Fever in Children
Temps
Axillary 1deg lower than core; TM’s unreliable
<3/12, appears ill:
SBI 13-21%
<3/12, UTI:
SBI 30%
<3/12, appears well: SBI <5%
(Neonates have 2x risk of SBI than 4-8/52)
Height of fever irrelevant; may be hypothermic; concern if >38; those <3/12 with viral illness have significant incidence of
UTI, so still need to do urine
Any fever = 10% SBI
T >40 = 40% SBI (UTI most common)
>3/12, UTI: SBI 5%
3-6/12: SBI <1%; UTI in 3-8%
Definitions
Fever
bacteria
6/12 – 2yrs: T<38.9 = 1% bacteraemia
UTI most common cause of fever without focus
T >39 = 3% (concerning fever)
T >40 = 10%
WCC >15 + fever = 10%
3-36/12 + febrile + appear well = 0.5-0.7% sepsis
SIRS:
T >38 / <36
+ HR >160 (infants) / >150 (children)
+ RR >60 (infants) / >50 (children)
+ WCC >12 / >10% band forms
Severe sepsis: above + hypotension (<65 infants, <75 children, <90 adolescent)
Simple febrile convulsion: 6/12 - 5yrs; T >38.5; generalised seizure; short post-ictal period; 1 seizure / fever; duration
<15mins; no FND afterwards
In order of commoness:
Sepsis
Neonate
Pneumonia
.
Gp B Strep (30%), E coli (30-40%)
N meningitidis > Hib > Strep pneumoniae
Listeria, Enterococci, C trachomatis, klebsiella
Other G-ive 15-20% (eg. Klebsiella), G +ive 10%
Herpes simplex; enterovirus, RSV, influenza A
<3/12
N meningitidis > Hib > Strep pneumonia
Grp B strep > E coli > Listeria
.
Strep pneumonia, Staph aureus, Hib
Chlamydia trachomatis
RSV > other viruses
Bordatella pertussis
.
RSV > parainfluenza > other viruses
<1yrs
Strep pneumoniae > Hib, S pyogenes, Staph aureus
C trachomatis
M pneumoniae
<5yr
N meningitidis > strep pneumonaie > Hib
.
Viruses (90%)
S pneumonaie > Hib
M pneumoniae
C pneumoniae
S aureus, B pertussis
>5yr
N meningitidis > strep pneumoniae
M pneumoniae
S pneumonaie
C pneumoniae
Hib/a
Adenovirus > other viruses
S aureus, Legionella
Neonate: Vertical transmission more likely; higher mortality
Immunocomp, neurosurg, trauma: Staph, gram negs, cryptococcus neoformans
Developing: mycoplasma TB
Brain abscess: strep viridans, anaerobes, G negs, staph aureus
Chronic lung disease (pneumonia): CF: S aureus, pseudomonas
SCA: encapsulated
.
.
Febrile
convulsions
UTI
Meningitis
Immunocomp: pneumocystis, aspergillis, histoplasma (nodular on CXR), CMV, fungi
Epidemiology: in 3-5% children; 30-40% recurrent esp if <1yr; 3% go on to suffer epilepsy; have no effect on CSF WCC
LP in first febrile convulsion: if you think it’s meningitis, trt and do LP when improve
Pros: mental state difficult to assess post-ictally; fulminant infections require early diagnosis; quick
Cons: <5% have meningitis; traumatic to child / family; may cause meningeal seeding if bacteraemia; coning
Mng: seek cause of fever; seek concurrent Abx; investigate as per usual fever; consider need for Ca / glucose / pyridoxine
Remember: weight = (age + 4) x 2
or
>10yrs = age x 3
1. Diazepam 0.25mg/kg IV / 0.5mg/kg PR
Midazolam 0.15mg/kg IV / IM
0.3mg/kg buccal
2. Repeat after 5mins
3. Phenytoin 18mg/kg over 30mins
will be slow at controlling seizures
Phenobarbitone 18mg/kg over 30mins
4. Thiopental 5mg/kg IV + RSI
If no IV access: paraldehyde 0.3mg/kg PR (good if mentally handicapped / recurrent seizures)
Prognosis: incr risk of febrile convulsion recurrence if: repetitive seizures, focal features, onset <1yr, brief duration
between fever onset and seizure; FH; lasted >15mins; >1 seizure in 24hrs
