International Neonatology Training Program" INTP                                    BY DR M OSAMA HUSSEIN MD
DEFINITIONS OF TERMS IN PRACTICE GUIDELINE ON THE MANAGEMENT                    OF FEVER IN INFANTS AND YOUNG CHILDRENTerm...
Infant appears generally well                                                                 ROCHESTER CRITERIA FORInfant...
Why we pay special                attention to fever ?• Parental concern   • “fever phobia”• Clinician concern   • we don’...
BY DR M OSAMA HUSSEIN MD
Fever Without a Source• Fever without a source “FWS”= fever with no  apparent cause• “Fever of Unknown Origin”= a febrile ...
Pediatric Fever Algorithm                       Fever 38 C     Non toxic appearing, 28 – 90 days and “Low Risk”     No    ...
Child 3 to 36 months with FWS: Occult              Bacteremia• S. pneumoniae>>H. influenzae>N. meningitidis  – conjugate v...
Child 3 to 36 months with FWS:          Practice Guidelines• Toxic - Admit with full work up• Non-toxic – Consider workup ...
Pediatric Fever Algorithm                 Child 3 to 36 months with FWS                          Appears toxic?      Yes  ...
Child 3 to 36 months with FWS:          Practice Guidelines• Toxic - Admit with full work up• Non-toxic – Consider workup ...
Child 3 to 36 months with FWS:             Occult Pneumonia• Children with high fever and leukocytosis are  more likely to...
Pediatric Fever Algorithm         Child 3 to 36 months with FWS                  Appears toxic?       Yes                 ...
Summary of Testing: 3 to 36 months and FWS,           non-toxic, temp ≥39 C• Urine   – All females < 2 years   – Males    ...
Fever with a Source• More common than fever without a source• Clinically identifiable viral or bacterial illnesses        ...
Fever with a Source: Viral– Varicella– Measles (recent outbreaks)– Mumps (recent Midwest  outbreaks)– Adenovirus  (pharyng...
Fever with a Source: Viral• Pediatric exanthems  – Roseola (HHV 6)  – Fifths disease (Parvo    B19)→                      ...
Fever with a Source: Bacterial• Clinically evident bacterial infections  – Readily diagnosed from H&P     •   Pneumonia   ...
Antipyretics• Triage protocols  – acetaminophen by protocol• Acetaminophen dose  – 15 mg/kg q 4 hr prn• Ibuprofen dose (fo...
Bug Drugs: <1 month• Ampicillin and gentamycin  – covers GBBS, E. coli, Listeria monocytogenes  – ampicillin specifically ...
Bug Drugs: 1-2 months• Ampicillin and cefotaxime  – covers the < 1 month etiologic agents and also S.    pneumoniae  – wit...
Bug Drugs: >2 months• Ceftriaxone  – covers S. pneumoniae, H. influenzae, and N.    meningitidis  – theoretically shouldn’...
Kawasaki’s Disease• Fever for at least 5 days duration and the presence  of 4 of the following   – Extremities changes (er...
Febrile Seizures• Simple Febrile Seizure   – 1 event in a 24 hour period   – Non-focal• Complex   – Whenever it is not sim...
Febrile Seizures• Work up for the source of the fever• “Strongly consider LP” for under 12 months –  AAP guidelines• Brain...
Pediatric Fever Summary: Golden                   Rules• A toxic appearance demands immediate  action    – Work-up/antibio...
Fever with xanthem   Infectious causes       Virus:            Classic viral exanthem: Measles, Rubella, VZV, Parvoviru...
Clinical Manifestation   Incubation: 8-12 days, the average interval between appearance of    rash in the source case and...
BY DR M OSAMA HUSSEIN MD
BY DR M OSAMA HUSSEIN MD
Complication   Pneumonia   Otitis media   Diarrhea   Meningoencephalitis   Croup   Subacute sclerosing panencephalit...
Treatment and Care   Supportive and Symptomatic   Vit A supplementation      6 mo-2 yr hospitalized with measles and co...
Treatment and Care   Isolation: Airborne Precaution      1-2 day before onset of symptom or 3-5 days       before onset ...
