This presentation discusses causes & general management of fever in pediatric poatien

1. International Neonatology Training Program" INTP
BY DR M OSAMA HUSSEIN MD

2. DEFINITIONS OF TERMS IN PRACTICE GUIDELINE ON THE MANAGEMENT
OF FEVER IN INFANTS AND YOUNG CHILDREN
Term Definition
Fever Rectal temperature of 38°C (100.4°F)*
Fever Acute febrile illness in which the etiology of the fever is not
without apparent after a careful history and physical examination
source
Serious Meningitis, sepsis, bone and joint infections, urinary tract
bacterial infections, pneumonia, enteritis
infection
Toxic Clinical presentation characterized by lethargy, evidence of poor
appearance perfusion, cyanosis, hypoventilation or hyperventilation
Lethargy Poor or absent eye contact; failure of child to recognize parents or
to interact with persons or objects in the environment
BY DR M OSAMA HUSSEIN MD

3. Infant appears generally well
ROCHESTER CRITERIA FOR
Infant has been previously healthy: IDENTIFYING FEBRILE INFANTS
AT LOW RISK FOR SERIOUS
Born at term (≥37 weeks of gestation) BACTERIAL INFECTION
No perinatal antimicrobial therapy
No treatment for unexplained hyperbilirubinemia
No previous antimicrobial therapy
No previous hospitalization
No chronic or underlying illness
Not hospitalized longer than mother
Infant has no evidence of skin, soft tissue, bone, joint or ear infection
Infant has these laboratory values:
White blood cell count of 5,000 to 15,000 per mm3 (5 to 15 × 109 per L)
Absolute band cell count of ≤1,500 per mm3 (≤1.5 × 109 per L)
Ten or fewer white blood cells / high-power field on microscopic examination of urine
Five or fewer white blood cells per high-power field on microscopic examination of
BY DR M OSAMA HUSSEIN MD
stool in infant with diarrhea

4. Why we pay special
attention to fever ?
• Parental concern
• “fever phobia”
• Clinician concern
• we don’t want to miss a life threatening infection
• Most common complaint in pediatric visits
• Some of these kids are sick
• most do well without intervention
• need an approach to sort them out
BY DR M OSAMA HUSSEIN MD

5. BY DR M OSAMA HUSSEIN MD

6. Fever Without a Source
• Fever without a source “FWS”= fever with no
apparent cause
• “Fever of Unknown Origin”= a febrile illness of
at least three weeks' duration, at least 38.3°C
on at least three occasions and failure to
establish a diagnosis in spite of intensive
evaluation.
BY DR M OSAMA HUSSEIN MD

7. Pediatric Fever Algorithm
Fever 38 C
Non toxic appearing, 28 – 90 days and “Low Risk”
No Yes
Outpatient Management
ADMIT
Blood Culture, Option 1 Option 2
Urine Culture, Blood Cx, Urine Cx, Blood Cx, Urine
CSF Cx, antibx CSF Cx, ceftriaxone Cx, Re-eval in 24
+/-CXR 50 mg/kg IV/IM, re- hours
eval in 24 hours
BY DR M OSAMA HUSSEIN MD

8. Child 3 to 36 months with FWS: Occult
Bacteremia
• S. pneumoniae>>H. influenzae>N. meningitidis
– conjugate vaccine for H influenzae virtually
eliminated this type of bacteremia
BY DR M OSAMA HUSSEIN MD

9. Child 3 to 36 months with FWS:
Practice Guidelines
• Toxic - Admit with full work up
• Non-toxic – Consider workup when fever is
39°C
BY DR M OSAMA HUSSEIN MD

10. Pediatric Fever Algorithm
Child 3 to 36 months with FWS
Appears toxic?
Yes No
Full sepsis work up and Temperature ≥ 39
antibiotics and admit
No Yes
No testing, Selective
assure follow up workup
in 48 hrs
BY DR M OSAMA HUSSEIN MD

11. Child 3 to 36 months with FWS:
Practice Guidelines
• Toxic - Admit with full work up
• Non-toxic – Consider workup when fever is
39°C (102.2°F)
BY DR M OSAMA HUSSEIN MD

