initiation of necessary antibiotics References Avner, J. R., & Baker, M. D. (2002). Management of fever in infants and children. Emergency Medicine Clinics of North America, 20(1), 49-67. Baker, M.D., Bell, L.M., Avner, J.R. (1999). The efficacy of routine outpatient management without antibiotics of fever in selected infants. Pediatrics, 103(3), 627-631. Baker, M.D., Fosarelli, P.D., Carpenter, R.O. (1987). Childhood fever: Correlation of diagnosis with temperature response to acetaminophen. Pediatrics, 80(3), 315-318. Cheng, T. L., & Partridge, J. C. (1993). Effect of bundling and high environmental temperature on neonatal body temperature. Pediatrics, 92(2), 238-240. Craig, J.V., Lancaster, G.A., Taylor, S., Williamson, P. R., & Smyth, R. (2002). Infrared ear thermometry compared with rectal thermometry in children: A systematic review. Lancet, 360(9333), 603-609. Craig, J.V., Lancaster, G.A., Smyth, R. L., & Williamson, P.R. (2000). Temperature measured at the axilla compared with rectum in children and young people: Systematic review. BMJ, 320(7243), 1174-1178. Graneto, J.W., Soglin D.F. (1996). Maternal screening of childhood fever by palpation. Pediatric Emergency Care, 12(3), 183-184. Grover, G., Berkowitz, C. D., Lewis, R. J., Thompson, M., & Berry, L. (1994). The effects of bundling on infant temperature. Pediatrics, 94(5), 669-673. Hooker, E.A., Smith, S.W., Miles, T., & King, L. (1996). Subjective assessment of fever by parents: Comparison with measurement by noncontact tympanic thermometer and calibrated rectal glass mercury thermometer. Annals of Emergency Medicine, 28(3), 313317. Jean-Mary, M.B., Dicanzio, J., Shaw J., Bernstein, H. H. (2002). Limited accuracy and reliability of infrared axillary and aural thermometers in a pediatric outpatient population. Journal of Pediatrics, 141(5), 671-676. Pantell, R.H., Newman, T.B., Bernzweig J., Bergman, D. A,. Takayama, J. Segal, J. I., … & Wasserman, R. C. (2004). Management and outcomes of care of fever in early infancy. JAMA, 291(10),1203-1212.
© Copyright 2021