Rubella   RNA virus: Family Togaviridae, genus Rubivirus   IP: 14-21 days   Infectivity: 7 days before – 5 days after o...
Clinical Manifestation   Prodromal period 1-5 days   MP rash for < 3 days   LN at postauricular and cervical area   CB...
BY DR M OSAMA HUSSEIN MD
Rubella   Complication      arthritis      thrombocytopenia      meningoencephalitis   Treatment: supportive   Isola...
Chickenpox   VZV, HHV-3:   Transmission      airborne      contact vesicular fluid      vertical transmission   Incu...
Clinical Manifestation   Prodromal period: 2-3 days   Generalized, pruritic, vesicular rash 250-500 lesions    involving...
BY DR M OSAMA HUSSEIN MD
BY DR M OSAMA HUSSEIN MD
BY DR M OSAMA HUSSEIN MD
Treatment and care   Supportive and symptomatic      antipruritic drug      for severe case: ACV, famciclovir, valacycl...
Child Care and School   Children may return to school when all lesion are    crusted.   For compromised children with pr...
Hand-foot-mouth Disease   coxackie virus type 16 (A 16) most common,    other include A5, A7, A9, A10, B2, B5(31)    and ...
HFMD       BY DR M OSAMA HUSSEIN MD
BY DR M OSAMA HUSSEIN MD
Roseola Infantum   Exanthem subitum   3 mo- 3 yr. (6 mo-1 yr)   HHV-6,7: DNA virus, Herpesviridae   Uncertain incubati...
Clinical Manifestation   High fever 39-41 c for 3-4 days      nonspecific symptom      bulging AF      febrile convuls...
BY DR M OSAMA HUSSEIN MD
Erythrema infectiosum (Fifth Dz)   Parvovirus (PV) B19 Family Parvoviridae   3-15 year   Droplet transmission   Incuba...
BY DR M OSAMA HUSSEIN MD
BY DR M OSAMA HUSSEIN MD
Meningococcemia   N meningitidis: GNDC, bean shape   Clinical manifestation      acute febrile illness      petechiae,...
BY DR M OSAMA HUSSEIN MD
Scarlet fever   GAS or S aureus: pyrogenic exotoxin (SPE)   Acute febrile illness with:      Sore throat      Goosefle...
BY DR M OSAMA HUSSEIN MD
Scarlet fever         BY DR M OSAMA HUSSEIN MD
Scarlet fever         BY DR M OSAMA HUSSEIN MD
Scarlet fever         BY DR M OSAMA HUSSEIN MD
Staphylococcal scaldedskin syndrome (SSSS/4S)   Staphylococcus toxigenic strain phage group    2 with epidemolylic toxin ...
BY DR M OSAMA HUSSEIN MD
Impetigo contagiosa        BY DR M OSAMA HUSSEIN MD
BY DR M OSAMA HUSSEIN MD
Upcoming SlideShare
Loading in...5
×

Fever in pediatric practice

1,342

Published on

This presentation discusses causes & general management of fever in pediatric poatien

Published in: Health & Medicine
0 Comments
5 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,342
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
146
Comments
0
Likes
5
Embeds 0
No embeds

No notes for slide

Fever in pediatric practice

  1. 1. International Neonatology Training Program" INTP BY DR M OSAMA HUSSEIN MD
  2. 2. DEFINITIONS OF TERMS IN PRACTICE GUIDELINE ON THE MANAGEMENT OF FEVER IN INFANTS AND YOUNG CHILDRENTerm DefinitionFever Rectal temperature of 38°C (100.4°F)*Fever Acute febrile illness in which the etiology of the fever is notwithout apparent after a careful history and physical examinationsourceSerious Meningitis, sepsis, bone and joint infections, urinary tractbacterial infections, pneumonia, enteritisinfectionToxic Clinical presentation characterized by lethargy, evidence of poorappearance perfusion, cyanosis, hypoventilation or hyperventilationLethargy Poor or absent eye contact; failure of child to recognize parents or to interact with persons or objects in the environment BY DR M OSAMA HUSSEIN MD