DD: Infantile spasm: sudden brief flexion of arms, head and trunk, occuring in clusters
Breath-holding spells: noxious stimulus; after brief cry / vigorous crying
Benign neonatal sleep myoclonus / Benign focal epilepsy of childhood / Nocturnal frontal lobe seizures
/ Night terrors
Epidemiology: incidence 5% children age 3-24/12 with fever; affects 1% boys, 3% girls before puberty; F:M 3:1 (except in
neonates); circumcised:unC 10:1; most common SBI; present in 3-8% young children presenting with fever and no
obvious source; 5-10% with symptomatic UTI will develop renal scarring ( HTN, CRF, eclampsia) and bacteraemia;
systemic sepsis in 30% 1-3/12, 5% >3/12; 2% children have asymptomatic bacteruria which is not cause for
presentation; pyelo suggested if T >39 and +ive urine; 10% young infants with UTI have sterile WCC in CSF
Pathophysiology: haematogenous seeding in neonates; ascending otherwise; cystitis can cause vesicoureteric reflux
Bacteria: 84% E coli, 6% proteus, 5% klebsiella, 3.5% enterococcus; G+ives in older boys and children with underlying
medical conditions
Ix: Urine: always send for culture if suspect UTI; always send for microscopy regardless of result of dipstick (unless low
risk and negative dipstick); do repeat urine at 10/7 to ensure clearance
Nitrites:
40% sens (doesn’t develop with G+ives)
95-99% spec
WBC dipstick:
70-80% sens; Gram stain 80-97% sens
80-90% spec
sens decr if <2yrs
WBC:
50-90% sens
50-90% spec
Bacteria:
50-90% sens
10-90% spec
Microscopy: 15% false negative rate; significant number missed; may get mod leucs in 40% febrile children without UTI
MSSU: good sens, positive if WCC >5-10
Bag spec: unreliable; if negative still needs to be sent for culture (unless low risk and well)
Catheter: positive if WCC >1-5
SPA: positive if WCC >0; must have at least 15ml on USS, go 1cm superior to pubic symphysis with 23G needle;
50% success rate blind, 95% with USS guidance
Blood: do blood culture if positive urine and <1yr, or ill enough to require admission
LP: consider if <1/12
Renal USS: do in all children with 1st UTI, 3-6/52 after infection; also do if sibling of child with VUR; abnormalities found
in 40%; obstructive lesions found more commonly in young (<3/12)
DMSA scan: do after 6/12 or at age 3-4yrs to look for scarring if required hospitalisation
MCU: do if <3/12 or if abnormal USS
Admit if: <6/12, septic, signficant underlying disease, urinary obstruction, pyelonephritis, failure to respond to PO’s
Prophylaxis: give if recurrent UTIs, <3/12 awaiting MCU, known VUR or other renal abnormality; continue until after
USS; give 2mg/kg co-trimoxazole or 3mg/kg nitrofurantoin nocte or 5-10mg/kg cefaclor nocte
Epidemiology: 90% occur <5yrs; 4.5% mortality; 10-20% intellectual / auditory complications; asymptomatic N
meningitidis nasal carriage in 10%; meningococcal sepsis bimodal (0-4yrs, 15-25yrs); <3/12 + febrile = 1% incidence
Pathophysiology: usually haematogenous spread from URTI; can also be direct (eg. OM), inj
Risk factors: young, male, low SEG, congenital abnormalities, shunt, trauma, immunocomp
Assessment: may be afebrile / hypothermic; bulging fontanelle is late finding and masked by dehydration; signs of
meningeal irritation may be absent <18/12; FND in 15% (30% pneumococcus); seizures in 30% (with worse than expected
mental status after); 15-20% decr LOC (more in pneumococcus); subdural effusion / empyema (30% in Hib, 20% in strep);
