Catastrophic Case Report
Pediatric Fever Death
8 month old child:
∙ Temp 40.3°C . . . HR 199
∙ Looks well
∙ No Treatment, discharged
∙ Sudden Death 48 hours later
PAEDIATRIC FEVER 3-36 MONTHS:
RECOMMENDATIONS FOR EVALUATION
A Report from the FH Patient Safety Review Committee
Report Prepared May 2008
CONFIDENTIAL for Quality Improvement Purposes only.
This material is designed to provide FH clinicians involved in the development of the Guideline with a starting point.
Further consultation with key stakeholders and adoption of a uniform FH guideline will occur in the next 3-6 months.
PAEDIATRIC FEVER 3-36 MONTHS: A CLINICAL APPROACH
Case Summary
An eight month old was brought to the Emergency Department for assessment of fever and grunting. The
temperature was 40.3 and 199. The RN was concerned and highlighted the vital signs in red. The Emergency
Physician felt that the child looked well and was non toxic. The examination was brief and the infant was
discharged. The child remained listless for two days, became lethargic and suddenly died as the family
prepared to return to the ED. Case review found: there was no suspicion of significant illness. The Emergency
Physician’s examination was abbreviated. Discharge instructions minimal; Tylenol and follow up with FP after
the weekend (approximately 60 hours later). The child likely died from complications of pneumonia.
The key Recommendation was that:
Fraser Health endorse and disseminate a “Best Practice Guideline” for the care
of febrile children.
Background
Fever accounts for 10-20% of paediatric clinic visits. Despite nationally published treatment guidelines,
evaluation and treatment of febrile infants and young children is inconsistent. Some of the observed variance
is a result of a reducing incidence of Pneumococcal and Haemophilis influenzae infections with newer
immunizations (Prevnar/HIB). This review focuses on children aged 3-36 months, and reflects some recent
changes in the approach to the febrile child.
Temperature above 38°C and Bacteremia
Fever is defined as a rectal temperature greater than 38°C. Twenty percent of childhood fevers have no
apparent cause but a small but significant number of these patients may develop a serious bacterial infection
(SBI). The risk is greatest among febrile infants and children younger than 36 months.
“A small but significant number may develop a serious bacterial infection”
Initial evaluation is directed at identifying serious bacterial infections (SBI) or those at high risk for occult
bacteremia (OB). Physical examination and patient history do not always identify patients with SBI or OB.
SBIs that are not recognized promptly and treated appropriately can cause significant morbidity or mortality.
Since the 1980’s, management decisions for 3-36 month children has been based on the degree of toxicity
and the height of temperature. Most algorithms were based on fevers greater than 39.5°C defining a higher
risk group. These cases represent about 2% of all Paediatric visits.
Some authors argue that, with immunization against Haemophilis (HIB) and Pneumococcus (SPn), risk
stratifying based on fever may no longer be needed except temperatures over 40°C.
Report Prepared May 2008
CONFIDENTIAL for Quality Improvement Purposes only.
This material is designed to provide FH clinicians involved in the development of the Guideline with a starting point.
Further consultation with key stakeholders and adoption of a uniform FH guideline will occur in the next 3-6 months.
Evidence: Bacterial Infections in febrile 3-36 month children
(before HIB/Prevnar)
A pre-HIB/SPn immunization study found temperatures of 39-39.5°C correlated with a 2-4% risk of occult
bacteremia (OB). Those with temperatures higher than 39.5°C had a 5% chance of having OB. Other studies
confirmed that 2.5-3% of highly febrile children younger than 3 years (greater than 39.0°C) had OB (typically
S pneumoniae).
Another pre- HIB/SPn study, found that 6.5% of 3-36month patients with a temperature of 39.0°C or more
had a UTI. E coli is the most common cause of UTIs. Approximately 15% of end-stage renal disease is
believed to be related to undertreated childhood UTIs.
6.5% UTI risk with temp>39.0°C
Report Prepared May 2008
CONFIDENTIAL for Quality Improvement Purposes only.
This material is designed to provide FH clinicians involved in the development of the Guideline with a starting point.
Further consultation with key stakeholders and adoption of a uniform FH guideline will occur in the next 3-6 months.
Suggested Approach 2008 – T>38°C in a 3-36 month child:
In general febrile 3-36 month children do not require work up if they are; healthy prior to onset of fever,
appear nontoxic and are otherwise healthy with reliable “informed” caregivers.
Clinical Evaluation should include the following:
•
•
•
1.