  3. 3. Infant appears generally well ROCHESTER CRITERIA FORInfant has been previously healthy: IDENTIFYING FEBRILE INFANTS AT LOW RISK FOR SERIOUS Born at term (≥37 weeks of gestation) BACTERIAL INFECTION No perinatal antimicrobial therapy No treatment for unexplained hyperbilirubinemia No previous antimicrobial therapy No previous hospitalization No chronic or underlying illness Not hospitalized longer than motherInfant has no evidence of skin, soft tissue, bone, joint or ear infectionInfant has these laboratory values: White blood cell count of 5,000 to 15,000 per mm3 (5 to 15 × 109 per L) Absolute band cell count of ≤1,500 per mm3 (≤1.5 × 109 per L) Ten or fewer white blood cells / high-power field on microscopic examination of urine Five or fewer white blood cells per high-power field on microscopic examination of BY DR M OSAMA HUSSEIN MD stool in infant with diarrhea
  4. 4. Why we pay special attention to fever ?• Parental concern • “fever phobia”• Clinician concern • we don’t want to miss a life threatening infection• Most common complaint in pediatric visits• Some of these kids are sick • most do well without intervention • need an approach to sort them out BY DR M OSAMA HUSSEIN MD
  5. 5. BY DR M OSAMA HUSSEIN MD
  6. 6. Fever Without a Source• Fever without a source “FWS”= fever with no apparent cause• “Fever of Unknown Origin”= a febrile illness of at least three weeks duration, at least 38.3°C on at least three occasions and failure to establish a diagnosis in spite of intensive evaluation. BY DR M OSAMA HUSSEIN MD
  7. 7. Pediatric Fever Algorithm Fever 38 C Non toxic appearing, 28 – 90 days and “Low Risk” No Yes Outpatient Management ADMITBlood Culture, Option 1 Option 2Urine Culture, Blood Cx, Urine Cx, Blood Cx, UrineCSF Cx, antibx CSF Cx, ceftriaxone Cx, Re-eval in 24+/-CXR 50 mg/kg IV/IM, re- hours eval in 24 hours BY DR M OSAMA HUSSEIN MD
  8. 8. Child 3 to 36 months with FWS: Occult Bacteremia• S. pneumoniae>>H. influenzae>N. meningitidis – conjugate vaccine for H influenzae virtually eliminated this type of bacteremia BY DR M OSAMA HUSSEIN MD
  9. 9. Child 3 to 36 months with FWS: Practice Guidelines• Toxic - Admit with full work up• Non-toxic – Consider workup when fever is 39°C BY DR M OSAMA HUSSEIN MD
  10. 10. Pediatric Fever Algorithm Child 3 to 36 months with FWS Appears toxic? Yes NoFull sepsis work up and Temperature ≥ 39 antibiotics and admit No Yes No testing, Selective assure follow up workup in 48 hrs BY DR M OSAMA HUSSEIN MD
  11. 11. Child 3 to 36 months with FWS: Practice Guidelines• Toxic - Admit with full work up• Non-toxic – Consider workup when fever is 39°C (102.2°F) BY DR M OSAMA HUSSEIN MD
  12. 12. Child 3 to 36 months with FWS: Occult Pneumonia• Children with high fever and leukocytosis are more likely to have occult bacterial pneumonia – some suggest getting CXR with no resp symptoms and WBC>20,000 and temp 39.5 C (103.1°F) BY DR M OSAMA HUSSEIN MD
  13. 13. Pediatric Fever Algorithm Child 3 to 36 months with FWS Appears toxic? Yes NoFull sepsis work up Temperature ≥ 39and antibiotics andadmit No Yes No testing, Selective assure follow workup up in 48 hrs BY DR M OSAMA HUSSEIN MD
