Pediatric fever


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  • Rectal temperature is long time recognised standard All other methods have prooved to be inconsistent and unreliable in peds Remember the poster with the infant’s blown out eyes because he is getting is rectal temparature taken????? No documented post-traumatic disorders related to rectal temperature taken … or maybe one
  • Most of the fevers will have an identified source and will be treated accordingly.
  • 6 items clinical scale to assess risk of SERIOUS ILLNESS 5points scale = normal 1, moderate impairment 3, severe impairment 5 scoring from 6 to 30 list of description found in sick kids interobservers agreement correlation validation by reapplying scale to their study group randomly divided in 2. 4 mo period nov 80-mar81 312 consecutive febrile child, <24mo 165 with complete defined scale points, 16% serious illness INCLUDED CHILD WITH KNOW DISEASE Sensitivity 88% Specificity 77% PPV 56% NPV 95,3%
  • In studies involving roughly 600 children, it was found that moderate or severe impairment on the YOS (score 10) had sensitivity of 83% to 88% specificity of 64% to 80% PPV of 48% to 56 NPV of roughly 97% . When the history, physical examination, and the YOS did not suggest serious illness, the probability of SBI being found was 1% to 4%. That chance increased to approximately 10% to 28% (seven- to tenfold) when either the history, physical, or YOS suggested serious illness. Other studies have shown that for YOS >10, sensitivity = 5% PPV 5% but included sick child 12% rate of occult bacteremia.
  • PPV of WBC is 8-15%, despite the fact that WBC>15000 are more common in bacterial infection. Much lower, the less prevalent the disease (meningitis) A HIGH WBC DOES NOT = DISEASE!!!! CBC predictive values may vary with the pathogens involved Hx does not contribute to prediction of occult bacteremia Most occult bacteremias had fever for less than 24h Young boys with high fevers may be at higher risk RISK of occult bacteremia increases with temperature 39-39,4 1.2% 39,5-39,9 2,5% 40-40,4 3,2% >40,5 4,4% WBC <5 0 5-9,9 .3% 10-14,9 1.3% 15-19.9 4% >20 8% ANC >10 12%most sensitive and most accurate from ROC ABC >1.5 5,2% BNR ANC, temp and age are the only sgnificant after adjusment for confounding variable
  • Clinical and Lab criterias to assess risk of serious bacterial infection Predicts poorly who will be sick Fairly good to triage who will not be sick criterias based on previous reports all hospitalized infants < 3mo; 39% <30d; 41% 31-60d; 15 >60d temp 38 233 144 low risk; 1 SBI; 89 high risk; 22 SBI; NPV for SBI 99,3% NPV for sepsis 100% 90% admission for benign disease
  • It makes no clinical sens to order a CBC and Blood cultures. The latter obviates the need of the former.
  • Knowing that since 1933, We had to start looking for the unknown
  • Prevention of either death or serious morbidity is extremely rare. No testing other than U/A in certain situations. FOLLOW-UP
  • The majority of kids do not have persistent bacteremia and so on. The data on meningitis comes from meta-analysis on the topic
  • Conclusions are drawn over a very small number of outcomes, even if a large number of kids with fever enter the study. Analyzed over the wrong denominator, ie bacteremic as opposed to febrile. ANALYSE WHAT YOU RANDOMIZE
  • 41/100 000 to 1,6/100 000, most cases in incomplete vaccination
