Guided notes to accompany asynchronous "Evaluating Pediatric Fever" module

1. Evaluating Pediatric Fever
The objective of this module is to provide you with an organized approach to evaluating the child with acute fever. There are
three videos:
 “Fever and Serious Bacterial Illness” covers the definition of fever, identifying which children are at risk of serious
disease, and provides a paradigm for initial classification/decision-making when confronted with a febrile child.
 “Who’s trying to die?” covers recognizing ‘sick’, establishes that very young infants cannot be identified clinically, and
provides an approach to identifying serious disease in these infants.
 “Who’s faking you out?” covers older children, the changing risk of SBI in this population, and the separate paradigm
used for identifying serious disease in these kids.
A guided note-taking template is provided. Cases are presented to help clarify varying decision points. The last page is a
fillable template that allows consolidation of all three videos into a unified flow chart that can be used for any child with acute
fever.

2. Video 1: Fever and Serious Bacterial Illness
Core temp above 100.4 F
Definition of Fever
• methods of measurement? different methods for different ages?
• should tactile temp count? should reported temp count?
• what about teething?
Serious Bacterial Illness
What can fever
mean?
• Invasive disease leads to sepsis leads to death.
• Most frequent sources?
Threshold of concern?
Who's sick and who
isnt?
• Ill-appearing
•
• Very Young Infants (Why are they at higher risk for invasive disease and progression?)
• <28 days of age
• 29-60 days of age
• Age 2 months to 2/3/5 years
• Age 2/3/5 and older

4. Video 2: Who’s Trying to Die?
Principle: In the last video, I talked about the idea that every kid with fever should be evaluated (whether formally or
informally) for risk of sepsis. The next two videos build on that by showing how. First, we’ll concentrate on the kids in
whom sepsis is assumed until proven otherwise-or, stated differently, the ones who have to prove they’re NOT sick.
CASE:
A 21 day old child presents to your office (or Urgent Care, or ED) with a fever.
Step 1: From last time: confirm the fever. (state how here:_______________________________________)
Step 2: Sick-not-sick?(ie: are they already shocky?)
https://www.sciencedirect.com/science/article/pii/S0021755717305028
http://www.pedscases.com/sites/default/files/Vital%20Signs%20Shortcut%201.2_0.png
appearance
work of
breathing
circulation
RR
•
HR
•
BP
•
SaO2
•
THE PEDIATRIC ASSESSMENT TRIANGLE VITAL SIGNS BY AGE

5. Video 2: Who’s Trying to Die?
Also step 2: Who else is sick?
High Risk
Historical
Features
High Risk
exam
features

6. Video 2: Who’s Trying to Die?
CASE, Continued:
A 21 day old neonate presents to your urgent care with complaint of fever.
What’s step 1?
Step 2:
Make up a PAT constellation and a set of vital signs that you’d expect from a ‘sick’child?
Now assume the baby’s PAT and Vitals are WNL. What historical features might make you classify him as ‘sick’
anyway?
What if you can clearly see the baby has purulent rhinorrhea and a cough (URI sxs?) Does this raise or lower your
concern for SBI/sepsis?
NOW, assume the baby has no concerning PAT findings, normal vital signs, and no historical/exam features of
concern. Just the fever.
This is a “well-appearing” baby. You’re ready for Step 3.

7. Video 2: Who’s Trying to Die?
Step 3: How old are they?
Now what? How do you prove they don’t have sepsis?
Test for the < 28 day-old
baby
Test for the 29-60 day-
old baby
Reassuring result
Indicator of infx? WBC <
Indicator of bacterialinfx?
Indicators of UTI/pyelo?
Indicators of Pneumonia? If, then If, then
Test for Bacteremia?
Test for Meningitis? If, then
Which 0-28 day olds can get away without an LP?
Which 29-60 day olds can get away without an LP?
If your UA is normal, do you need to send a culture? (Hint: YES!!!!)
Which kids 0-60 days can be admitted without antibiotics?
Which kids 0-60 days need empiric acyclovir?
Which kids 0-60 days can be sent home?
< 28 days
prove it
29-60 days
prove it
2 months-2/3/5
years
sometimes
have to prove
it: see video 3
2/3/5 years +
don't have to
prove it.
WYSIWYG
Fever age 0-28 days

8. Video 2: Who’s Trying to Die?
CASE #1 RESOLUTION:
Your 21-day old with fever, no obvious signs of shock, confirmed rectal temp >100.4 F, and an uncomplicated peri-natal
course, initially had no obvious source of fever. An investigation for sepsis was begun based on patient age. CBC,
Procalcitonin, UA, CXR, and LP appear to be normal. What’s your plan for this baby?
ADMIT or D/C?
ABX or Not?
CASE #2
You are seeing a 6 week old girl with fever at home of 101.6 F.
What’s Step 1?: (rectal temp in the office is 100.3)
Does this child get a work-up?
Step 2: What are the 3 criteria for ‘well-appearing?’
Step 3: Assume the Hx, Pex, and available labs are normal. Does she need an LP? Admission? Abx?
Why or why not?
Assume the Procalcitonin is elevated. Does she need an LP? Admission? Abx?
Assume the Urine has mod leukocytes and + nitrites. Does she need an LP? Admission? Abx?
Why or Why not?
Fever age 29 - 60 days

