Pediatric Fever
Emergency Medicine Clerkship
Indiana University
Objectives
• Review the approach to pediatric fever
• Examine the work up for pediatric fever
without a source (FWS) in stratified age
groups
• Discuss the impact of current vaccines on our
approach
Fever
• 20% of Pediatric Emergency Department visits
• 35% of Ambulatory visits
• 20% have fever without a source after H&P
• “Fever Phobia”
“Fever Phobia”
• Study of 340 caregivers
– 56% very worried about potential harm of fever
– 7% thought temp could rise >110 F if left untreated
– 91% believed fever could cause harmful effects
• 21% brain damage
• 14% death
– 46% perceived their doctors to be very concerned
about fever
– 14% gave acetaminophen and 44% gave ibuprofen
at too frequent dosing intervals
Pediatrics. 2001;107 (6): 1241-1246.
“Fever Phobia”
• “Pediatric health care providers have a unique
opportunity to make an impact on parental
understanding of fever and its role in illness”
Pediatrics. 2001;107 (6): 1241-1246.
What is the definition of fever?
• Generally fever defined as at least 100.4°F
– < 3 months fever is ≥100.4°F (38°C)
– > 3 months still has same lower limit of 100.4°F
(but diagnostic testing usually begins at 102.2°F or
39°C)
Defining Fever: How do we take the
temperature?
• Axillary and tympanic temps are unreliable in
young children (sensitivity 50-65%)
– rectal temperature is the “gold” standard
• Expert panel concluded 100.4°F(38°C) by
rectal thermometer should be used as the
lower limit of the definition of fever
Defining Fever
• Fever documented at home by similar means
should be considered the same as that
documented in the ED
• 92% of the infants who had rectal fever at
home had subsequent fever in next 48 hours.
So, even if they are afebrile on presentation
you can trust the rectal temperature at home.
Pediatric Infect Dis J. 1990 Mar;9(3):158-60
Defining Fever
• Be sure to communicate with the parents
– ask how it was taken and if they added degrees
– i.e. make sure 103°F was not 100.3°F
Why is fever so important?
• Your Goal is to rule out Serious Bacterial
Infection (SBI)
– UTI
– Meningitis
– Septicemia
– Bone and joint infections
– Pneumonia
– Bacterial gastroenteritis
“Sick or Not Sick?”
History
• Birth history? Specifically for neonatesmaternal infection or fever at delivery
• Eating?
• Urine output?
• Irritability?
• Excessive sleepiness?
• Immunized?
Physical
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Hypo- or Hyperthermic
Vitals
Rash
Fontanel
Respiratory
Circ or no Circ?
“Sick or Not Sick?”
• All febrile children less than 36 months [or for
that matter any age] that appear toxic should
be hospitalized for evaluation and treatment
of possible serious bacterial infection (SBI)
– What is a “toxic” appearance?
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Lethargy
Signs of poor perfusion
Hypoventilation/hyperventilation
Cyanosis
The Dilemma
• What do you do with the well appearing child
with fever?
– What diagnostics need to be done?
– Antibiotics or no antibiotics?
– What is the availability and reliability of
follow up? How does that affect your
management?
The Dilemma
• Lots of literature
– No definitive rules for the treatment of pediatric
fever
– “Guidelines” available
• Mostly opinion papers over last 15 years despite
changes in epidemiology
• Art versus science
– each patient is different
– each staff is different
– workups may change during community epidemics
Pediatric Fever
• Stratification into different risk groups:
– Neonates: 0 to 28 days
– Young infants: 29 to 90 days
– Older infants and young children: 3 to 36
months
Let’s see some patients!
Case 1
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3 week old white female
CC: congestion and fever.
Unremarkable PMHx/BHx.
ROS neg.
Initial temp at triage was 100.1° F.
PE is non-toxic alert infant with no abnormal
findings.
Do you want additional information
about the fever?
• How was it taken at triage?
• Were there any antipyretics given?
• What was the fever at home?
– fever in this case at home was 101.2°F
Infant 0 to 28 days
• Risk of SBI is as high as 20%
• All of these patients require:
– Full sepsis workup including CBC, Blood Cx, UA,
Urine Cx, CSF studies and CSF Cx
– Consider CXR and stool studies
– Empiric antibiotics
– Admission
Antibiotics
• Ampicillin and gentamicin
– covers GBBS, E. coli, Listeria monocytogenes
– Ampicillin specifically for Listeria and provides
some synergy with gentamicin for GBBS
• 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 gentamicin
Antibiotics
• Ceftriaxone is not used in neonates
• Why?