  • Kupperman: no test if Temp <39.5 in 2-3 y or <39 3-36mo, F/U 24h,risk<1% CBC if Temp >39.5 or 39 Approximately 76% of cases of occult pneumococcal bacteremia would be correctly identified by this strategy. For every 1000 febrile pediatric outpatients screened with an ANC, approximately 240 would have ANCs of 10 × 10 9 cells/L or more and therefore have blood cultures obtained and receive empiric antibiotics. Of these 240 patients, approximately 20 would have pneumococcal bacteremia, of whom approximately 1 would develop meningitis if not treated with empiric antibiotics. Shapiro: No test besides U/A,No ATB Baker: Temp>38 + IOS<10 + -ve full septic W/U, WBC AND BNR with easy follow-up, NPV 100%, with or without ATB Baskin: Like Baker, WBC 20 000 Baraff: 0-3MONTHS :Temp<38-ve clinical criteria + WBC + ABC + BNR, urine culture, blood cultures, ± Ceftriaxone if LP 3-36 MONTHS and no Prevnar : Temp <39.5, U/A +cultures if risks, WBC + ANC then blood cultures If +ve, Ceftriaxone anyways, CXR prn Dagan: Temp>38, <2Mo, home low risk with ± ATB pending cultures McCarthy: Nosuggestions for management
  • The management of febrile pediatric patient will remain a clinical situation that calls for an educated guess of a patient’s risk for bacteremia based on the available data at hand Avoid double standards of treatment
  • Pediatric fever

    1. 1. Fever in kidsFrançois Gaumont, md
    2. 2. Antipastoq Ron Dagan q Rochester ,NYq Paul McCarhty q West Haven,Ctq Douglas Baker q Philadelphia, Penq Baskin q Boston, Massq Larry Baraff q Los Angeles,Caq Nathan q Davis, Ca Kuppermann
    3. 3. Historyq 1920-30; Recognition of potential serious bacterial infection in well looking febrile child. Dunham EC:Septicemia in the newborn, Am J Dis Child 1933;45;229-253q Age 8 weeks or lessq Tº 38ºC rectalq Long standing controversies • What risks, who is/who is not, who looks sick/who doesn’t, who to keep/who to send, who to treat who not to.q No consistency
    4. 4. FEVER = 38º C rectal
    5. 5. Epidemiology of feverq 10-20% of all ER visitsq 20% of fevers are FWSq 1.6% of all ED visits, 3-36 Mo > 39°C, non-toxicq Most common complaint < 6 Moq Most high fever are benign
    6. 6. Fever Phobia Revisited: Have Parental Misconceptions About Fever Changed in 20 Years? Pediatrics, Volume 107, Number 6, June 2001, Michael Crocetti 1 MD Harmful effects of feverq Type Schmitt (n = 81) Crocetti et al (n = 340 )q Seizure 15% 32%q Brain damage 45% 21%q Death 8% 14%q Dehydration 4% 4%q Really sick 1% 2%q Coma 4% 2%q Delirium 12% 1%q Blindness 3% 1%q No response 6% 9%q Other - 14%q Total 100% 100%
    7. 7. Clinical Thought Process FEVER S IC K N O T S IC KW O RK UP F O C A L IN F E C T IO N N O F O C A L IN F E C T IO N A D M IT hx and PE IN V E S T IG A T E W H O W IL L G E T S IC K A N D W H A T TR E AT A D M IT
    8. 8. None of this applies to the sick looking child... That is assuming we know what a sick kid is?!
    9. 9. Relevant Age Groups and developmentq 0………4wq 0………………..8wq 0……….……………….12wq 12w………..3yq > 3 years oldq Age stratification of risk for SBI
    10. 10. LOW AND HIGH-RISK CRITERIA COMMONLY USED IN STUDIES OF FEVER WITHOUT SOURCEq Low-risk Criteria High-risk Criteriaq Term gestation (37 weeks) Recurrent febrile illnessesq Uncomplicated prenatal course Prematurityq No recent (7d) antibiotic Congenital immune diseaseq No recent surgery Sickle cell diseaseq No chronic illness Aspleniaq No perinatal ATB Malignancy/chemotherapy Recent steroid therapyq Hospitalized = to mother HIV disease
    11. 11. Yale Observation Scale Score q Quality of cry q Score 6-10 well q Alertness q Score 11-15 mod q Color q Score > 15 toxic q Hydration q Response to parents q Response to othersMcCarthy PL, Sharpe MR, Spiesel SZ, et al: Observation scales to identify serious illness infebrile children. Pediatrics 1982; 70:802
    12. 12. Yale Observation Scale Score q OBq 6-10 well q 2,5%q 11-15 mod q 4,7%q > 15 toxic q 5,7%
