The Pyrexial Child

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  • Children with feverish illness should be assessed for the presence or absence of symptoms and signs that can be used to predict the risk of serious illness using the traffic light system
  • 5% skin - decreased turgor dry m membranes fontanelle - may be slighly depressed eyes - slightly sunken pulses - normal resp pattern- may be abnorm mental state - may be normal   10% skin - decreased turgor with poor CR dry m membranes fontanelle - depressed eyes - sunken pulses - poor vol resp pattern - abnormal mental state - lethargic oliguria may be noted   > shock - falling BP with tachycardia coma anuria
  • 5% skin - decreased turgor dry m membranes fontanelle - may be slighly depressed eyes - slightly sunken pulses - normal resp pattern- may be abnorm mental state - may be normal   10% skin - decreased turgor with poor CR dry m membranes fontanelle - depressed eyes - sunken pulses - poor vol resp pattern - abnormal mental state - lethargic oliguria may be noted   > shock - falling BP with tachycardia coma anuria
  • Symptoms and signs of specific diseases  
  • Care at home ● Advise parents and carers: – of the antipyretic interventions available – to offer their child regular fluids (if breastfeeding then continue as normal) – to look for signs of dehydration: ◆ sunken fontanelle ◆ dry mouth ◆ sunken eyes ◆ absence of tears ◆ poor overall appearance – to encourage their child to drink more fluids and consider seeking further advice if they see signs of dehydration – how to identify a non-blanching rash – to check their child during the night – to keep their child away from nursery/school while the fever persists and to notify the nursery/school of the illness. ● Advise parents and carers to seek further advice if: – the child has a fit – the child develops a non-blanching rash – they feel that the child’s health is getting worse – they are more worried than when they last received advice – the fever lasts longer then 5 days – they are distressed or concerned that they are unable to look after their child.
  • ● Provide the parent or carer with verbal and/or written information on warning symptoms and how further healthcare can be accessed. ● Arrange a follow-up appointment at a certain time and place. ● Liaise with other healthcare professionals, including out-of-hours providers, to ensure the parent/carer has direct access to a further assessment for their child.
  • The Pyrexial Child