  14. 14. Summary of Testing: 3 to 36 months and FWS, non-toxic, temp ≥39 C• Urine – All females < 2 years – Males • Uncircumcised <12 months • Circumcised < 6 months• Stool culture – If bloody diarrhea or >5 wbc’s/hpf• CXR – If respiratory symptoms or hypoxic• LP – Signs of meningitis• Blood cultures and Antibiotics – Option 1: All with fever ≥ 102.2 – Option2 : All with fever ≥ 102.2 and WBC ≥ 15,000 – Option3: Practitioner/immunization dependent BY DR M OSAMA HUSSEIN MD
  15. 15. Fever with a Source• More common than fever without a source• Clinically identifiable viral or bacterial illnesses BY DR M OSAMA HUSSEIN MD
  16. 16. Fever with a Source: Viral– Varicella– Measles (recent outbreaks)– Mumps (recent Midwest outbreaks)– Adenovirus (pharyngoconjunctival fever)– Coxsackie infections • Herpangina→ • Hand-foot-and-mouth– Croup– Bronchiolitis (as in our case)– Influenzae BY DR M OSAMA HUSSEIN MD
  17. 17. Fever with a Source: Viral• Pediatric exanthems – Roseola (HHV 6) – Fifths disease (Parvo B19)→ BY DR M OSAMA HUSSEIN MD
  18. 18. Fever with a Source: Bacterial• Clinically evident bacterial infections – Readily diagnosed from H&P • Pneumonia • Meningitis • Septic arthritis • Osteomyelitis • Lymphadenitis • Cellulitis/Abscess • Bacterial enteritis BY DR M OSAMA HUSSEIN MD
  19. 19. Antipyretics• Triage protocols – acetaminophen by protocol• Acetaminophen dose – 15 mg/kg q 4 hr prn• Ibuprofen dose (for greater than 6 months old) – 10 mg/kg q 6 hr prn BY DR M OSAMA HUSSEIN MD
  20. 20. Bug Drugs: <1 month• Ampicillin and gentamycin – covers GBBS, E. coli, Listeria monocytogenes – ampicillin specifically for Listeria and provides some synergy with gentamycin for GBBS• Consider acyclovir – Maternal history of Herpes (especially if primary outbreak with vaginal delivery) or any noted skin or mucosal lesions BY DR M OSAMA HUSSEIN MD
  21. 21. Bug Drugs: 1-2 months• Ampicillin and cefotaxime – covers the < 1 month etiologic agents and also S. pneumoniae – with cefotaxime you don’t have to worry about oto/renal toxicity associated with gentamycin BY DR M OSAMA HUSSEIN MD
  22. 22. Bug Drugs: >2 months• Ceftriaxone – covers S. pneumoniae, H. influenzae, and N. meningitidis – theoretically shouldn’t give < 1 month because of biliary sludging• Add vancomycin if any concern for S. pneumoniae on LP in any age range (resistant strains have been appearing in CSF) BY DR M OSAMA HUSSEIN MD
  23. 23. Kawasaki’s Disease• Fever for at least 5 days duration and the presence of 4 of the following – Extremities changes (erythema, edema, and desquamation) – Conjunctivitis (no exudate). – Polymorphous rash (not vesicular) is usually generalized – Cervical lymphadenopathy usually unilateral and greater than 1.5 cm – Lip or oral cavity changes (erythema, dry/fissured or swollen lips, and strawberry tongue) BY DR M OSAMA HUSSEIN MD
  24. 24. Febrile Seizures• Simple Febrile Seizure – 1 event in a 24 hour period – Non-focal• Complex – Whenever it is not simple – Consider larger work-up• 30% chance of recurrence BY DR M OSAMA HUSSEIN MD
  25. 25. Febrile Seizures• Work up for the source of the fever• “Strongly consider LP” for under 12 months – AAP guidelines• Brain imaging not often necessary• Need to explain to parents why you aren’t worried about the seizure BY DR M OSAMA HUSSEIN MD
  26. 26. Pediatric Fever Summary: Golden Rules• A toxic appearance demands immediate action – Work-up/antibiotics and admit• Know the age-specific algorithm for FWS• Test the urine (most common SBI)• Look for specific bacterial and viral etiologies• Careful follow up must be assured• Recommendations continue to evolve with new immunizations BY DR M OSAMA HUSSEIN MD