    13. 13. Patients Patients with OB without OB Sens Spec PPV NPVYOS No. % No. % % % % %>6 55 28.6 1122 17.5 28.6 82.5 4.7 97.4>8 32 16.7 522 8.1 16.7 91.9 5.8 97.3>10 10 5.2 210 3.3 5.2 96.7 4.5 97.1>12 1 0.5 75 1.2 0.5 98.8 1.3 97.1Efficacy of an observation scale in detecting bacteremia in febrile children three to thirty-six months ofage, treated as outpatients. Stephen J. Teach Journal of Pediatrics, Volume 126, Number 6, June 1995
    14. 14. Predictors of bacteremia q History q WBC q Physical exam q ANC q Gender q Bands q Height of fever q Band/Neutrophils ratio q PMN% q ESR-CRP-cytokinesDaniel Isaacman, Predictors of bacteremia in febrile children 3-36 Mo of age, Pediatrics;106;5;Nov 2000 ageNathan Kupperman, Predictors of occult bacteremia in young febrile children, Ann Emerg Med June 98;31;679-687 children
    15. 15. Rochester Criterias for infants under 3 months q Term q 15 000 WBC q Previously q 1500 bands healthy q 5 WBC/hpf in q Non-toxic stool q No focus q 10 WBC/hps in q No previous ATB spun urineRon Dagan, Identification of infants unlikely to have serious bacterial infection althoughhospitalized for suspected sepsis, J Pediatr 1985;107;855-860
    16. 16. Rochester Criterias for infants under 3 months q Risk of 0.5-1.1% for SBI including meningitis q NPV 98,5%Jaskiewicz JA, McCarthy CA, Richardson AC, et al: Febrile infants at low risk for seriousbacterial infection-an appraisal of the Rochester criteria and implications for management.Pediatrics 1994;94:390-396
    17. 17. Philadelphia Criteriasq Non-toxic q WBC < 15 000q No focus q BNR < .2q No immuno- q U/A deficiency • < 10 wbc/hpf spun, • -ve gram stain q CSF • < 8 wbc • -ve gramstain • normal gluc, prot q CXR, if signs
    18. 18. “It has been well describedthat a well appearing young infant may have an SBI… therefore, laboratoryinvestigation is necessary.”1-Baraff LJ, Oslund S, Schriger DL, et al. Probability of bacterial infections in infants lessthan three months of age: a meta-analysis. Pediatr Infect Dis J. 1992;11:257-2652-Baker MD, Avner JR, Bell LM. Failure of infant observation scales in detecting seriousillness in febrile 4 to 8 week old infants. Pediatrics. 1990;85:1040-10433-Larry J. Baraff Management of fever without source in infants and childrenAnnals of Emergency Medicine Volume 36 Number 6 December 2000
    19. 19. Clinical Thought Process FEVER S IC K N O T S IC KW O RK UP F O C A L IN F E C T IO N N O F O C A L IN F E C T IO N A D M IT hx and PE IN V E S T IG A T E W H O W IL L G E T S IC K A N D W H A T TR E AT A D M IT
    20. 20. Predictors of bacteremia qe w / 1+e w q w = .1673x ANC + .2006x Tº + . 8434x gender - 12.454Isaacman J., Predictors of bacteremia in febrile children 3 to 36 months of age, Pediatrics Nov2000;106;5,
    21. 21. Common bugs of OBq S.pneumoniae 1-3%q Salmonella non-thyphoïd .1-.2%q N.meningitidis .025%
    22. 22. Managementq Mood swingsq ED waiting timeq Gut feelingq Guidelinesq Clinical policiesq Decision analysisq Algorithmq Resolution of conflicts in Freud’s second stage of development
    23. 23. Clinical Guidelines in the Setting of Incomplete Evidence DAVID L. SCHRIGER ,Pediatrics, Volume 100 Number 1 July 1997 q “...the infectious disease experts who predominate the article by Baraff et al emphasize their experience with the rare child who does poorly; Kramer and Shapiro emphasize primary care practitioners experience with the hundreds of children who do well…” q “...while most academic pediatric researchers have approached the febrile child as if there is only one opportunity to make the correct diagnosis and initiate treatment…”Kramer MS, Management of the febrile infant: a commentary on recent practice guidelines,Pediatrics;100;1;July 1997