may deteriorate after Abx (bacteriolysis  inflamm); beware partially treated meningitis (more frequent V, longer
duration of Sx); suspect encephalitis if seizures / altered LOC / behaviour; early purpura may just be erytematous
macules
LP: consider pre-oxygenation before LP; use non-styleted needle in small infants; neck in mid-flexion
CSF interpretation: CSF protein incr 0.01g for every 1000 RBC; lymphocytes >50% in 10% bacterial meningitis; Gram
stain 80% sens (50% if pre-treated); may mistake G+ive for G-ive if pre-treated; nearly 100% mononuclear when
viral (may be more PMN’s if <48hrs); visible budding MO’s on Indian ink staining = cryptococcal; CSF Ag tests have high
sens and spec (esp for Hib and N meningititis)
CT before LP if: FND, decr LOC
CI to LP: signs of incr ICP, coma, FND, focal seizures, seizures >30mins, haemodynamically unstable, significant resp
compromise, purpura, coagulopathy, decr plt, localised skin infection
Opening p
WCC
%PMN
PMN (neut)
MMN (lymph)
Protein
Glu
Glu % serum
RBC
Gram Stain
Culture
Pneumonia
Assessment
N neonate
5
<30
<2
<5
<20
<0.3
>2.5
50
<2
N child
8.5
<5-10
0
0
<5
<0.4
>2.5
>40
<2
Bacterial
Prtl trted
Viral
Encephalitis
TB
200-10,000
Up to 100%
>100-10,000
<100
Up
Low
200-5000
Lower
>10-100
Higher
N / Up
N / Low
100-700
Low
<100
>100
0.4-1
N
<500
100-500
<100
Up
0.4-1
N
High early
High late
Up ++
Low late
.
.
.
.
.
+
+
+/+/-
-
+ late
Other Ix: bloods; meningococcal PCR; Ag studies on blood and urine; throat swab for N meningitidis
Mng: if shocked, 10-20ml/kg N saline; SIADH in 30% so use 50% maintenance after resus; trt seizure, fever, hypoG,
hypoNa (fluid restriction if Na <135), incr ICP
Abx: give Abx before LP if there will be >20min delay to LP
Dexamethasone: 0.25mg/kg (max 10mg) IV/IM Q6h for 48hrs; use if >1/12 to decr host response to bacteria and
decr deafness; give at least 15-30mins before (or within 1hr of Abx); best in Hib + pneumococcal, but use in all
Contact prophylaxis: meningococcus / Hib – give rifampicin 10mg/kg BD x4 (CI’ed in pregnancy and liver disease;
ceftriaxone IM or ciprofloxacin PO if CI’ed); contact = family and household contacts, those exposed to oral secretions,
sexual partners, health care workers, staff and children at pre-school in last 10/7
Epidemiology: up to 40% are mixed; viral more common than bacterial; strep pneumoniae most common bacterial cause
(esp <5yrs); mycoplasma up to 30%
History: if neonate, ask about mother’s pre- and peri-natal health inc infections and fever, PROM, peri-partum
complications, meconium; wheeze in young infant = bronchiolitis, in child = mycoplasma
Atypical pneumonias (eg. Mycoplasma, C pneumoniae)  non-specific appearance, wheeze, hacking dry cough,
arthralgia, rash (in 10%), indolent course, Kawasaki syndrome, erythema multiforme, GBS; on XR
bronchopneumonia, hilar adenopathy, plate like atelectasis
Staph  rapidly progressive Sx  high fever, toxic, abscesses, cavitations, pleural effusions, empyema,
pneumatocoele
C trachomatis  staccato cough, diffuse rales, no fever, sore throat
B pertussis  paroxysmal coughing, gasping, colour change (apnoeas and bradycardias), URTI
Pneumococcal  round pneumonia (should have FU to ensure resolution)
If severely unwell: ?staph aureus, grp B strep
If underlying lung disease: ?Hib
Apnoeas: more common in RSV, chlamydia, B pertussis