• because it competes for bilirubin binding sites
and may lead to hyperbilirubinemia
Acyclovir?
• Consider acyclovir
– Maternal history of Herpes (especially if primary
outbreak with vaginal delivery) or any noted skin
or mucosal lesions
• BUT in the majority of patients with neonatal
HSV, there is no maternal history of HSV.
• Definitely give if ill-appearing, pleocytosis with
negative gram stain, vesicles, or seizures
Case 2
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6 week old white male
Presents to the ED with fever to 101
PMHx/BHx unremarkable
No source of infection on the exam
Looks non-toxic
Protocols
• We may not be able to determine sick vs not
sick by H&P alone in this age group
• Several studies have attempted to develop a
protocol for infants < 90 days of age
– Rochester
– Philadelphia
Rochester Criteria
& Philadelphia Criteria
• Attempt to develop more sensitive ways
to detect serious illness in febrile
pediatric patients using:
– History
– Physical
– Laboratory Evaluation
Rochester Criteria
& Philadelphia Criteria
• Clinical Criteria:
– Previously healthy, term infant with
uncomplicated nursery stay
– Non-toxic clinical appearance
– No focal bacterial infection on exam
Rochester Criteria
& Philadelphia Criteria
Lab criteria for “low risk infant”
• CBC:
– WBC count 5-15,000/mm3
– <1500 bands/mm3
– Band/neutrophil ratio <0.2
• Urine:
– <5 WBC/hpf
– Negative gram stain of
unspun urine (preferred)
– Or negative urine leukocyte
esterase and nitrite
• CSF:
– <8 WBCs/mm3
– Negative Gram stain
• Stool (when diarrhea):
– <5 WBC/hpf
Back to your patient
• Labs are all negative
– Normal Urine, LP, CBC
• What is the disposition?
– Admit or send home
• Empiric Antibiotics?
Low Risk Febrile Infants 28 to 90 Days
Option 1
Option 2
• Full Sepsis work up:
Blood, Urine, CSF
• Ceftriaxone (50
mg/kg)
• Follow up in 24
hours
• Partial sepsis work
up: Blood and Urine
• NO Antibiotics
• Follow up in 24
hours
Low Risk Febrile Infants 28 to 90 Days
• Parents must be reliable
– Phones
– Ability to understand instructions
• Close follow up must be ensured
– May need to wake up the primary care physician
Non-Low Risk Febrile Infants 28 to 90
Days
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In other words: Failed Rochester Criteria
Full Sepsis work up
Empiric antibiotics
Admit
Antibiotics
• Ceftriaxone
– covers S. pneumoniae, H. influenzae, and N.
meningitidis
• Add vancomycin if any concern for S.
pneumoniae on LP in any age range (resistant
strains have been appearing in CSF)
Special Considerations
Case 3
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2 month old asian male
Fever at home to 101
Immunizations given today at PMD clinic
PMHx/BHx negative
Well appearing
Fever after immunizations
• 2.8% of infants < 12 weeks who presented to
the ED with fever within 24 hours of
immunizations still had a UTI.
• There were not any other serious bacterial
infections noted in the first 24 hours.
• After the first 24 hours, rates of serious
bacterial infection (including UTI) increased to
8.9%.
Acad Emerg Med. 2009 Dec; 16(12):1284-9
Fever after immunization
• If less than 24 hours since immunizations
– Consider UA, Urine Cx
– May not need further work up
• If more than 24 hours since immunizations
– Consider full vs partial sepsis work up
Special Consideration
Case 4
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2 month old hispanic female
Nasal congestion, cough
PMHx/BHx negative
Tachypneic, mild retractions and wheezing on
exam
• Clinical dx: Bronchiolitis
Bronchiolitis with fever
• Significantly lower risk of most SBIs
• However, the rate of UTI remains significant
(2.4-5.4%)
• 1.1% of infants with bronchiolitis had
bacteremia compared to 2.3% of febrile
infants without bronchiolitis
Pediatrics 2004 Jun; 113(6):1728-34
Pediatrics 2009 Jul; 124(1):30-9
Bronchiolitis with fever
• 0-28 days: Full sepsis work up
• >29 days: UA and Urine Cx
Case 5
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7 month old male
Fever to 103 for 2 days
PMHx/BHx negative
Immunizations are UTD
Exam is unremarkable
What is your work up?