Vital signs: rectal temperature, heart rate, respiratory rate, blood pressure, pulse oximetry.
Focused examination – identifying: toxic appearance, a focus of infection (e.g. otitis media,
pharyngitis), identifiable viral infection, petechial or purpuric rashes
Risk stratification
Risk Stratification; High Risk children have any one of the following:
•
•
•
Incomplete HIB or Pneumococcus vaccine (less than 4 doses SPn)
Temperature greater than 40°C
Toxic appearance
The Yale Observation Scale is another method for determining degree of toxicity in febrile children.
•
It consists of six variables: quality of cry, reaction to parent stimulation, state variation, color,
hydration, and response. A score of 10 or less has a 2.7% risk of serious bacterial infection. A score
of 16 or greater has a 92% risk of serious bacterial infection.
Observation
Items
1
(Normal)
3
(Moderate Impairment)
5
Severe Impairment)
Quality of cry
Strong with normal tone or
contentment without crying
Whimpering or sobbing
Weak cry, moaning, or
high-pitched cry
Reaction to
parent
stimulation
Brief crying that stops or
contentment without crying
Intermittent crying
Continual crying or
limited response
Color
Pink
Cyanotic or pale extremities
Pale or cyanotic or
mottled or ashen
State variation
If awake, stays awake; if asleep,
wakes up quickly upon
stimulation
Eyes closed briefly while
awake or awake with
prolonged stimulation
Falls asleep or will not
arouse
Hydration
Skin normal, eyes normal, and
mucous membranes moist
Skin and eyes normal and
mouth slightly dry
Skin doughy or tented,
dry mucous membranes,
and/or sunken eyes
Response
(e.g. talk, smile)
to social
overtures
Smiling or alert (<2 mo)
Briefly smiling or alert
briefly (<2 mo)
Unsmiling anxious face or
dull, expressionless, or
not alert (<2 mo)
Report Prepared May 2008
CONFIDENTIAL for Quality Improvement Purposes only.
This material is designed to provide FH clinicians involved in the development of the Guideline with a starting point.
Further consultation with key stakeholders and adoption of a uniform FH guideline will occur in the next 3-6 months.
2.
Targeted Investigations
Testing is based on assessment and high-risk factors. General recommendations are:
Very ill appearing, any Temp:
•
Intravenous (IV) or intramuscular (IM) antibiotics, once urine and blood specimens are obtained
(delay LP in child with altered mental status as risk cerebral herniation).
“Toxic” appearing T >38.0°C:
•
CBC diff, Blood cultures, UA and urine culture based on the following:
o All males younger than 6 months and all uncircumcised males younger than 12 months
o All females younger than 24 months and older female children if symptoms suggested a UTI
o Consider LP
Non toxic T 38-39.4°C with high-risk factor or temp>39.4°C:
•
•
•
CBC/diff.
Blood cultures; if WBC >15,000 or neutrophils >10,000
Urinalysis/C&S clean catch or:
by bladder catheterization based on the following:
o all males < 6 months
o uncircumcised males < 12 months
o all females < 24 months
•
Lumbar Puncture-CSF studies/culture.
Non toxic T 38-39.4°C No high-risk factor:
•
•
•
History, Examination, Antipyretics and “Optimal Observation”
Aftercare instructions
Planned reassessment (includes ER, Pediatrician or FP)
Chest Radiograph
Chest radiography is indicated when the patient has tachypnea, retractions, local auscultatory findings, or
oxygen saturation level in room air of less than 95%. Although viral etiologies are considered the cause of
most paediatric pneumonias, establishing a viral or bacterial etiology may be challenging.
•
Chest radiographs should be considered if the WBC count is more than 20,000. (One study found a
high correlation with WBC > 20,000 even with a lack of findings suggestive of pneumonia.)
Report Prepared May 2008
CONFIDENTIAL for Quality Improvement Purposes only.
This material is designed to provide FH clinicians involved in the development of the Guideline with a starting point.
Further consultation with key stakeholders and adoption of a uniform FH guideline will occur in the next 3-6 months.
3.
Optimal Observation/Disposition:
Administer antipyretic and observe the child for an hour or two while observing child’s appearance, behaviour,
temperature and awaiting any diagnostics results.
Medical Care Summary: 3-36 months Fever >39.4°C Without a focus:
Not Toxic:
• Consider no antibiotics; however, if absolute neutrophil > 10,000, consider ceftriaxone (50
mg/kg/dose).