Effusions: strep pneumoniae most common cause; also mycoplasma, Hib
Examination: toxic appearance has better sens than other parts of exam; SaO2 <90% OA incr risk of trt failure with PO
amox; fever + incr RR / decr BS / fine crackles predicts XR positive pneumonia with 93-96% sens; fever + all 3 = 98% sens;
absence of incr RR, resp distress, rales and decr BS excludes pneumonia in 100%; SOB is best sign to rule out
Bloods: blood culture +ive in <5% (30-40% if parapneumonic effusion / empyema); NPA helpful to identify virus in
younger, mycoplasma in older; mycoplasma cold agglutinins 72-92% sens
CXR: cons: may be false –ive / +ive; may be poor quality image; cost; delay; exposure to radiation; can’t distinguish
between bacterial and viral
Indications for CXR: toxic appearance with resp findings; <3/12 as part of septic screen; <5yrs with T >39, WCC >20 and
no source; ambiguous clinical findings; ?complication; not responding to Abx; ?congenital lung malformation; FU of
round pneumonia; specific exam findings suggesting pneumonia
Admission criteria: <6-12/12, toxic, altered LOC, complicated pneumonia, hypoxia, unrelieved resp distress; inability to
feed; co-morbidities, dehydration, not tolerating PO Abx, social issues
If find source, still do extensive search esp if <3/12; after fever reduction, no difference between appearance of
bacteraemic and non-bacteraemic child (fever reduction may mask signs of severe infection); ask about birth history,
peri- or neonatal complications; all criteria missed SBI in those <1/12
Rochester Criteria: if <60d and well looking, no peri-partum or prior illness, normal FBC, urine and CXR– SBI excluded;
Investigation
Mng
Antibiotic
choice
will miss 1% SBI; least sensitive of the 3
Philadelphia Protocol: if 29-56d and well looking, no immunodef, normal RBC, urine, CXR and CSF; sens 98%, spec 44%
Boston Criteria: if 28-89d and well looking, no recent immunisations / Abx, WBC <20, normal urine, CXR and CSF; >99%
sens
<1/12, appears well: FBC, blood culture, urine, CSF, CXR; stool if diarrhoea; admit and give Abx
<3/12, appears well: as above; can discharge if WCC <15, urine –ive, CSF WBC <10, normal CXR; admit and treat
otherwise
<3/12, ?bronchiolitis: still need to do urine
<3/12, ?viral: still need to do urine and bloods
>3/12, appears well: urine; discharge if negative
If unwell: admit and trt
Septic screen: do if: 3/12 or under
Concurrent Abx use and fever without focus
Toxic appearance
Bloods: WCC, ANC, CRP, procalcitonin improve prediction of SBI; CRP 75% sens and spec for SBI
Fever reduction:
Pros: decr metabolic demands; improved neuro assessment; symptomatic relief
Cons: doesn’t decrease febrile convulsions, fever increases WBC motility and Fe, fever beneficial to immune
response, decr ability to assess children with SBI
Admit for Abx if: <1/12 (regardless of septic screen result); <3/12 with WCC >15 or any abnormal result on septic screen
Sepsis: 10-20ml/kg IV saline bolus until perfusion improves (stop if rales or hepatomegaly develops); if shock not
reversed, begin inotrope (use dopamine if “cold shock”, norad if “warm shock”); give hydrocortisone if resistant to
inotropes
Cons: most infections will become clinically evident without sequelae with delayed Abx; incr resistance
Ceftriaxone CI’ed <1/12 – causes incr bil
Fever without focus:
<3/12:
amoxicillin/ampicillin 50mg/kg QID (TDS if <1/52)