Child 3 to 36 months with FWS:
Occult Bacteremia
• PCV7 (Prevnar):
– Targets 7 capsular serotypes of S. pneumo that
caused 80% of the infections
– Licensed in US in 2000
– Studies have shown a 90% reduction in invasive
disease in children receiving the vaccine
Child 3 to 36 months with FWS: Occult
Bacteremia
• Post Hib and PCV7 vaccines:
• Causes of bacteremia have changed:
– E.Coli 33%
– Non-vaccine serotype S. pneumoniae 33%
– S. aureus, Salmonella, N. meningitidis, S.
pyogenes 33%
Pediatr Infect Disease J. 2006; 25:293-300
Child 3 to 36 months with FWS:
Occult Bacteremia
• Post Hib and PCV7 era:
• Occult bacteremia rates are now between 00.74%!
• So…..do you really need to blood culture??
Child 3 to 36 months with FWS:
Occult Bacteremia
• In addition, in the post vaccine era, studies
have shown that the rate of contaminated
blood cultures equaled the rate of pathogenic
blood cultures.
• In one study, children less than 6 months old
were more likely to have contaminated blood
cultures than true bacteremia.
Pediatric Adolescent Medicine. 1998; July; 152; 624-628
Child 3 to 36 months with FWS:
Occult Bacteremia
• “For countries with widespread vaccination
with Hib and PCV7, the data indicates that
rates of occult bacteremia and subsequent SBI
are extremely rare”
• So, in the non toxic appearing child, age 3-36
months with FWS. The blood culture and CBC
are not a necessary part of the work up.
Minerva Pediatr 2009;61: 489-501.
Child 3 to 36 months with FWS:
Urinary Tract Infection
• Most common SBI
Child 3 to 36 months with FWS:
Urinary Tract Infection
• UTI’s almost always occult < 2 years of age
• Most common occult bacterial infection
• UTI occur in 7% of males < 6 months and 8%
of females < 12 months with fever without a
source
Child 3 to 36 months with FWS:
Urinary Tract Infection
• Who needs a UA and Urine Cx
– All females <24 mo
– All males <6 mo
– Uncircumcised males <12 mo
Child 3 to 36 months with FWS:
UA/Urine Culture
• Get cath specimens
– supra-pubic or trans-urethral
– clean catch impossible
– bags are usually not helpful (unless retrospectively
the culture is negative)
• If you get urine, SEND for culture
– up to 20% of negative UA’s will grow pathogen
Child 3 to 36 months with FWS:
Meningitis
• In this age group, children will start showing
signs of meningitis (clinical evaluation is more
useful)
• LP is not mandatory – use clinical discretion
Child 3 to 36 months with FWS:
Chest X-ray
• Usually negative in children with fever without
a source and no signs and symptoms of lower
respiratory infections
Child 3 to 36 months with FWS:
Empiric Antibiotic Therapy
Don’t Do IT!
Pediatric Fever Algorithm
Child 3 to 36 months with FWS
Appears toxic?
Yes
Full sepsis work up
and antibiotics and
admit
No
Temperature ≥ 102.2
No
No testing,
assure follow
up in 48 hrs
Yes
Selective
workup
Summary of Testing: 3 to 36 months and FWS
• Blood cultures
– Consider if child is unimmunized or immunocompromised
• Urine
– All females < 2 years
– Males
• Uncircumcised <12 months
• Circumcised < 6 months
• CXR
– If respiratory symptoms or hypoxic
• LP
– Signs of meningitis
Fever with a Source
• More common than fever without a source
• Clinically identifiable viral or bacterial illnesses
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
Fever with a Source: Viral
• Pediatric exanthems
– Roseola (HHV 6)
– Fifths disease (Parvo
B19)→
Fever with a Source
• What is the risk of concurrent serious bacterial
infections with identifiable viral syndromes?
– Low, in general
• Not zero
Special Consideration
Case 6
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6 week old female
Red area on leg noticed today
Febrile to 100.8 F
PMHx/BHx negative
Cellulitis in the neonate
• Up to 90% of febrile neonates with cellulitis
may have bacteremia. Because of the high
rate of systemic infection in these patients,
these infants require IV antibiotics and
hospitalization initially
Pediatrics. 1998;102(4 pt1):985-986
Cellulitis in the neonate
• What if this infant was afebrile?