  27. 27. Fever with xanthem Infectious causes  Virus:  Classic viral exanthem: Measles, Rubella, VZV, Parvovirus, Roseola  Others:, HSV, EBV, HBV, Enterovirus, Dengue  Bacteria: Scarlet fever, Staph infection (sepsis, 4S,toxic shock syndrome), Meningococcemia, typhoid  Mycoplasma  Rickettsial infection Noninfectious cause  Allergy: Food, drug, toxin, serum sickness  Uncertain cause: Kawasaki disease BY DR M OSAMA HUSSEIN MD
  28. 28. Clinical Manifestation Incubation: 8-12 days, the average interval between appearance of rash in the source case and subsequent cases is 14 days, with a range of 7-18 days. Prodromal period: fever 2-4 day + 3C  cough  coryza  conjunctivitis  Koplik spot Rash: erythematous maculopapular rash  facesole in 72 hr.  face and trunk: mostly distributed  pneumonia Convalescence  cough may persist for 1 week BY DR M OSAMA HUSSEIN MD
  29. 29. BY DR M OSAMA HUSSEIN MD
  30. 30. BY DR M OSAMA HUSSEIN MD
  31. 31. Complication Pneumonia Otitis media Diarrhea Meningoencephalitis Croup Subacute sclerosing panencephalitis (SSPE) BY DR M OSAMA HUSSEIN MD
  32. 32. Treatment and Care Supportive and Symptomatic Vit A supplementation  6 mo-2 yr hospitalized with measles and complication  > 6 mo who have risk for severe measles and vit A deficiency: immunodef, vitamin A def, impaired intestinal absorption, malnutrition, recent immigration from high mortality rated due to measles Antibiotic for superimposed bacterial infection BY DR M OSAMA HUSSEIN MD
  33. 33. Treatment and Care Isolation: Airborne Precaution  1-2 day before onset of symptom or 3-5 days before onset of rash  4 days after onset of rash in healthy children  For the duration of illness in immunocompromised pt.  Isolated room (negative pressure ventilation) Prevention: immunization  9-15 months  4-6 years BY DR M OSAMA HUSSEIN MD
  34. 34. Rubella RNA virus: Family Togaviridae, genus Rubivirus IP: 14-21 days Infectivity: 7 days before – 5 days after onset of rash BY DR M OSAMA HUSSEIN MD
  35. 35. Clinical Manifestation Prodromal period 1-5 days MP rash for < 3 days LN at postauricular and cervical area CBC: normal range Dx: viral isolation  Serologic test: CF, HI, IgM ELISA BY DR M OSAMA HUSSEIN MD
  36. 36. BY DR M OSAMA HUSSEIN MD
  37. 37. Rubella Complication  arthritis  thrombocytopenia  meningoencephalitis Treatment: supportive Isolation:  droplet precaution for 7 days after onset of rash,  contact precaution for congenital rubella until > 1 yr- old Prevention: immunization BY DR M OSAMA HUSSEIN MD
  38. 38. Chickenpox VZV, HHV-3: Transmission  airborne  contact vesicular fluid  vertical transmission Incubation period:  14-16 days, (10-21days) Infectivity: winter season  Most contagious: 1-2 days before onset of rash until crusting of lesion. BY DR M OSAMA HUSSEIN MD
  39. 39. Clinical Manifestation Prodromal period: 2-3 days Generalized, pruritic, vesicular rash 250-500 lesions involving skin and oral mucosa Complication  Herpes Zoster, Shingles  Congenital varicella: Scar, limb, ocular, CNS defect  Bacterial infection  Severe chickenpox  CNS: encephalitis, cerebellar ataxia, Reye’s Syndrome BY DR M OSAMA HUSSEIN MD
  40. 40. BY DR M OSAMA HUSSEIN MD
  41. 41. BY DR M OSAMA HUSSEIN MD
