One of the most common reasons for office visits in pediatrics: 10-20% visits.

Majority of children presenting with ___ < years old

Fever:

Both minor and life-threatening infectious diseases common in this age group

Respiratory infections

Occult bacteremia

Meningitis

Occult Bacteremia

(Fever)

Protective role in the immune system

Inhibition of growth and replication of microorganisms

Aids in body's acute phase reaction

Enhanced immunologic function of WBC's

Incrase lymphocyte response mitogens

Incrase bactericidial activity of neutrophils

Increase production of interderon

Promotion of monocyte maturation into macrophages

Promotion of lymphocyte activation and antibody production

Decreased availability of free iron for bacterial replication

Fever of Short Duration

Fever without a Focus

Fever of Unknown Origin

Rectal- most accurate

Oral

Tympanic

Axillary (not very accurate)

Fever

Pathophysiology: 3 causes

Raising of hypothalamic set point in CNS

Heat production exceeding heat loss

Defective heat loss

Fever

Raising of hypothalamic set point in CNS

Infection, collagen vascular disease, malignancies

Lowered by antipyretic medications and removing heat

Fever

Heat production exceeding heat loss

Fever

Defective heat loss

Feel better/decrease anxiety

Lower morbidity/mortality

Prevent febrile seizures

Ambient temp control

Light clothing/bedding

Fluids

Sponge bath

Antipyretics

Inhibit cyclo-oxygenase enzyme, prevent synthesis of prostaglandin

Do not interfere with immune response to infection

Fever

Acetaminophen and Motrin

Acetaminophen 15mg/kg every 4-6 hours

Ibuprofen 10mg/kg every 6 hours

Alternate??

Evidence shows some minor benefits in reducing fever faster and lasting loonger BUT...

Potential for dosage/scheduling errors; synergistic renal toxicity; difficult to understand and comply

Detailed information/handout at appropriate reading level on administration of antipyretics should be given to caregivers!!

Guidelines for Evaluating fever in children

See immediately if:

Child is <3mo with fever > 38C

Fever is > 40.6 C

Child is crying inconsolably or whimpering

Child is crying when moved or touched

Child is difficult to awaken

Child's neck is stiff

Purpuric or petechial rash

Child's breathing is difficult and not better after nasal passages are cleared

Child is drooling saliva and unable to swallow anything

A seizure has occurred

Child has sickle cell disease, splenectomy, HIV, chemotherapy, organ transplant, chronic steroids

Child acts or looks "very sick"

History:

Duration

Degree

Additional symptoms

Household contacts

Immunizations

Physical Exam:

General appearance: for experienced clinician, the most important aspect of exam

Vital Signs

Physical Exam:

Temperature

>40C (104F) marker for increased risk of bacteremia

Physical Exam:

Respiratory Rate

Tachypnea out of proportion to fever suggests pneumonia

Physical Exam:

Blood pressure

Pulse rate

Oxygen saturation if available

Physical Exam:

State of hydration

Peripheral perfusion

Detailed mental status exam needed to diagnose CNS infection

Physical Exam:

Head to toe exam

-Physical abnormalities

-Tenderness to palpation

Toxic appearing

Clinical picture consistent with sepsis

Toxic appearance

(Fever)

Toxic appearance

(Fever)

Poor eye contact, failure to recognize parents or interact with environment

Poor perfusion

Toxic appearance

(Fever)

Hypoventilation or hyperventilation

Cyanosis

Toxic appearance

(Fever)

Diagnostics:

Febrile neonates

Diagnostics:

Young infants (fever)

Diagnostics:

Febrile children aged 3 months to 3 years

The clinical management of infants and toddlers with fever is based on their age groups

Management should be individualized based on risk factors, clinical appearance, and clinical judgement

Neonates and young infants: hospitalize with IV antibiotics pending results of laboratory tests and cultures

In the absence of focal findings, any child in the target age group who appears ill or has excessive fever, vomiting, or tachypnea with retractions should be evaluated further.

Meningitis

Sepsis

Bone and joint infections

UTI

Pneumonia

Enteritis

SBI= UTI, bacteremia, meningitis, osteomyelitis, pneumonia, gastroenteritis, cellulitis, septic arthritis

Risk is about 6-10% in these kids, with those younger than 1 month having the highest chance of SBI

Serious Bacterial Illness

Kids under 3 months may present looking like

Fever in infants < 3 mo of age

They are divided into 2 major categories:

Neonates (birth to 28 dyas)

Young infants (29 to 90 days)

12-28% will have a serious bacterial infection

UTI is the most common

Neonates

(Fever)

0-1.2% of all febrile ____ will have bacterial meningitis

0.3% will have HSV

Immature immune system

Exposure to pathogens during delivery (esp GBS)

Cannot mount immune response to prevent localized infection from disseminating

Fever

Infant < 28 days old

Risk of overwhelming sepsis

Clinical evaluation inadequate to determine which

Infants at risk for serious bacterial infection

History:

Associated symptoms may be system specific (diarrhea, cough) or nonspecific (poor feedinig, irritability, lethargy).