    24. 24. Clinical Policy for the Initial Approach toChildren Under the Age of 2 Years Presenting with Fever Annals of Emergency Medicine Volume 22 Number 3 March 1993 q “...If the rules regarding admission appear too stringent at times, we remind our members that deviation from the rules requires only that the physician justify the deviation. In general, the rules are meant to protect the child…”
    25. 25. A survey about management of febrilechildren without source by primary care physicians. Wittler RR - Pediatr Infect Dis J - 1998 Apr; 17(4): 271-7 q 1600 mailing list q GP, EP, Paeds q 3w, 7w, 4 mo, 16 mo, fever without source q Strong agreement to admit 3w and 7w q Outpatient ATB for 4 mo • GP 28%, Paeds 45%, EP 59% ¢¯ x3À of ceftriaxone since ‘91
    26. 26. Pediatricians Awareness of andAttitudes About Four Clinical Practice Guidelines Pediatrics Volume 101 Number 5 May 1998q National survey, 300 respondants • 64% aware
    27. 27. How about no treatment for OBq Persistent fever • 76% Vs 24%q Persistent bacteremia • 17% Vs 1,6%q Admitted • 50% Vs 12%q Cellulitisq Pneumoniaq Meningitis • 2.7%-5.8% Vs 0.4%
    28. 28. Serious bacterial infection q MENINGITIS • risk of OB 3% (85% pneumococcal) • risk of pneumococcal meningitis 3% • case fatality rate of 7,7% • 25-30% neurologic sequelaeArditi M, Mason EO Jr, Bradley JS, et al. Three-year multicenter surveillance of pneumococcal meningitis inchildren: clinical characteristics, and outcome related to penicillin susceptibility and dexamethasone use.Pediatrics. 1998;102:1087-1097.Pikis A, Kavaliotis J, Tsikoulas J, et al. Long-term sequelae of pneumococcal meningitis in children. Clin Pediatr.1996;35:72-78.
    29. 29. Treatmentq Antibiotics ??? q Route ??? • Benzathine pen • PO • amoxil • IM • amoxil/clavulanic • IV acid • ceftriaxone
    30. 30. Admission q Is it safe? Reassuring? q Iatrogenic and financial cost • nosocomial infections • iv infiltrates, fluid overload • drug toxicity • repeated testing, lost samples, contaminted samples, mislabeling • Stolen infant q There is no such thing as a short admission q Higher rates of admission if referredIatrogenic risks and financial costs of hospitalizing febrile infants, DeAngelis C., AM J DisChild;137;1146-1149;Dec 1983
    31. 31. Pneumococcal vaccine q Capsular polysaccharide, major virulence factor q Conjugate, improved immunogenicity in young infants q Pneumococcal proteins • pneumolysin, pneumococcal surface protein A and pneumococcal surface adhesin A q Decreases colonisation as well as invasive infection q Replacement colonisationRubin L.G, Pneumococcal vaccine, Pediatric Clinics of North AmericaVolume 47 Number 2 April 2000
    32. 32. Pneumococcal vaccineq Efficacy • meningitis • invasive disease • pneumoniaq Schedule at 2,4,6,12,15 months
    33. 33. Fever in the post- S.pneumoniae era q 95% HI-b invasive decrease 1987-1994 q Median age for bacterial meningitis • 1986 - 15 months • 1995 - 25 yearsAnne Schuchat, Bacterial meningitis in the US in 1995, N Engl J Med1997;337;970-6
    34. 34. Who will you go with?q Ron Dagan q Rochester ,NYq Paul McCarhty q New Haven, Ctq Douglas Baker q Philadelphia, Penq Baskin q Boston, Massq Larry Baraff q Los Angeles,Caq Nathan q Davis, Ca Kuppermann
    35. 35. CONCLUSIONq Adopt one line of conductq Primum non-nocereq Elevate yourself beyond statistical numbersq Clinical judgment, medical common sens and decision making is what we trained for
    36. 36. Definitionsq Fever without a source (FWS) • No apparent etiology from history and physical examinationq Fever of unknown origin (FUO) • No apparent etiology from history and physical examination lasting for at least 14 daysq Serious bacterial infection (SBI) • Meningitis, bacteremia, pneumonia, uti, otitis,cellulitis,osteomyelitis
    37. 37. Definitionsq Occult bacteremia • presence of pathogenic bacterial organism in blood cultures of child with suspected infection