12. Child 3 to 36 months with FWS:
Occult Pneumonia
• Children with high fever and leukocytosis are
more likely to have occult bacterial
pneumonia
– some suggest getting CXR with no resp symptoms
and WBC>20,000 and temp 39.5 C (103.1°F)
BY DR M OSAMA HUSSEIN MD

13. Pediatric Fever Algorithm
Child 3 to 36 months with FWS
Appears toxic?
Yes No
Full sepsis work up Temperature ≥ 39
and antibiotics and
admit
No Yes
No testing, Selective
assure follow workup
up in 48 hrs
BY DR M OSAMA HUSSEIN MD

14. Summary of Testing: 3 to 36 months and FWS,
non-toxic, temp ≥39 C
• Urine
– All females < 2 years
– Males
• Uncircumcised <12 months
• Circumcised < 6 months
• Stool culture
– If bloody diarrhea or >5 wbc’s/hpf
• CXR
– If respiratory symptoms or hypoxic
• LP
– Signs of meningitis
• Blood cultures and Antibiotics
– Option 1: All with fever ≥ 102.2
– Option2 : All with fever ≥ 102.2 and WBC ≥ 15,000
– Option3: Practitioner/immunization dependent
BY DR M OSAMA HUSSEIN MD

15. Fever with a Source
• More common than fever without a source
• Clinically identifiable viral or bacterial illnesses
BY DR M OSAMA HUSSEIN MD

16. Fever with a Source: Viral
– Varicella
– Measles (recent outbreaks)
– Mumps (recent Midwest
outbreaks)
– Adenovirus
(pharyngoconjunctival fever)
– Coxsackie infections
• Herpangina→
• Hand-foot-and-mouth
– Croup
– Bronchiolitis (as in our case)
– Influenzae
BY DR M OSAMA HUSSEIN MD

17. Fever with a Source: Viral
• Pediatric exanthems
– Roseola (HHV 6)
– Fifths disease (Parvo
B19)→
BY DR M OSAMA HUSSEIN MD

18. Fever with a Source: Bacterial
• Clinically evident bacterial infections
– Readily diagnosed from H&P
• Pneumonia
• Meningitis
• Septic arthritis
• Osteomyelitis
• Lymphadenitis
• Cellulitis/Abscess
• Bacterial enteritis
BY DR M OSAMA HUSSEIN MD

19. Antipyretics
• Triage protocols
– acetaminophen by protocol
• Acetaminophen dose
– 15 mg/kg q 4 hr prn
• Ibuprofen dose (for greater than 6 months
old)
– 10 mg/kg q 6 hr prn
BY DR M OSAMA HUSSEIN MD

20. Bug Drugs: <1 month
• Ampicillin and gentamycin
– covers GBBS, E. coli, Listeria monocytogenes
– ampicillin specifically for Listeria and provides
some synergy with gentamycin for GBBS
• Consider acyclovir
– Maternal history of Herpes (especially if primary
outbreak with vaginal delivery) or any noted skin
or mucosal lesions
BY DR M OSAMA HUSSEIN MD

21. Bug Drugs: 1-2 months
• Ampicillin and cefotaxime
– covers the < 1 month etiologic agents and also S.
pneumoniae
– with cefotaxime you don’t have to worry about
oto/renal toxicity associated with gentamycin
BY DR M OSAMA HUSSEIN MD

22. Bug Drugs: >2 months
• Ceftriaxone
– covers S. pneumoniae, H. influenzae, and N.
meningitidis
– theoretically shouldn’t give < 1 month because of
biliary sludging
• Add vancomycin if any concern for S.
pneumoniae on LP in any age range (resistant
strains have been appearing in CSF)
BY DR M OSAMA HUSSEIN MD

23. Kawasaki’s Disease
• Fever for at least 5 days' duration and the presence
of 4 of the following
– Extremities changes (erythema, edema, and
desquamation)
– Conjunctivitis (no exudate).
– Polymorphous rash (not vesicular) is usually generalized
– Cervical lymphadenopathy usually unilateral and greater
than 1.5 cm
– Lip or oral cavity changes (erythema, dry/fissured or
swollen lips, and strawberry tongue)
BY DR M OSAMA HUSSEIN MD