9. Video 3: Who’s faking you out?
As babies grow, their defenses improve, they receive vaccine protection, and their compensatory mechanisms mature. In the
age group 2 months to 2 years (or 3 or 5, depending who you ask) the search for SBI changes because the risks change.
What’s different for older babies and toddlers?
CASE #3:
A 9 month old girl is rushed to the ED by her parents because she is burning up.
Step 1: confirm the temp
(her rectal temp in the ED is 103.9 F)
Step 2: sick-or-not sick?
She is clingy and whiny and cries when she sees you. Extremities and lips are pink. HR is 140, RR is variable because
she is crying.
How can you reassure yourself she is not-sick?
Here’s what’s different:
Step 2 1/2 : can you find a source?
Assume she has a bilateral otitis media. Does she need further workup?
Now assume she has a normal exam.
She’s now well-appearing, but without source of infection.
Well appearing? No source? You’re ready for step 3.
Fever age 2 months to 2 years

10. Video 3: Who’s faking you out?
Step 3: How old are they?
Its not so much frank sepsis anymore, because these kids will sometimes look sick when they ARE sick. But they don’t always.
And there’s still some risk of invasive bacterial disease and occult bacteremia in the well-appearing child, so the search is now
focused on those.
AGE 2 mo to 2 years Prevalence in well-appearing FWS Risk factors How to
know?
UTI/pyelo
Shaikh PIDC 2008; 27(4): 302
Gorelick and Shaw
Aap clinical practice guideline
Girls
5-8%
W = 8%
B = 5%
Boys
Uncirc
2-3 mo
20%
Circ
2%
W
< 12 mo
Temp >39
Duration 2
days +
No other
source
2-3 factors
+
Mod leuk or
+ nitr
UA >
5wbc/hpf +
bact
Pneumonia
s. pneumo
https://pneumonia.biomedcentral.com/articles/10.15172/pneu.2013.
2/229
Vaccinate
d
Unvaccinated
20 %
https://www.ncbi.nlm.nih.gov/pubmed/20577
140
Tachypnea/WO
B
Exam, CXR
Occult Bacteremia
Mcgowan jaffe et al
S. pneumo/Hib
Vaccinated
0.25 %
Unvaccinated
2-4 %
Consider the
‘herd’ that the
patient lives in
CRP,
procalcitoni
n
(procalcitoni
n better if
temp is
brand new
<8 hrs)
Fever age 2 months to 2 years

11. Meningitis*
Age is still a factor. Even though you have the 2-
month olds lumped in this pathway with the 2-year
olds, doesn’t mean their risks are the same. At 68
days, I might still evaluate under Video 2’s rules,
whereas at23m3wks, I would not be as concerned in
the absence of hx/exam findings
Video 3: Who’s faking you out?
CASE, continued.
The baby is 9 months old, well-appearing, with a documented temperature and no source.
What’s her numerical risk of UTI/pyelo? What else do you need to know?
What’s her risk of pneumonia? What else do you need to know?
What’s her risk of bacteremia? What else do you need to know?
How will you work her up? (check all that apply)
o UA
o CBC
o CXR
o Urine culture
o Procalcitonin
o Blood culture
Fever age 2 months to 2 years

13. Paradigm mash up (age birth to 100)
Fever,
documented
sick
PAT Vitals Risks
not sick
<28 days 29-60 days 2mo-/3 yrs older yrs

14. References/Links
https://journals.lww.com/pidj/pages/articleviewer.aspx?year=2018&issue=11000&article=00028&type=Fulltext
 http://papers.mrotte.com/pediatric_fever.pdf
 https://fpnotebook.com/ID/Peds/BctrmInChldrn.htm
 Greenhow https://pediatrics.aappublications.org/content/139/4/e20162098
 Nice guideline sick-notsick tablehttps://www.nice.org.uk/guidance/cg160/chapter/recommendations#table-1-traffic-light-system-for-
identifying-risk-of-serious-illness
 https://www.saem.org/cdem/education/online-education/peds-em-curriculum/approach-to/fever
 Step by step https://pediatrics.aappublications.org/content/138/2/e20161579.full
 Bacteremia numbers https://pediatrics.aappublications.org/content/135/4/635
 Prevalence of SBI by dx REVISE (for intro lecture) https://hosppeds.aappublications.org/content/5/10/528
 https://www.aappublications.org/news/2018/11/13/febrile-infants-less-than-two-months-of-age-do-they-all-need-a-lumbar-puncture-
pediatrics-11-13-18
 https://www.acep.org/globalassets/new-pdfs/clinical-policies/pedi-fever.pdf
 https://www.ncbi.nlm.nih.gov/pubmed/22452986
 Chop fever mash up https://www.chop.edu/clinical-pathway/child-with-fever-clinical-pathway
https://emergency.med.ufl.edu/files/2013/02/Management-of-fever-without-source-in-infants-and-children.pdf
Sicknot sick https://www.aappublications.org/news/2017/04/12/Sick-Not-Sick-Low-Not-Low-Pediatrics-In-Review-4-12-17
Pediatricassessmenttringlehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4318552/
https://journals.lww.com/pec-online/Fulltext/2010/04000/The_Pediatric_Assessment_Triangle__A_Novel.15.aspx
https://www.ncbi.nlm.nih.gov/pubmed/27176906
Alsosick:https://www.uptodate.com/contents/febrile-infant-younger-than-90-days-of-age-outpatient-evaluation#H3906313364