Management of the Febrile Infant and Young Child

Benjamin P. Harrison, MD, LTC, MC, USA Program Director, Madigan-University of Washington Emergency Medicine Residency
*Revised from previous edition by Ann Egland, MD and Kim Forman, MD

Government Services Chapter

American College of Emergency Physicians

Scope of the Problem

Fever = Temp > 100.4 F or 38.0 C (some use 100.5 or greater) 10-20% of all pediatric visits to the ER. 20% will have fever without source

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Approach to the Febrile Infant / Child

The Great Debate
Approaches in the 1 month 36 month old febrile infant/child vary greatly Guidelines change as disease prevalence fluctuates; data/studies conflict at times Grey Areas are abundant; be open to change! One-size-fits-all approach discouraged

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Occult Bacteremia
Transient bacteremia is a daily occurrence (tooth brushing, dental or bowel procedures) Identifying occult bacteremia increases with increasing fever, WBC, and ANC. Vast majority of infants/children with fever are viral, even if hyperpyrexic
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Occult Bacteremia
2-3% of febrile children < 3 y.o. had occult bacteremia in past (H. influenza B and S pneumoniae predominately) Numbers much lower now OPB = occur pneumococcal bacteremia SBI = serious bacterial infection

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Occult Bacteremia
By definition, a well-appearing child with bacteria in his/her blood. Initially bacteremia occult or hidden May progress to toxicity, septic shock or produce focal infections

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Incidence of Occult Bacteremia (Post HiB

and Pre Pneumococcal Vaccine Era)

1.9% incidence of bacteremia

82.9% S. pneumoniae 13 times more likely to be pathogen (vs. contaminant) if grew in less than 18 hrs. 95.7% resolved without parenteral antibiotics

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Predictors of Occult Bacteremia

Age Dependent
Premature Infants Infants and children
Birth to 28 days 28-60 days 2 to 36 months Above 3 years
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Predictors of Occult Bacteremia

OPB pts younger, ill-appearing, with higher temperatures, WBC, ANC, and ABC Occult bacteremia in 8.1% with ANC >10,000 vs. 0.8% if ANC <10,000
ANC more specific than WBC

BUTWBC count does not reliably predict bacteremia nor bacterial meningitis in recent study
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Predictors of Occult Bacteremia

When a recognizable viral syndrome present, low risk for occult bacteremia.
i.e. Croup, varicella, bronchiolitis, stomatitis 0.2% rate of occult bacteremia Blood cultures are not indicated in these cases
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Occult Urinary Tract Infections

Occult UTIs 4% of boys < 12 mos and 9% of girls < 24 mos (Not immunized against E. coli !) Uncircumcised males more at risk UA & urine culture < 6 months for circumcised and < 12 months old in uncircumcised Get UA in hyperpyrexia even if other sources present (AOM, AGE, etc)

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Occult UTI Diagnosis

Urine Culture > 103-105 cfus = gold std Tr. LE, > 10 WBC/hpf and neg- Gm stain or no bacteria are all highly senstitive Nit +, >Mod LE, + Gm Stain, > 10 WBC/hpf and bacteruria are all very specific for UTI on cath UA

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Occult Urinary Tract Infection

75% of febrile UTIs are pyelonephritis Consequences of missed pyelonephritis in childhood
Renal scarring in 27-64% (with risk of HTN, renal failure and pre-eclampsia as an adult) 13-15% of end-stage renal disease is thought to be related to under-treated childhood UTI.

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Occult Pneumonia
40% of children suspected of pneumonia confirmed with CXR 26% without pneumonia clinically had positive CXR in subgroup with WBC > 20,000
Strongly consider CXR in children < 5 y.o. with WBC > 15K even if normal RR, pulse Ox and lung exam!
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Consequences of Missing OPB

10-25% of children with OPB will develop cellulitis, pneumonia, or sepsis if not treated 3-6% will develop meningitis (Pre Prevnar) Much lower numbers now
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Why Not Treat All Highly Febrile Children with Antibiotics?