24. Febrile Seizures
• Simple Febrile Seizure
– 1 event in a 24 hour period
– Non-focal
• Complex
– Whenever it is not simple
– Consider larger work-up
• 30% chance of recurrence
BY DR M OSAMA HUSSEIN MD

25. Febrile Seizures
• Work up for the source of the fever
• “Strongly consider LP” for under 12 months –
AAP guidelines
• Brain imaging not often necessary
• Need to explain to parents why you aren’t
worried about the seizure
BY DR M OSAMA HUSSEIN MD

26. Pediatric Fever Summary: Golden
Rules
• A toxic appearance demands immediate
action
– Work-up/antibiotics and admit
• Know the age-specific algorithm for FWS
• Test the urine (most common SBI)
• Look for specific bacterial and viral etiologies
• Careful follow up must be assured
• Recommendations continue to evolve with
new immunizations
BY DR M OSAMA HUSSEIN MD

27. Fever with xanthem
 Infectious causes
 Virus:
 Classic viral exanthem: Measles, Rubella, VZV, Parvovirus, Roseola
 Others:, HSV, EBV, HBV, Enterovirus, Dengue
 Bacteria: Scarlet fever, Staph infection (sepsis, 4S,toxic shock
syndrome), Meningococcemia, typhoid
 Mycoplasma
 Rickettsial infection
 Noninfectious cause
 Allergy: Food, drug, toxin, serum sickness
 Uncertain cause: Kawasaki disease
BY DR M OSAMA HUSSEIN MD

28. Clinical Manifestation
 Incubation: 8-12 days, the average interval between appearance of
rash in the source case and subsequent cases is 14 days, with a range
of 7-18 days.
 Prodromal period: fever 2-4 day + 3C
 cough
 coryza
 conjunctivitis
 Koplik spot
 Rash: erythematous maculopapular rash
 facesole in 72 hr.
 face and trunk: mostly distributed
 pneumonia
 Convalescence
 cough may persist for 1 week
BY DR M OSAMA HUSSEIN MD

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31. Complication
 Pneumonia
 Otitis media
 Diarrhea
 Meningoencephalitis
 Croup
 Subacute sclerosing panencephalitis (SSPE)
BY DR M OSAMA HUSSEIN MD

32. Treatment and Care
 Supportive and Symptomatic
 Vit A supplementation
 6 mo-2 yr hospitalized with measles and complication
 > 6 mo who have risk for severe measles and vit A
deficiency:
immunodef, vitamin A def, impaired intestinal absorption,
malnutrition, recent immigration from high mortality rated due
to measles
 Antibiotic for superimposed bacterial infection
BY DR M OSAMA HUSSEIN MD

33. Treatment and Care
 Isolation: Airborne Precaution
 1-2 day before onset of symptom or 3-5 days
before onset of rash
 4 days after onset of rash in healthy children
 For the duration of illness in immunocompromised
pt.
 Isolated room (negative pressure ventilation)
 Prevention: immunization
 9-15 months
 4-6 years
BY DR M OSAMA HUSSEIN MD

34. Rubella
 RNA virus: Family Togaviridae, genus Rubivirus
 IP: 14-21 days
 Infectivity: 7 days before – 5 days after onset of
rash
BY DR M OSAMA HUSSEIN MD

35. Clinical Manifestation
 Prodromal period 1-5 days
 MP rash for < 3 days
 LN at postauricular and cervical area
 CBC: normal range
 Dx: viral isolation
 Serologic test: CF, HI, IgM ELISA
BY DR M OSAMA HUSSEIN MD

36. BY DR M OSAMA HUSSEIN MD

37. Rubella
 Complication
 arthritis
 thrombocytopenia
 meningoencephalitis
 Treatment: supportive
 Isolation:
 droplet precaution for 7 days after onset of rash,
 contact precaution for congenital rubella until > 1 yr-
old
 Prevention: immunization
BY DR M OSAMA HUSSEIN MD

38. Chickenpox
 VZV, HHV-3:
 Transmission
 airborne
 contact vesicular fluid
 vertical transmission
 Incubation period:
 14-16 days, (10-21days)
 Infectivity: winter season
 Most contagious: 1-2 days before onset of rash until
crusting of lesion.
BY DR M OSAMA HUSSEIN MD