  42. 42. BY DR M OSAMA HUSSEIN MD
  43. 43. Treatment and care Supportive and symptomatic  antipruritic drug  for severe case: ACV, famciclovir, valacyclovir Isolation:  Airborne and contact isolation 1-2 days before rash until crusting of all lesion. Prevention  Immunization BY DR M OSAMA HUSSEIN MD
  44. 44. Child Care and School Children may return to school when all lesion are crusted. For compromised children with prolonged course should excluded for the duration of the vesicular eruption. Older children and staff members with zoster should be instructed to wash their hands if they touch potentially infectious lesion BY DR M OSAMA HUSSEIN MD
  45. 45. Hand-foot-mouth Disease coxackie virus type 16 (A 16) most common, other include A5, A7, A9, A10, B2, B5(31) and enterovirus 71 Fever, sore throat, drooling DDx from Herpes gingivostomatitis Self-limited, symptomatic treatment BY DR M OSAMA HUSSEIN MD
  46. 46. HFMD BY DR M OSAMA HUSSEIN MD
  47. 47. BY DR M OSAMA HUSSEIN MD
  48. 48. Roseola Infantum Exanthem subitum 3 mo- 3 yr. (6 mo-1 yr) HHV-6,7: DNA virus, Herpesviridae Uncertain incubation period (9-10 days) BY DR M OSAMA HUSSEIN MD
  49. 49. Clinical Manifestation High fever 39-41 c for 3-4 days  nonspecific symptom  bulging AF  febrile convulsion MP Rash after defervescence CBC: normal range of WBC, lymphocyte predominated BY DR M OSAMA HUSSEIN MD
  50. 50. BY DR M OSAMA HUSSEIN MD
  51. 51. Erythrema infectiosum (Fifth Dz) Parvovirus (PV) B19 Family Parvoviridae 3-15 year Droplet transmission Incubation period: 4-14 days S/S: lowgrade fever, constitutional symptoms, arthralgia Classical 3 phases  Sunburn-like rash both cheek (classic slapped-cheek appearance) 2-4  Day 1-4 after facial rash  macular – to – morbiliform eruption at extremities (extensor surface)  Lacy pattern: some w/o classic slapped-cheek pattern BY DR M OSAMA HUSSEIN MD
  52. 52. BY DR M OSAMA HUSSEIN MD
  53. 53. BY DR M OSAMA HUSSEIN MD
  54. 54. Meningococcemia N meningitidis: GNDC, bean shape Clinical manifestation  acute febrile illness  petechiae, hemorrhagic manifestation: purpura fulminan  rapid progressive with HT or coma  meningoencephalitis Diagnosis: gram stain, antigen detection, buffy coat smear and culture Treatment: penicillin, CTX, CRO BY DR M OSAMA HUSSEIN MD
  55. 55. BY DR M OSAMA HUSSEIN MD
  56. 56. Scarlet fever GAS or S aureus: pyrogenic exotoxin (SPE) Acute febrile illness with:  Sore throat  Gooseflesh or coarse sand-paper rash within 12- 48 hr.  Most intense at pressure area: axilla, groin  Pastia’s line  Strawberry tongue  Pustule (Staph scarlet) Desquamation begins toward the end of the 1st week BY DR M OSAMA HUSSEIN MD
  57. 57. BY DR M OSAMA HUSSEIN MD
  58. 58. Scarlet fever BY DR M OSAMA HUSSEIN MD
  59. 59. Scarlet fever BY DR M OSAMA HUSSEIN MD
  60. 60. Scarlet fever BY DR M OSAMA HUSSEIN MD
  61. 61. Staphylococcal scaldedskin syndrome (SSSS/4S) Staphylococcus toxigenic strain phage group 2 with epidemolylic toxin A and B Start with local infection e.g. purulent conjunctivitis, otitis media, nasopharyngeal infection Fever, MP rash or erythroderma with periorificial and flexural accentuation with Nikolski sign BY DR M OSAMA HUSSEIN MD
  62. 62. BY DR M OSAMA HUSSEIN MD
  63. 63. Impetigo contagiosa BY DR M OSAMA HUSSEIN MD
  64. 64. BY DR M OSAMA HUSSEIN MD
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×