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An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
An approach to a child with fever
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An approach to a child with fever

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fever 0-3 months

fever 0-3 months

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  • A number of studies have been done to find and evaluate clinical indicators of bacteremia. A strong indicator of the disease must be present in bacteremic children, and for this indicator to be useful, the frequency with which it appears must be significantly different than in nonbacteremic children. There are no highly reliable indicators known at the present time. This fact can most likely be explained by the complex nature of clinical studies. Investigations are made at different times and in different places; the groups studied are not always homogeneous; data-gathering methods are not standardized; and some statistical analyses are not sufficiently rigorous. No study is truly satisfactory.
  • A number of studies have been done to find and evaluate clinical indicators of bacteremia. A strong indicator of the disease must be present in bacteremic children, and for this indicator to be useful, the frequency with which it appears must be significantly different than in nonbacteremic children. There are no highly reliable indicators known at the present time. This fact can most likely be explained by the complex nature of clinical studies. Investigations are made at different times and in different places; the groups studied are not always homogeneous; data-gathering methods are not standardized; and some statistical analyses are not sufficiently rigorous. No study is truly satisfactory.
  • Transcript

    • 1. An Approach to Fever in Infants & Children DR. TAREK KOTB MCH BURAYDAH
    • 2. 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.
    • 3. To Work Up or Not to Work Up? • Do all febrile children with no obvious infection site need To be investigated. • Specific Questions: • – Blood tests • – Lumbar Puncture • – Urinalysis / Urine Culture • – CXR • – Antibiotic use • – Observation • – Hospital admission
    • 4. Significant Fever: Definition 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.”
    • 5. • In children, fever is generally a sign of infection. • Fever due to other causes including malignancy is rare. • The prognosis for the most common forms of paediatric infections is usually excellent; these infections are much more likely to be viral (rhinitis, pharyngitis, laryngitis, bronchitis, bronchiolitis, gastroen teritis, exanthems) than bacterial (pneumonia, urinary tract infections [UTIs], sinusitis, tonsillitis, otitis).
    • 6. The medical history, physical examination when necessary, a few additional complementary tests usually lead to a prompt diagnosis Reassurance Treatment
    • 7. Neither the medical history, the physical examination, nor complementary tests indicate a bacterial infection that can potentially lead to serious complications. How can a fever of viral origin be differentiated from one of bacterial origin? Do all febrile children with no obvious infection site need a blood culture? Should antibiotics be administered before the results of the blood culture have been received?
    • 8. Bacteremia 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 20
    • 9. Bacteremia • In a study performed in children between three and 36 months with a rectal or tympanic temperature of 39°C or higher, the incidence of various types of bacteremia was 1.6% . • H influenzae was not among the isolated germs. • Over 90% of all bacteremias are caused by pneumococcus . • The remaining 10% are caused by various bacterial germs, such as Neisseria meningitidis, nontyphoidal salmonella, group A streptococcus, group B streptococcus, Escherichia coli, Staphylococcus aureus and other more unusual germs . Meningococcus is the most dangerous of them.
    • 10. Bacteremia • In the absence of treatment, bacteremias either resolve spontaneously, persist or are complicated by other symptoms. • The most serious complications arising from occult bacteremia include septicemia, meningitis, pneumonia, arthritis, osteomyelitis and cellulitis. • The usual prognosis for pneumococcus bacteremia is excellent. Most cases (90.3%) resolve completely without treatment.# • Meningococcus bacteremia is rare but high risk. In the absence of prompt treatment, the speed at which it develops can be rapid. Any delay in treatment can be catastrophic for the child and have serious legal repercussions for the physician . The immediate danger arising from meningococcus bacteremia is that it may lead to purpura fulminans, with irreversible septic shock and death.
    • 11. AGE • Bacteremia appears at all ages; however, it is more frequent in infants between the ages of three and 36 months. • • Before the age of three months, the incidence of bacterial disease in febrile infants is about 10% and that of bacteremia is between 2% and 3%. • As a rule, bacterial infections are more serious and insidious in infants less than three months. • This group, particularly the neonates, is more vulnerable and is exposed to a greater variety of causal agents; group B streptococcus and E coli being the two main ones. • The main danger during the neonatal period is for UTI or meningitis
    • 12. Temperature • the physician’s clinical judgement is usually based on the temperature and the general appearance at the time of the examination, not the temperature taken at home. This applies to all children except those younger than three months. In the case of normal temperature at the time of the examination but a history of fever, a sepsis examination is indicated for neonates and possibly some infants between the ages of one and three months or if there is the slightest appearance of toxicity • The degree of temperature is an important but misleading indicator. • Bacteremia is more frequent in children with a temperature of 39°C or highe . • The absence of fever or the presence of a low grade fever does not preclude the possibility of a serious infection .
    • 13. 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)
    • 14. General appearance of the febrile child An alert and active child with a healthy appearance, who is:-  well hydrated,  smiles,  cries vigorously but is easily consoled;  who watches the physician’s movements,  seeks his parents’ hand or their soothing eyes and does not cause worry. These signs are reassuring and usually indicate a benign febrile state.
    • 15. General appearance of the febrile child 1.Quality of cry 2.Reaction to parents’ stimulation 3.State variation 4.Colour 5.Hydration 6.Response to social overtures (Yale criteria for febrile children between three and 36 months) (up to Each criterion is given a score of either 1 (normal), 2 (moderate impairment) or 3 (severe impairment). A child with a score of 10 or less is unlikely to have a serious illness (less 2.7%). A child with a score of 16 or more has a great probability of serious illness 92.3%). Data from reference(McCarthy PL, Sharpe MR, Spiesel SZ, et al. Observation scales to identify serious illness in febrile children. Pediatrics. 1982;70:802–9