Seizures have been reported in 20-50% of ___ with meningitis

Presentation- Neonates

(fever)

History:

Exposure to sick contacts in the household or daycare

Duration of fever

Presentation- Neonates

(fever)

History:

Prenatal and postnatal history

Recent history of a previous illness

Immunization

Antibiotic use

Presentation- Neonates

(fever)

Physical Examination:

Tachycardia

Tachypnea

General appearance should be noted for activity level, color, tone, and irritability.

Physical Examination:

Signs of localized infection should be identified via a thorough examination of the skin, mucous membrane, ear, and extremities.

Phsyical Examination:

Irritability, inconsolability, poor perfusion, poor tone, decreased activity, and lethargy can be signs of a serious infection in this age group.

CBC with differential

Blood Cx

UA

Urine Cx

CSF analysis and culture

Respiratory viral panel for respiratory symptoms

Consider CXR if white count > 20,000, tachypnea, or respiratory symptoms

Stool culture for diarrhea

Admit to hospital

ABCs...consider intubation for respiratory ditress, hypoxia, altered mental status

fluid resuscitation: 20ml/kg IV/IO fluids to total of 60-100 ml/kg (if hypovolemia persists)

Cultures prior to Abx, if possible

Sterilization of CSF can occur as quickly as 15 min - 2 hrs after receiving Abx, so watch results!

Broad spectrum treatment:

Ampicillin + (Gentamycin or Cefotaxime)- avoid Rocephin in kids < 28 days

Vanc? Acyclovir?

Fever Management- Neonates

Ill-appearing neonates

Acyclovir (60mg/kg/d divided every 8 hrs) is recommended for febrile neonates who appear ill, have mucocutaneous vesicles, experience seizures, or have a CSF pleocytosis

Viral cultures and direct fluorescent antigen detection should be performed on skin vesicles and conjunctival, nasopharyngeal, and rectal mucous membranes.

CSF should be assessed for herpes simplex virus (HSV) and undergo polymerase chain reaction (PCR) and viral culture.

28-60

(Young Infants)

History:

PMH

FMH

diet, sleep, intake

Exposure

Vaccination status of pt and contacts

Presentation Young Infant

(Fever)

A thorough review of systems

Vital signs (temperature 30C = 100.4F)

Pulse oximetry

Presentation Young Infant

(Fever)

Presentation Young Infant

(Fever)

CBC with diff

Blood Cx

UA and urine Cx

Stool culture (if diarrhea present)

Pulmonary studies

Lumbar puncture?

Young Infant Management

Empiric antibiotics

Ampicillin and gentamicin, or ampicillin and cefotaxime for the neonate, covers GBS, E. coli, Listeria, and most S pneumoniae and N meningitides.

For infants aged 1-2 months, recommended empiric coverage includes ampicillin, cefotaxime, and vanco,ycin

For infants older than 2 months, vancomycin and cefotaxime

Management of Fever in Young Infants

Well-appearing and relatively well-appearing infants

Infants older than 28 days who look well and whose history, PE, and laboratory evaluation findings classify them as low risk can be treated as outpatients with ceftriaxone (50mg/kg in a single intramuscular dose), as long as 24-hour follow-up can be ensured.

Infants older than 28 days who are diagnosed with bronchiolitis or influenza and are relatively well-appearing should undergo a limited laboratory evaluation, including complete blood cell (CBC) count with differential, blood culture, urinalysis, and urine culture. if the CBC ount and urinalysis findings are benign, these pts can be initially managed without antibacterial therapy.

History of present illness:

Documantation fo the child's temperature and how it was measured is essential.

Onset and duration of fever.

History of present illness:

Additional symptoms (diarrhea, vomiting, rhinorrhea, cough, rash, changes in appetite, weight loss, changes in frequency of voiding, pain with voiding, failure to bear weight, pain on passive motion of an extremity, and overt neurologic symptoms.

Past medical history:

Underlying chronic disease, previous surgery, histroy of UTIs, and incomplete immunization to Streptococcus pneumoniae or Haemophilus influenzae type B

In children < 9 months, neonatal and perinatal history

FHX

Social Hx and household contacts

Physical Examination:

Rash, conjunctivitis, ear pain or drainage, lymphadenopathy, respiratory symptoms, general state of nutrition, level of activity, and level of arousal

Ill appearance, fever, vomiting, tachypnea with retractions, and delayed capillary refill.