• One small retrospective cohort study that evaluated the
presence of serious bacterial infection in afebrile infants 0 to
28 days with skin and soft tissue infections.
• None of the neonates had serious bacterial infections.
• Skin and soft tissue infections (SSTI) in the study were
pustulosis, cellulitis, and abscesses.
• This was a small study so it is hard to use to guide practice
definitively. However, it may suggest that well appearing
infants without fever can be managed without a full
evaluation.
Pediatr Emerg Care, 2012. 28(10): p. 1013-6.
Fever with a Source
• Take Home Points
– A clear viral illness is a source and portends a low risk of
SBI
• However in infants ≤ 28 days, SBI risk is still high enough to
warrant sepsis evaluation
– Bronchiolitis/Influenza
• ≤ 28 days = full sepsis evaluation
• 29-60 days = at least check urine
– Be careful with nonspecific viral infections (no well defined
viral illness)
Pediatric Fever Summary: Golden
Rules
• A toxic appearance demands immediate
action
– Work-up/antibiotics and admit
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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
References
1. Schwartz, S., et al., A week-by-week analysis of the low-risk criteria for serious bacterial infection in febrile neonates. Arch Dis
Child, 2009. 94(4): p. 287-92.
2. Caviness, A.C., et al., The prevalence of neonatal herpes simplex virus infection compared with serious bacterial illness in
hospitalized neonates. J Pediatr, 2008. 153(2): p. 164-9.
3. Bonadio, W.A., M. Hegenbarth, and M. Zachariason, Correlating reported fever in young infants with subsequent temperature
patterns and rate of serious bacterial infections. Pediatr Infect Dis J, 1990. 9(3): p. 158-60.
4. Albanyan, E.A. and C.J. Baker, Is lumbar puncture necessary to exclude meningitis in neonates and young infants: lessons from
the group B streptococcus cellulitis- adenitis syndrome. Pediatrics, 1998. 102(4 Pt 1): p. 985-6.
5. Kharazmi, S.A., et al., Management of afebrile neonates with skin and soft tissue infections in the pediatric emergency
department. Pediatr Emerg Care, 2012. 28(10): p. 1013-6.
6. Wolff, M. and R. Bachur, Serious bacterial infection in recently immunized young febrile infants. Acad Emerg Med, 2009.
16(12): p. 1284-9.
7. Krief, W.I., et al., Influenza virus infection and the risk of serious bacterial infections in young febrile infants. Pediatrics, 2009.
124(1): p. 30-9.
8. Levine, D.A., et al., Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections.
Pediatrics, 2004. 113(6): p. 1728-34.
9. Wolff M, Pomeranz E, Carney M. Febrile Young Infant Learning Module. MedEdPORTAL; 2013. Available from:
www.mededportal.org/publication/9568
10. McVey P. Fever Without a Source in Children Less Than 28 Days, 28 to 90 Days, and 3 to 36 Months. MedEdPORTAL; 2006.
Available from: www.mededportal.org/publication/316
11. Bandyopadhyay, S; Bergholte, J; Blackwell, CD; Friedlander, JR; Hennes, H. Risk of serious bacterial infection in children with
fever without a source in the post-haemophilus influenzae era when antibiotics are reserved for culture-proven
bacteremia. Arch Pediatric Adolescent Medicine. 2002;156; 512-517.
References
12. Klein, J. Management of the febrile child without a focus of infection in the era of universal pneumococcal immunization.
The Pediatric Infectious Disease Journal. 2002; 21; 584-587.
13. Lee, GM; Harper, MB. Risk of bacteremia for febrile young children in the post-haemophilus influenzae type b era. Arch
Pediatric Adolescent Medicine. 1998; July; 152; 624-628.
14. Chancey, RJ, Jhaveri, R. Fever without localizing signs in children: a review in the post-Hib and postpneumococcal era.
Minerva Pediatr 2009;61:489-501.
15. Herz, AM et al. Changing epidemiologhy of outpatient bacteremia in 3-36 month old children after the introduction of
heptavalent-conjugated pneumococcal vaccine. Pediatr Infect Dis J 2006;25:293-300.
16. Crocetti, M, Moghbeli, N., Serwint, J. Fever Phobia Revisited: Have Parental Misconceptions About Fever Changed in 20
Years?. Pediatrics. 2001;107 (6): 1241-1246.
QUESTIONS????