    • 16. General appearance of the febrile child 1.Infant appears generally well 1.Infant has been previously healthy 2.No evidence of skin, soft tissue, bone, joint or ear infection 3.Laboratory values:White blood cell count between 5000 and 15,000/mm 3 4.Bands 1500/mm 3 or less 5.Centrifuged urine sediment 10 leukocytes/field (×40) or less 6.Stool smear 5 leukocytes/field (×40) or less – for infants with diarrhea (Rochester criteria for febrile children between 30 and 90 days}
    • 17. Leucocytosis • Bacterial infections are more likely than viral infections to have a leukocytosis count of 15,000/mm3 or more, but because viral infections are much more frequent than bacterial infections, the majority of febrile children with a high leukocytosis count have a viral infection. • In healthy children from one to three years of age, the normal white cell count varies between 6000 and 17,500/mm3; • in children one month of age it varies between 5000 and 19,500/mm3 (36). • It is rightly possible to wonder why the risk level for bacteremia has been set at 15,000/mm3
    • 18. leucocytosis • The percentage and absolute number of total neutrophils are more precise and useful than those of unsegmented neutrophils (bands) ------- why ? • Children between three and 36 months of age with an absolute neutrophil count greater than 10,000 cells/m3 are at higher risk of occult pneumococcal bacteremia: 8% compared with 0.8% for those with an absolute neutrophil count less than 10,000 cells/m3. • Conclusion : White blood cell count results can be confusing for physicians when there is an obvious discrepancy between the number of leukocytes and the child’s general condition.
    • 19. OTHER MARKERS OF INFECTION ESR CRP IL8 PROCALCITONIN CRP AND ESR NON SPECIFIC PCT has the greatest sensitivity (85%) and specificity (91%) for differentiating patients with systemic inflammatory response syndrome (SIRS) from those with sepsis, when compared with IL-2, IL-6, IL-8, CRP and TNF- alpha.[3] Evidence is emerging that procalcitonin levels can reduce unnecessary antibiotic prescribing to people withlower respiratory tract infections Conclusion: It is likely to make the decision more confusing when there is a discrepancy between the general appearance of the child and the C-reactive protein result and/or white blood cell count.
    • 20. CHEST X-RAYS • An unexplained and persistent fever can be the only manifestation of pneumonia. • When faced with high fever and leukocytosis greater than 20,000/mm3, the physician should suspect pneumonia . • Up to 26% of children younger than five years old with an unexplained fever of 39°C or higher and leukocytosis 20,000/mm3 or higher, who have no respiratory symptoms, may have a pneumonia that can only be detected by a chest x-ray. • In the absence of respiratory symptoms, chest x-rays are usually normal.
    • 21. UTIs • Repeated spells of fever or normal tympanic membranes following several alleged bouts of otitis media should lead the physician to suspect UTI . • The diagnosis of a UTI must be confirmed by a culture; • Thus, febrile infants less than three months of age should either be catheterized or have a bladder tap. • Older febrile children who are not toilet-trained and who have a risk factor for a UTI, such as UTI symptoms, UTI past history, known renal anomalies, toxic appearance or who have positive urine analysis by bag specimen should be catheterized . • Febrile infants older than three months of age who are not toilet-trained and are at low risk of UTI should have a bag specimen taken initially
    • 22. EMPIRICAL ANTIBIOTIC THERAPY • may reduce the number of serious bacterial complications • it does not prevent meningitis • It has not been formally proven that the absence of treatment has ever been the direct cause of a serious accident • The scientific data are contradictory and unclear. • The choice of antibiotics can also be debated. • Oral antibiotic therapy cannot prevent the risk of meningitis, but it can delay its diagnosis • Too liberal a use of ceftriaxone will most likely lead to an increase in the number of resistant strains of bacteria • Ceftriaxone is not a panacea, nor is it total risk insurance. It is an expensive drug that is administered intravenously or intramuscularly in a painful way.
    • 23. EMPIRICAL ANTIBIOTIC THERAPY • The widespread use of pneumococcal immunization in the near future will likely reduce the morbidity and mortality associated with pneumococcal bacteremias . This will decrease the difference in outcome between the different approaches: observation in comparison to the approach of empirical treatment for all patients or based on an elevated white blood cell count • Efficacious and widespread use of pneumococcal immunization will likely favour the observational approach based on clinical judgement
    • 24. CASE MANAGEMENT STRATEGIES
    • 25. 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
    • 26. CONCLUSIONS • There are no sufficiently reliable markers of bacterial infection. • The physician must therefore practice medicine that is fraught with empiricism, but also based on sound scientific arguments and on his or her own personal experience. • The child’s general appearance, temperature and leukocyte count are the best evaluation criteria. • Practice guidelines never entirely compensate for a lack of clinical judgement.
    • 27. Let us practise • 1. In infants younger than 3 months of age, the most commonly occurring bacterial infection is: • A. Group B Streptococcal infection • B. Meningitis • C. Neonatal sepsis • D. Urinary tract infection
    • 28. Q2 • 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
    • 29. Q3 • 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
    • 30. Q4 • 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
    • 31. Q5 • A 3 week old infant presents with fever and cough. He has no signs of respiratory distress and has been healthy since birth. The nurse anticipates which of the following orders? • A. Blood culture • B. Chest x-ray • C. Lumber puncture • D. All of the above
    • 32. Q6 • 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. , the nurse anticipates which of the following orders? • A. Blood culture • B. Cath UA and culture • C. Lumbar puncture • D. RSV viral study
    • 33. Q7 • 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
    • 34. Q8 • 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
    • 35. Q9 • 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
    • 36. Finally •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)
    • 37. Thank you

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