(Fever- 3 months to 3 years)

CBC, Blood Cx

UA, Urine Cx

CXR and other imaging based on Hx and PE

6

2

(Evaluation and Management of fever 3-36 months)

Empiric antimicrobial therapy in non-toxic children aged 3 months to 3 years is NOT recommended.

For those requiring hospitalization, antimicrobial therapy must provide coverage against the suspected pathogens- Ceftriaxone

Length of illness

Use of antipyretics (**defervesence after use does NOT exclude bacteremia!)

Sick contacts

PO intake/output

Vaccination status

Any meds/Abx

Localized symptoms

HA

neck pain

sore throat

pulling at ears

cough (describe)

wheezing

vomiting

rash

dysuria, frequency, hesitancy

mental status

The febrile child older than 36 months (who has been previously fully immunized) is primarily evaluated by obtaining a history and performing a physical examination.

Specific workup and/or treatment is based on the clinical findings and suspicion of disease..

SxS

HA

Fever

Sore throat

Prutitus

SxS

Coryza

Abdominal pain

Arthralgias

Erythema Infectiosum

Occurrence in the United States

Erythema Infectiosum

Occurrence in the United States

Erythema Infectiosum

Occurrence in the United States

Erythema Infectiosum

Erythema Infectiosum

Phase 1

Erythema Infectiosum

Phase 2

Erythema Infectiosum

Phase 3

IgM assays- Exyme-linked immunosorbent assay (ELISA), radioimmunoassay (RIA)

Dot blot hybridization

Polymerase chain reaction (PCR) assay

Loop-mediated isothermal amplification

Reassure parents

Symptomatic relief

(Rubeola virus)

Rubeola (Common Measles)

Incidence:

In 1996 488 cases reported, 138 in 1997, < 50 in 2004, previously erradicated in US

Recent outbreak in US

Still a major disease overseas

7-21 days incubation

Infectious 4 days before until 4 after the rash

Measles

Measles

Measles virus

Measles virus

Complications:

Dehydration

Encephalitis (1:2,000 cases)

-Confusion

-Ataxia

-Persistent  vomiting

-Seizures

-Coma

Treatment is supportive. The World Health Organization recommends vit A for all children with acute measles, regardless of their country of residence, to reduce the risk of complications. Vit A administered once a day for 2 days at the following doses:

50,000 IU for infants aged <6 months

100,000 IU for infants aged 6-11 months

200,000 IU for children aged ≥ 12 months

An additional (third) age-specific dose of vit A should be given 2-4 weeks later to children with clinical signs and symptoms of vit A deficiency. Parental and oral formualtions of vit A are available in the US

PREVENTION- VACCINATION

Rubella

Symptoms last- 2-3 days

Rash that starts on the face and spread to the rest of the body

Symptoms:

low fever (less than 101 degrees)

Post auricular, occipital adenopathy

Symptoms:

Arthralgias

About half of the people who get rubella do not have symptoms

Complications:

Birth defects if acquired by a pregnant woman: deafness, cataracts, heart defects, mental retardation, and liver and spleen damage (at least a 20% chance of damage to the fetus if a woman is infected early in pregnancy)

Deafness

Cataracts

CHD's

Complications:

"Blueberry muffin baby

Petechiae

Jaundice

Neuro deficiencies

Deafness

Encephalitis

Pneumonia

????

Rubeola

Symptoms include:

Fever

HA

Muscle Aches

Symptoms include:

Tiredness

Loss of appetite

Swollen and tender salivary glands under the ears on one or both sides (parotitis)

Complications:

The most common complication is inflammation of the testicles (orchitis) in males who have reached puberty.

Complications:

Inflammation of the brain and/or tissue covering the brain and spinal cord (encephalitis/meningitis)

Complications:

Inflammation of the ovaries (oophoritis) and/or breasts (mastitis) in females who have reaches puberty

Deafness

Bacterial Meningitis

In older kids, Streptococcus pneumonia (pneumococcus) and Neisseria meningitis (meningococcus) are more often the causes.

Haemophilus influenza type b (Hib)

Symptoms:

Fever

lethargy (decreased consciousness)

Irritability

HA

Photophobia (eye sensitivity to light)

Symptoms:

Stiff neck

Skin rashes

Seizures

extreme irritability, lethargy, or fever

jaundice (a yellowish tint to the skin)

Stiffness of the body and neck

Fever or lower-than-normal temperature

Poor feeding

A weak suck

A high-pitched cry

Diagnostics:

CBC (WBC/differential)

Cultures

Lumbar puncture

H&P cannot reliably differentiate

WBC may be helpful

Bacterial vs. Aseptic

Meningitis

Bacterial vs. Aseptic: Meningitis

CSF analysis is most helpful

Bacterial: ___

Viral: ___

glucose low; norm is 1/2-2/3 of serum glucose

glucose normal (40-80mg/dl)

