This document discusses fever in children and provides definitions for key terms. It reviews the epidemiology of fever in kids and outlines historical perspectives on recognizing potential serious bacterial infections in febrile children. The document examines predictors of occult bacteremia, clinical guidelines for evaluating fever without source, and controversies around the management of febrile children. It also discusses serious bacterial infections like meningitis and the impact of the pneumococcal vaccine.

1. Fever in kids
François Gaumont, md

2. Antipasto
q Ron Dagan q Rochester ,NY
q Paul McCarhty q West Haven,Ct
q Douglas Baker q Philadelphia, Pen
q Baskin q Boston, Mass
q Larry Baraff q Los Angeles,Ca
q Nathan q Davis, Ca
Kuppermann

3. History
q 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;229-253
q Age 8 weeks or less
q Tº 38ºC rectal
q 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. FEVER = 38º C
rectal

6. Epidemiology of fever
q 10-20% of all ER visits
q 20% of fevers are FWS
q 1.6% of all ED visits, 3-36 Mo
> 39°C, non-toxic
q Most common complaint < 6 Mo
q Most high fever are benign

7. 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 fever
q 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%

8. Clinical Thought
Process
FEVER
S IC K N O T S IC K
W 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

9. None of this applies to the sick looking child...
That is assuming we know what a sick kid is?!

10. Relevant Age Groups
and development
q 0………4w
q 0………………..8w
q 0……….……………….12w
q 12w………..3y
q > 3 years old
q Age stratification of risk for SBI

11. LOW AND HIGH-RISK CRITERIA COMMONLY
USED IN STUDIES OF FEVER WITHOUT
SOURCE
q Low-risk Criteria High-risk Criteria
q Term gestation (37 weeks) Recurrent febrile illnesses
q Uncomplicated prenatal course Prematurity
q No recent (7d) antibiotic Congenital immune disease
q No recent surgery Sickle cell disease
q No chronic illness Asplenia
q No perinatal ATB Malignancy/chemotherapy
Recent steroid therapy
q Hospitalized = to mother HIV disease

12. 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
others
McCarthy PL, Sharpe MR, Spiesel SZ, et al: Observation scales to identify serious illness in
febrile children. Pediatrics 1982; 70:802

13. Yale Observation Scale
Score
q OB
q 6-10 well q 2,5%
q 11-15 mod q 4,7%
q > 15 toxic q 5,7%

14. Patients Patients
with OB without OB
Sens Spec PPV NPV
YOS 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 97.1
Efficacy of an observation scale in detecting bacteremia in febrile children three to thirty-six months of
age, treated as outpatients. Stephen J. Teach Journal of Pediatrics, Volume 126, Number 6, June 1995

15. 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-cytokines
Daniel Isaacman, Predictors of bacteremia in febrile children 3-36 Mo of age, Pediatrics;106;5;Nov 2000
age
Nathan Kupperman, Predictors of occult bacteremia in young febrile children, Ann Emerg Med June 98;31;679-687
children

16. 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 urine
Ron Dagan, Identification of infants unlikely to have serious bacterial infection although
hospitalized for suspected sepsis, J Pediatr 1985;107;855-860

17. 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 serious
bacterial infection-an appraisal of the Rochester criteria and implications for management.
Pediatrics 1994;94:390-396

18. Philadelphia Criterias
q Non-toxic q WBC < 15 000
q No focus q BNR < .2
q 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

19. “It has been well described
that a well appearing young
infant may have an SBI…
therefore, laboratory
investigation is necessary.”
1-Baraff LJ, Oslund S, Schriger DL, et al. Probability of bacterial infections in infants less
than three months of age: a meta-analysis. Pediatr Infect Dis J. 1992;11:257-265
2-Baker MD, Avner JR, Bell LM. Failure of infant observation scales in detecting serious
illness in febrile 4 to 8 week old infants. Pediatrics. 1990;85:1040-1043
3-Larry J. Baraff Management of fever without source in infants and children
Annals of Emergency Medicine Volume 36 Number 6 December 2000

20. Clinical Thought
Process
FEVER
S IC K N O T S IC K
W 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

21. Predictors of
bacteremia
qe w
/ 1+e w
q w = .1673x ANC + .2006x Tº + .
8434x gender - 12.454
Isaacman J., Predictors of bacteremia in febrile children 3 to 36 months of age, Pediatrics Nov
2000;106;5,

22. Common bugs of OB
q S.pneumoniae 1-3%
q Salmonella non-thyphoïd .1-.2%
q N.meningitidis .025%

23. Management
q Mood swings
q ED waiting time
q Gut feeling
q Guidelines
q Clinical policies
q Decision analysis
q Algorithm
q Resolution of conflicts in Freud’s second
stage of development

24. 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

25. Clinical Policy for the Initial Approach to
Children 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…”

26. A survey about management of febrile
children 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

27. Pediatricians' Awareness of and
Attitudes About Four Clinical Practice
Guidelines
Pediatrics Volume 101 Number 5 May 1998
q National survey, 300 respondants
• 64% aware

28. How about no treatment
for OB
q Persistent fever
• 76% Vs 24%
q Persistent bacteremia
• 17% Vs 1,6%
q Admitted
• 50% Vs 12%
q Cellulitis
q Pneumonia
q Meningitis
• 2.7%-5.8% Vs 0.4%

29. 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 sequelae
Arditi M, Mason EO Jr, Bradley JS, et al. Three-year multicenter surveillance of pneumococcal meningitis in
children: 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.

30. Treatment
q Antibiotics ??? q Route ???
• Benzathine pen • PO
• amoxil • IM
• amoxil/clavulanic • IV
acid
• ceftriaxone

31. 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 referred
Iatrogenic risks and financial costs of hospitalizing febrile infants, DeAngelis C., AM J Dis
Child;137;1146-1149;Dec 1983

32. 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 colonisation
Rubin L.G, Pneumococcal vaccine, Pediatric Clinics of North America
Volume 47 Number 2 April 2000

33. Pneumococcal vaccine
q Efficacy
• meningitis
• invasive disease
• pneumonia
q Schedule at 2,4,6,12,15 months

34. 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 years
Anne Schuchat, Bacterial meningitis in the US in 1995, N Engl J Med1997;337;970-6

35. Who will you go with?
q Ron Dagan q Rochester ,NY
q Paul McCarhty q New Haven, Ct
q Douglas Baker q Philadelphia, Pen
q Baskin q Boston, Mass
q Larry Baraff q Los Angeles,Ca
q Nathan q Davis, Ca
Kuppermann

36. CONCLUSION
q Adopt one line of conduct
q Primum non-nocere
q Elevate yourself beyond statistical
numbers
q Clinical judgment, medical common sens
and decision making is what we trained for

37. Definitions
q Fever without a source (FWS)
• No apparent etiology from history and
physical examination
q Fever of unknown origin (FUO)
• No apparent etiology from history and
physical examination lasting for at least
14 days
q Serious bacterial infection (SBI)
• Meningitis, bacteremia, pneumonia, uti,
otitis,cellulitis,osteomyelitis

38. Definitions
q Occult bacteremia
• presence of pathogenic bacterial
organism in blood cultures of child
with suspected infection