Pediatric Fever why/how old/ how to treat 1

Pediatric Fever
why/how old/ how to treat
Why is this important?
Especially in infants, fever is the bell, alerting you
that there could be a serious bacterial infection
(SBI) Pediatric literature reports the number to be
as high as 15%
Undiagnosed bacterial infection such as meningitis
and bacteremia can lead to overwhelming sepsis
and death
Undetected urinary tract infection can lead to
pyelonephritis and scarring of the kidney
Serious Bacterial Infections
bacterial meningitis
pneumonia (bacterial)
bacterial enteritis
septic arthritis
special challenges in this age group 0-2 mos
limited immune system
susceptible to perinatally and
community acquired infections
including B streptococcus
(GBS), E. coli, Strep
pneumonia and staph aureus
Neonatal listeria
monocytogenes and herpes
simplex infections are rare but
life threatening
Previously healthy 28 day old child is brought via
ambulance with fever of 103 F, pulse ox 92%, BP
70/42 with febrile seizure. 2 year old sibling is
hospitalized with RSV pneumonia.
Pre-hospital treatment
IV access, normal saline
20ml/kg bolus
if access obtained, IV ativan
intranasal versed, ativan or
valium suppository
tylenol suppository
child may require oxygen or
bagging if infection is
Febrile Seizures
simple febrile seizures 7075% of all febrile seizure
6 mos to 5 yrs
less than 15 minutes
neurologically healthy both before
and after the seizure
No risk for cognitive impairment
genetic component
boys slightly more freq than girls
Complex febrile seizures 20-25 % of all febrile
same criteria as simple febrile seizures, however
seizure lasts more than 15 minutes or are several
seizures in rapid succession.
oral diazepam is essential if you don’t want any
more of prolonged seizure activity
Symptomatic febrile seizure
preexisting neurologic abnormality and preexisting
5% of febrile seizures
1/3 of children who have one febrile seizure will
have another one
treatment of febrile seizure
intranasal midazolam/(Versed), IV
alprazolam/ativan, diazepam(valium) IV or rectal
If febrile seizures become a recurring problem, oral
diazepam(Valium) has the least side effects
compared with valproic acid or phenobarbital.
Diazepam can be given orally at the onset of fever.
history points
How was the temp taken? Axillary and tympanic temps can be inaccurate
in infants
how is the child feeding (poor or slow)
fussy or lethargic?
Premature or term?
is mom GBS positive or HSV?
did the child spend time in the NICU or did they receive antibiotics in the
newborn nursery?
Are any of the siblings ill?
Ill Appearing Infants
full sepsis workup includes:
chest x-ray is indicated only if there are respiratory
symptoms *
CBC, CMP, CRP, blood cultures
lumbar puncture (missed meningitis #1 malpractice)
broad spectrum antibiotics
Bramson RT, Meyer TL, Silbiger ML etal. The futility of the chest radiograph in the
febrile infant without respiratory symptoms. Pediatrics. 1993; 92(4):524-526
Young infants 0-28 days with a source
of infection
Even if the child has bronchiolitis or
viral respiratory infection the sepsis
workup should be done. These
infants are still at risk for SBI
Fever in Children over 90 days
a different approach
History points
Parents subjective reports of fever are usually accurate.
Infants still need a rectal temp.
Immunization history should be specific. Ask how many doses of
pneumococcal conjugate and H-flu vaccine have been administered.
Recent immunizations may actually be the cause of fever in some
Exposure to sick contacts, travel history
previous hospitalizations, changes in mental status, eating, irritability,
h/o neglect or abuse
More history points
was an antipyretic given in the right dose?
Has the child been snoring
complaining of ear pain, cough or sore throat
physical exam
quality of the cry
fearful of the exam?
skin color/cyanosis or
hydration/ assess fontanelle
in an infant, tears, oral
smiling, playful?
capillary refill
More physical exam points
dyspnea, grunting, flaring, retractions, tachypnea
irritability, inconsolability, lethargy, absent eye
mottled skin, cold hands and feet, cyanosis,
hemorrhagic rash
younger children with meningitis do not typically
have adult findings of Kernigs or Brudzinskis signs
Children at highest risk
pts with recently inserted medical devices/ foreign bodies
(VP shunts, central lines, pacemakers)
sickle cell disease
immunocompromised pts (malignancy, chemo, neutropenia,
cystic fibrosis, diabetics)
premature infants are at risk for bronchiolitis and necrotizing
check fecal leukocytes, if greater than 5 per HPF
suspect bacterial etiology. salmonella,
campylobcter, shigella, yersinia
low grade fever, vomiting and diarrhea + day care
center likely has rotavirus
Well Appearing Young Infants
less than 60 days of age
At risk for serious bacterial
illness (SBI) days 0-28. The
rate is nearly 20%.
8.8% of well appearing
infants 29-56 days have
culture positive infections
These children too require a
full sepsis evaluation.
Parameters for low risk infants
Rochester Criteria
full term, normal prenatal and
post natal histories, no postnatal
antibiotics, well appearing, no
focal infection
UA neg, WBC 5-15K, ABS band
count, stool less than 5 WBCs
treatment for low risk pt-home, 24
hr followup, no antibiotics
treatment for high risk pt hospitalize and antibiotics
In Summary
The treatment of pediatric fever
depends on several parameters
age and general appearance of
the child
perinatal factors such as
prematurity, ICU stay and
antibiotic exposure
co-morbidities such as shunts,
hereditary disorders
seizure activity
Evaluation of the Febrile Young Infant: An Update, EB
Medicine, Pediatric Emergency Practice, February
2013, Volume 10, Number 2
Medscape, Febrile Seizure
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