Bacterial vs. Aseptic: Meningitis

Culture of CSF: cell count:

Bacterial:

Viral:

1,000-50,000 (neutrophils)

< 1,000 mostly (lymphs)

Complications:

Seizures

Permanent brain damage (CP, MR, deafness) in up to 50% of cases

Death (5-20% mortality for pneumococcal, 50% in neonatal E. coli, 50% forsevere meningococcal cases)

< 1 month of age: Ampicillin IV 200-300mg/kg/d divided q 6-8h

> 1 month: Vacomycin IV 60mg/kg/d divided q 6h, cefotaxime or Ceftriaxone

Viral: supportive

Prognosis: Fatality 100% if untreated; viral - quite good

Epidemiology:

Occurs throughout the year

Commonly affects children 3 months to 4 years

The peak age 7 to 13 months

Epidemiology/;

90% of cases occur in the fiirst 2 years of life

Affects males and females equally

Incubation period is 5 to 15 days

Clinical Manifestation:

Rash appears as fever disappears and last 1 to 2 days cough

Coryza

Clinical Manifestation:

Children remain alert and are not ill appearing

Eyelid edema has been noted

Lymphadenopathy

Exanthem:

Fine, discrete maculopapules

Begins on trunk, spreads to extremities, face

Few hours to 1-2 days

Diagnosis:

Clinical

History very important (telltale rash)

Complications:

Febrile seizures due to high fever

Enterovirus family

Coxackie virus A16 infection

Epidemiology:

Minor epidemics in summer and fall

young children, aged 1-5 years

Spread by direct contact

Presentation:

Prodrome of mild fever and malaise, resolves before rash

Exanthem:

Vesicles or red papules on oral mucosa, hands, and feet

Resolves in 1-2 days

Diagnostics: History and PE

Complications: dehydration

Reassurance

Supportive care

Pharyngitis may be present

Examination of the lungs may reveal fine crackles.

Diagnostics:

Has been detected via culture (human fibroblast), serologies, antigen assays, polymerase chain reaction (PCR), and cytopathology.

Imaging

Supportive therapy

Ganciclovir

Foscarnet

Symptoms:

Fatigue

Fever

Inflamed throat

Swollen lymph nodes in the neck

Symptoms:

Enlarged spleen

swollen liver

Rash

Epstein-Barr virus (EBV)

Diagnostics:

CBC

Mono Spot

EBV specific serologies

Epstein-Barr virus (EBV) Management

Supportive

No physical activity

Corticosteroids

History:

Tick bites

Rash

Other symptoms (fatigue, HA, fever, chills, arthralgias)

Joint pain

SxS

Erythema migrans (EM)- rash

Fever

SxS

Myalgias

Malaise

Arthralgia

HA

 Tender local adenopathy (local, not diffuse)

ELISA

Western Blot

PCR

Lyme Disease

For serologic testing, the CDC recommends a two-tier testing procedure, as follows

Step 1: EIA or ELISA - total lyme titer or IgG and IgM titers

Step 2: Western blot testing

Children over 8 with early localized or early disseminated lyme disease associated with erythema migrans: Doxycycline, amoxicillin, or cefuroxime axetil

Children under 8 years and pregnant or nursing women

with early localized or early disseminated lyme disease: Amoxicillin or cefuroxime axetil

Neurologic lyme disease: Iv penicillin, ceftriaxone, or cefotaxime; oral doxycycline, when not contraindicated, in pts with lyme-associated meningitis, facial nerve palsy, or radiculitis

Chronic arthritis may require anti-inflammatory medicatioin or joint injection with steroids.

Haemophilus Influenza Type B (Hib)

Prevention:

Clinical Findings:

Meningitis

Acute Epiglottitis

Septic arthritis

Cellulitis

Leading cause of acquired heart disease in children in the US

Children under age 5 years

Physical Exam:

Often scarlatina-like rash < 24hrs after fever appears

Physical Exam:

High fever (over 103F) for at least 5 days

Physical Exam:

Marked erythema of conjunctivae, oral mucosa, tongue, lips (strawberry tongue)

Physical Exam:

Cervical lymphadenpathy

Lymph edema- accumulation of tissue fluid, peeling hands and fingers

Kawasaki Disease

Diagnostic Criteria

Fever for 5 or more days with 4 of the following changes

Bilateral conjunctival injection

Pharyngeal injection

Dry fissured lips, injected lips, strawberry tongue

Cervical lymphnapthy (greater or equal to 1.5cm in diameter, usually unilateral)

Polymorphus exanthema

Extremity changes (redness, swelling, desquamation))

Associated arteritis can cause coronary artery thrombosis and MI:

20% get cornary aneurysms

1-2% die from MI