+ cefotaxime 100mg/kg  50mg/kg QID (BD if <1/52) (or Gentamicin 7mg/kg OD)
consider aciclovir
>3/12:
cefotaxime 100mg/kg loading dose  50mg/kg QID
(? Or benpen)
(Listeria + Gp B strep)
(G-ive)
UTI:
<3/12, CNS not excluded:
amoxicillin 50mg/kg QID (TDS if <1/52)
cefotaxime 100mg/kg loading dose  50mg/kg QID (BD if <1/52)
<3/12, CNS excluded:
amoxicillin 50mg/kg QID (TDS if <1/52)
(use ceftriaxone 25mg/kg BD if penicillin allergy)
+ gentamicin 7.5mg/kg OD (not as good CSN penetration as cefotaxime)
>3/12:
gentamicin 7.5mg/kg OD (max 240-360mg) IV
or cefuroxime 25-30mg/kg/dose IV
Well child: if 6-24/12, give 1x IV/IM dose ceftriaxone 50mg/kg, then discharge on PO for 10/7 (<2yr) or 7/7 (older child)
augmentin 10mg/kg TDS PO
Or cotrimoxazole 4mg/kg BD PO
Or cephalexin 10mg/kg TDS PO
+
Meningitis:
<1/12:
amoxicillin 50mg/kg QID (TDS if <1/52)
+ cefotaxime 50mg/kg QID (BD if <1/52)
or
gentamicin 2.5mg/kg TDS (BD if <1/52)
<3/12:
amoxicillin 50mg/kg QID
+ cefotaxime 100mg/kg loading dose  50mg/kg QID
>3/12:
cefotaxime 100mg/kg loading dose  50mg/kg QID
or ceftriaxone IM 100mg/kg loading dose  80-100mg/kg OD if no IV access
Once sensitivities available:
if Hib – amoxicillin
if Pneumococcus / meningococcus – penicillin G, ?vanc
Meningococcal sepsis:
<1/12:
amoxicillin 50mg/kg QID (TDS if <1/52)
(?or benpen)
+ cefotaxime 50mg/kg QID (BD if <1/52)
(?+ gentamicin 7.5mg/kg OD (5mg/kg if <1/52))
<3/12:
amoxicillin 75mg/kg QID
+ cefotaxime 100mg/kg loading dose  50mg/kg QID
>3-12:
cefotaxime 100mg/kg loading dose  50mg/kg QID
or ceftriazone 50mg/kg BD
or ceftriaxone IM 100mg/kg loading dose  80-100mg/kg OD if no IV access; can be given pre-hospital
Brain abscess: fluclox 50mg/kg IV Q4hrly + cefotaxime 50mg/kg QID + metronidazole 7.5mg/kg TDS
HSV encephalitis: aciclovir <3/12 = 20mg/kg TDS <12yrs = 500mg/m2 TDS >12yrs = 10mg/kg TDS
Pneumonia
<3/12:
amoxicillin 50mg/kg QID (TDS if <1/52)
(or ampicillin 50mg/kg QID)
cefotaxime 100mg/kg loading dose  50mg/kg QID (BD if <1/52)
(or gent)
>3/12:
amoxicillin 30-50mg/kg TDS
>3/12, complicated:
augmentin 30mg/kg TDS-QID
(?staph, lung abscess, pleural effusion)
or cefuroxime 30mg/kg TDS
+ erythromycin / clarithromycin if severe (for atypicals, mycoplasma)
>3/12, unwell ++:
fluclox 50mg/kg QID IV (to cover staph)
+ cefotaxime 50mg/kg QID IV
If well:
amoxicillin 30mg/kg TDS PO for 5-7/7
Mycoplasma:
erythromycin 12.5mg/kg QID PO for 7-10/7
(if not improving on amox)
Or roxithromycin 4mg/kg BD PO
Staph:
flucloxacillin 50mg/kg QID IV
(unwell, post-viral, abscesses)
+/- clindamycin 10mg/kg TDS-QID IV
In fever: Term baby; no co-morbidities; no Abx during illness; WCC 5-15; other Ix normal; responsible carer; high
probability of follow up
In febrile convulsion: simple seizure, now normal neuro, source of fever determinted, sensible parents with action plan,
able to access help; consider seizure prophylaxis if prolonged recurrent seizures
+
Discharge
criteria
Notes from: Dunn
Normal values CSF (Starship):
WBC / mm3
Prem
neonate
Term
neonate
0-4 wks
4-8 wks
> 6 wks
Av
9
Range
0-29
8.2
0-22
11
7.1
2.3
0-50
0-50
No. neutrophils
Av
Range
% neutophils
Av
7
Range
0-66
61
0.4
0.18
0.68
0-7.5
0-2.1
2.2
2.9
0-15
0-42
0-35
Glucose mmol/l
Av
2.8
Range
1.3-3.5
CSF/blood
glucose ratio
Av
Range
0.74
0.55-1.05
2.8
1.9-6.6
0.81
2.6
2.6
3.4
2-3.4
1.6-3.4
2.5-3.6
0.6
0.44-2.48
Protein g/l
Av
1.15
Range
0.9
0.2-1.7
0.84
0.59
0.28