• Schedule a follow-up within 24 hours and instruct parents to return sooner if the condition worsens.
• Hospital admission is indicated for children whose condition worsens or whose evaluation findings
suggest a serious infection.
Toxic:
• Admit child for further treatment; pending culture results, administer parenteral antibiotics.
• Initially administer ceftriaxone, cefotaxime, or ampicillin/sulbactam (50 mg/kg/dose).
Developing a practice guideline for fever in 3-36 month children
A clinical guideline or clinical practice guideline is a document with the aim of guiding decisions and
criteria regarding diagnosis, management, and treatment. In contrast to previous approaches, which were
often based on tradition or authority, modern medical guidelines are based on an examination of current
evidence within the paradigm of evidence-based medicine. When evidence is lacking (double blind controlled
studies defining Number needed to treat-NNT and Relative Risk Values-RRV), best practice can be defined as
our best current understanding of gold standard care.
The primary objectives of clinical guidelines are to standardize and raise the quality of care, to reduce risk (to
the patient, to the healthcare provider, to the health authority) and to achieve the best balance between cost,
effectiveness, specificity, sensitivity, etc. It has been demonstrated repeatedly that the use of guidelines by
healthcare providers is an effective way of achieving improvement.
While Quality/Safety initiatives must guard against making broad generalizations when evidence is not robust,
the patient safety imperative necessitates thoughtful assertive responses to “Sentinel Events”. Ethical
decision making while respecting the risk of over-reaction can drive good guideline practice to choose a point
and begin improving.
While the guideline proposed is not perfect, nor derived from pure evidence, it represents a synthesis of
current literature and opinion. It is a starting point and an improvement from no start at all.
Report Prepared May 2008
CONFIDENTIAL for Quality Improvement Purposes only.
This material is designed to provide FH clinicians involved in the development of the Guideline with a starting point.
Further consultation with key stakeholders and adoption of a uniform FH guideline will occur in the next 3-6 months.
Suggested Guidelines for Management of 3-36 Month Paediatric Fever
Temperature Range
38.0°C< 39.4°C
39.5°C-40°C
40°C+
38°C-40°C+
(1A / 1B)
(2)
(3)
(4)
Non-Toxic /
No High Risk
Non-Toxic /
High-Risk Factor
Non-Toxic /
No High Risk
All
Toxic /
High Risk Factor
Consider
▪CBC diff
▪UA/C&S
▪ CBC/diff.
▪ Blood cultures if:
WBC >15,000 or
PMN’s >10,000
▪ CBC/diff.
▪ Blood cultures if:
WBC >15,000 or
PMN’s >10,000
▪ Blood cultures if
WBC > 15,000
UA/C&S
▪ Consider LP
UA/C&S
▪ Consider LP
Consider CXR as in
1B
CXR in many as in
1B/2
CXR
▪ Consider no
antibiotics; (if
absolute neutrophil
>10,000, consider
ceftriaxone50 mg/kg/dose).
▪ Schedule follow-up
within 24 hours and
instruct parents to
return sooner if
condition worsens.
▪ Hospital admission
is indicated if
condition worsens
or findings suggest
serious infection.
▪ Admit;
▪ Parenteral
antibiotics.
▪ Ceftriaxone,
cefotaxime, or
ampicillin /
sulbactam
(50 mg/kg/dose).
Evaluation
Examination
Antipyretic
Observation
Advice
Follow-up
Consider
▪ CBC diff
▪ Blood cultures
▪ Urinalysis
(UA)/C&S:
- males <6 months
- uncircumcised
males
<12 months
- females <24
months
Consider CXR if:
↑ RR , retractions,
auscultatory Δ, or
Sa02 < 95% (and
possibly WBC count
>20,000).
Management
Expectant
with advice,
after-care
instructions
and recheck
▪ Consider no
antibiotics; (if WBC
>15000 or absolute
neutrophil >10,000,
consider
ceftriaxone50 mg/kg/dose).
▪ Schedule follow-up
within 24 hours and
instruct parents to
return sooner if
condition worsens.
▪ Hospital admission
is indicated if
condition worsens
or findings suggest
serious infection.
Report Prepared May 2008
Expectant with
advice, after-care
instructions and
recheck
▪ Consider no
antibiotics; (if
WBC >15000 or
absolute
neutrophil
>10,000, consider
ceftriaxone50 mg/kg/dose
+< 24 hour
follow-up).
CONFIDENTIAL for Quality Improvement Purposes only.
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