39. Clinical Manifestation
 Prodromal period: 2-3 days
 Generalized, pruritic, vesicular rash 250-500 lesions
involving skin and oral mucosa
 Complication
 Herpes Zoster, Shingles
 Congenital varicella: Scar, limb, ocular, CNS defect
 Bacterial infection
 Severe chickenpox
 CNS: encephalitis, cerebellar ataxia, Reye’s
Syndrome
BY DR M OSAMA HUSSEIN MD

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43. Treatment and care
 Supportive and symptomatic
 antipruritic drug
 for severe case: ACV, famciclovir, valacyclovir
 Isolation:
 Airborne and contact isolation 1-2 days before
rash until crusting of all lesion.
 Prevention
 Immunization
BY DR M OSAMA HUSSEIN MD

44. Child Care and School
 Children may return to school when all lesion are
crusted.
 For compromised children with prolonged course
should excluded for the duration of the vesicular
eruption.
 Older children and staff members with zoster should
be instructed to wash their hands if they touch
potentially infectious lesion
BY DR M OSAMA HUSSEIN MD

45. Hand-foot-mouth Disease
 coxackie virus type 16 (A 16) most common,
other include A5, A7, A9, A10, B2, B5(31)
and enterovirus 71
 Fever, sore throat, drooling
 DDx from Herpes gingivostomatitis
 Self-limited, symptomatic treatment
BY DR M OSAMA HUSSEIN MD

46. HFMD
BY DR M OSAMA HUSSEIN MD

47. BY DR M OSAMA HUSSEIN MD

48. Roseola Infantum
 Exanthem subitum
 3 mo- 3 yr. (6 mo-1 yr)
 HHV-6,7: DNA virus, Herpesviridae
 Uncertain incubation period (9-10 days)
BY DR M OSAMA HUSSEIN MD

49. Clinical Manifestation
 High fever 39-41 c for 3-4 days
 nonspecific symptom
 bulging AF
 febrile convulsion
 MP Rash after defervescence
 CBC: normal range of WBC, lymphocyte
predominated
BY DR M OSAMA HUSSEIN MD

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51. Erythrema infectiosum (Fifth Dz)
 Parvovirus (PV) B19 Family Parvoviridae
 3-15 year
 Droplet transmission
 Incubation period: 4-14 days
 S/S: lowgrade fever, constitutional symptoms, arthralgia
 Classical 3 phases
 Sunburn-like rash both cheek (classic slapped-cheek
appearance) 2-4
 Day 1-4 after facial rash  macular – to – morbiliform
eruption at extremities (extensor surface)
 Lacy pattern: some w/o classic slapped-cheek pattern
BY DR M OSAMA HUSSEIN MD

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54. Meningococcemia
 N meningitidis: GNDC, bean shape
 Clinical manifestation
 acute febrile illness
 petechiae, hemorrhagic manifestation: purpura
fulminan
 rapid progressive with HT or coma
 meningoencephalitis
 Diagnosis: gram stain, antigen detection, buffy coat
smear and culture
 Treatment: penicillin, CTX, CRO
BY DR M OSAMA HUSSEIN MD

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56. Scarlet fever
 GAS or S aureus: pyrogenic exotoxin (SPE)
 Acute febrile illness with:
 Sore throat
 Gooseflesh or coarse sand-paper rash within 12-
48 hr.
 Most intense at pressure area: axilla, groin
 Pastia’s line
 Strawberry tongue
 Pustule (Staph scarlet)
 Desquamation begins toward the end of the 1st week
BY DR M OSAMA HUSSEIN MD

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58. Scarlet fever
BY DR M OSAMA HUSSEIN MD

59. Scarlet fever
BY DR M OSAMA HUSSEIN MD

60. Scarlet fever
BY DR M OSAMA HUSSEIN MD

61. Staphylococcal scalded
skin syndrome (SSSS/4S)
 Staphylococcus toxigenic strain phage group
2 with epidemolylic toxin A and B
 Start with local infection e.g. purulent
conjunctivitis, otitis media, nasopharyngeal
infection
 Fever, MP rash or erythroderma with
periorificial and flexural accentuation with
Nikolski sign
BY DR M OSAMA HUSSEIN MD

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63. Impetigo contagiosa
BY DR M OSAMA HUSSEIN MD

64. BY DR M OSAMA HUSSEIN MD