    1. 1. The Pyrexial Child   in primary care setting Dr Hassan Dawood SHO GP
    2. 2. Structure of the Presentation <ul><li>How to measure T? </li></ul><ul><li>  </li></ul><ul><li>Causes of pyrexia in childhood </li></ul><ul><li>  </li></ul><ul><li>Assessment (Traffic Light System) </li></ul><ul><ul><li>Signs & symptoms </li></ul></ul><ul><ul><li>Specific diseases </li></ul></ul><ul><li>  </li></ul><ul><li>Management </li></ul><ul><li>  </li></ul><ul><li>Antipyretics </li></ul><ul><li>  </li></ul><ul><li>Management by the paediatric specialist </li></ul><ul><li>  </li></ul>
    3. 3. How To Measure T? <ul><li>NICE Guidelines ( < 5 yrs ) </li></ul><ul><li>  </li></ul><ul><li>DON'T : ( ORAL / RECTAL ) ROUTE </li></ul><ul><li>- < 4 wks: electronic thermometer in the axilla </li></ul><ul><li>  </li></ul><ul><li>- 4  wks - 5 yrs: </li></ul><ul><ul><li>electronic thermometer in the axilla </li></ul></ul><ul><ul><li>chemical dot thermometer in the axilla  </li></ul></ul><ul><ul><li>infra-red tympanic thermometer </li></ul></ul><ul><li>  </li></ul><ul><li>- Parental perception </li></ul>
    4. 4. Causes Of Pyrexia In Children <ul><li>I - C - C - R - Ex - ++ </li></ul><ul><ul><li>Infections </li></ul></ul><ul><ul><li>Convultions  * <===> </li></ul></ul><ul><ul><li>CA </li></ul></ul><ul><ul><li>Rheumatoid </li></ul></ul><ul><ul><li>External factors </li></ul></ul><ul><ul><li>Over dressing </li></ul></ul>
    5. 5. Assessment <ul><li>Level of Risk ( Traffic Light System) </li></ul><ul><li>  </li></ul><ul><li>  </li></ul><ul><ul><li>ABCD inc CR ( + T ) ? DEFG </li></ul></ul><ul><li>  </li></ul><ul><ul><li>Hx / Ex: </li></ul></ul><ul><ul><ul><li>? Abroad </li></ul></ul></ul><ul><ul><ul><li>? Source </li></ul></ul></ul><ul><ul><ul><li>? Specific signs & Symptoms </li></ul></ul></ul><ul><li>  </li></ul><ul><ul><li>? Infection screen </li></ul></ul><ul><li>  </li></ul>
    6. 8. Colour <ul><li>  </li></ul>
    7. 9. Activity <ul><li>  </li></ul>
    8. 10. Respiratory <ul><li>  </li></ul>
    9. 11. Hydration <ul><li>  </li></ul>
    10. 12. Other <ul><li>  </li></ul>
    11. 13. Herpes Simplex Encephalitis Meningitis, Meningococcal Dis Pneumonia Kawasaki disease UTI Septic arthritis/osteomyelitis • Neck stiffness • Bulging fontanelle • level of consciousness  Non-blanching with 1 or more: • an ill-looking child • larger than 2 mm in diameter • CRT ≥3 seconds • neck stiffness Fever >5 days & 4 of the following: • bilateral conjunctival inj • change in URT mucous membranes ( eg, injected pharynx, dry cracked lips or strawberry tongue ) • change in the periph extremities ( eg,oedema, erythema or desquamation ) • polymorphous rash • cervical lymphadenopathy • Focal neur signs/ fits • level of consciousness • Tachypnoea     0–5 m – RR > 60 b/m     6–12 m – RR > 50 b/m    > 12 m – RR > 40 b/m • Crackles, Nasal flaring, Chest indrawing,     Cyanosis • Sats ≤95% (> 3 months) • Poor feeding, Vomiting, Lethargy, Irritability, Abdo pain • Frequency or dysuria • Offensive urine or haematuria • Swelling of a limb or joint • Not using an extremity • Non-weight bearing + FEVER
    12. 15. Management <ul><li>GREEN ( LOW RISK ) </li></ul><ul><li>  </li></ul><ul><li>Manage at home with advice: </li></ul><ul><li>  </li></ul><ul><ul><li>Antipyretic </li></ul></ul><ul><ul><li>Hydrate ++ (if breastfeeding to cont as normal) </li></ul></ul><ul><ul><li>Off school/ nursery </li></ul></ul><ul><ul><li>When to seek help: </li></ul></ul><ul><ul><ul><li>Signs of dehydration :  </li></ul></ul></ul><ul><ul><ul><ul><ul><li>fontanelle, eyes, tears, mouth, overall appearence </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Non-blanching rash (glass test) </li></ul></ul></ul><ul><ul><ul><li>Fits </li></ul></ul></ul><ul><ul><ul><li>Parents ditress/ concern </li></ul></ul></ul><ul><ul><ul><li>Fever >5 days </li></ul></ul></ul>
    13. 16. Management <ul><li>AMBER ( INTERMEDIATE RISK ) </li></ul><ul><li>Provide parents / carers with a safety net: </li></ul><ul><ul><li>Verbal ± written info re warning symp </li></ul></ul><ul><ul><li>How to access further healthcare / Liaise on with out of hrs </li></ul></ul><ul><ul><li>? F/U </li></ul></ul><ul><li>RED ( HIGH RISK ) </li></ul><ul><li>Ref urgently to Paeds </li></ul>
    14. 17. Further  Invx & Management <ul><li>● Test fo UTI </li></ul><ul><li>  </li></ul><ul><li>● If pneumonia is suspected but the child has not been referred to hospital, do not routinely perform CXR </li></ul><ul><li>● Do not prescribe oral ABx to a child with fever without apparent source </li></ul><ul><li>● If meningococcal disease is suspected, give parenteral ABx ASAP (benzylpenicillin or a third-generation cephalosporin) </li></ul>
    15. 18. Antipyretics <ul><li>● Tepid sponging is not recommended. ● Do not over or under dress a child with fever. ● Consider either paracetamol or ibuprofen as an option if the child appears distressed or is unwell.  </li></ul><ul><li>● Do not administer paracetamol and ibuprofen at the same time, but consider using the alternative agent if the child does not respond to the first drug.   </li></ul><ul><li>● Do not routinely give antipyretics with the sole aim of reducing body temperature .  </li></ul><ul><li>● Do not use antipyretics with the sole aim of preventing febrile convulsions . </li></ul>
    16. 19. Management by the paediatric specialist <ul><li>● Children with fever without apparent source presenting to paediatric specialists with one or more ‘red’ features should have the following investigations performed: – FBC – BC – CRP – urine testing for UTI. </li></ul><ul><li>● The following investigations should also be considered in children with ‘red’ features, as guided by the clinical assessment: – LP in children of all ages (if not contraindicated) – CXR irrespective of body temperature & WCC – U+Es & BG </li></ul>
    17. 20. Structure of the Presentation <ul><li>How to measure T? </li></ul><ul><li>  </li></ul><ul><li>Causes of pyrexia in childhood </li></ul><ul><li>  </li></ul><ul><li>Assessment (Traffic Light System) </li></ul><ul><ul><li>Specific signs & symptoms </li></ul></ul><ul><ul><li>specific diseases </li></ul></ul><ul><li>  </li></ul><ul><li>Management </li></ul><ul><li>  </li></ul><ul><li>Antipyretics </li></ul><ul><li>  </li></ul><ul><li>Management by the paediatric specialist </li></ul><ul><li>  </li></ul>

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