Indiscriminate use of antibiotics contributes to emerging resistance of S. pneumoniae Adverse drug reactions Decreases patient discomfort and ED costs
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The Febrile Child

Rectal temperature is the gold standard Age > 36 months much less at risk Definition of fever for selective protocols to be discussed are as follows:
Birth to 28 days 29-90 days 3-36 months
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What about the Temperature?

Recent immunization history Overbundling is not the cause of a fever Accept the T-max at home Parents good at identifying fever (tactile) Normal/low temp doesnt preclude SBI

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Toxic Appearing?
Eval toxic-appearing children immediately Septic workup and admit, regardless of age Toxicity is defined as:
Lethargy Signs of poor perfusion Hypoventilation, hyperventilation, or cyanosis I.E. Shock / sepsis / meningitis / encephalitis
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Approach to the Toxic Patient

Fever alone may make a child appear ill Ask about childs behavior when not febrile and observe in ED if afebrile
Normal? Still ill appearing? Eating/drinking?

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Vital Signs
Fifth Vital Sign Pulse Ox mandatory with abnormal lung exam, resp rate or respiratory symptoms
RR will increase with fever Pulse oximetry more reliable predictor infection than respiratory rate

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Vital signs
Address Abnormal Vital Signs Get accurate weight for treatment Elevated pulse may be from fever or crying Repeat pulse after antipyretics or hydration Try to document vitals when patient is calm

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Physical Exam Findings

Petechial / purpuric rashes (invasive bacteremia) Toxic appearance and WBC >15,000 are 100% sensitivity for identification these rashes Meningococcemia associated with purpura more than petechiae alone.
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Birth to 28 Days Old

Documented temperature above 100.4 degrees F requires a full septic workup and admission

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Birth to 28 Days Old

Septic work-up includes:
CBC with manual differential Blood culture Urinalysis and urine culture CXR LP for CSF analysis and culture; Herpes PCR Testing Stool culture and fecal WBCs for diarrhea
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Birth to 28 Days Old

If ill-appearing, give parenteral antibiotics once urine/blood obtained ( < 30 mins & before LP !) Ampicillin 50-100 mg/kg/dose IV + Cefotaxime 50 mg/kg/dose IV up to 2g OR Ampicillin + Gentamicin 2.5 mg/kg IV
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Nontoxic 28 to 90 Days Old

Various approaches and debatable area 10% will have aseptic meningitis if LP done Management also depends on risk factors
Low Risk Group may be discharged home High Risk Group requires more extensive workup and admission

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28 to 90 Days Old Low Risk Patients

No bacterial focus on PE (excluding OM) Non-toxic, previously healthy Not hospitalized, term infant , no antibiotics Reliable parents with car/phone, close F/U

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28 to 90 Days Old Low Risk Patients

WBC 5-15k (<1500 bands) Neg. Gm. Stain (preferred) or Neg- LE and Nitrite or < 5 WBC/hpf on UA Stool Gm Stain neg. and < 5 WBC/hpf CSF < 8 WBC/mm3 and negative CSF gram stain (if LP done) No infiltrate on CXR
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Nontoxic 28 to 90 Days Old Most conservative approach

Full Septic Workup Antibiotics within 30 minutes of arrival
Ceftriaxone 100 mg/kg o.k. after 6 weeks age

Admit pending culture results Consider Acyclovir treatment if Herpes PCR testing not returned yet and CSF results not clearly bacterial in etiology
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Nontoxic 28 to 90 Days Old The Minimalist approach

UA, Blood and Urine cultures 1 in 1,000 missed meningitis (most viral) if no LPparents/provider o.k. with that risk? No antibiotics Follow up visit in 24 hours

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Nontoxic 28 to 90 Days Old My Approach

Lab/CXR work-up for fever >38 degrees C / 100.4 degrees F, observe patient in ED No antibiotics if no LP and Close F/U ensured LP added if:
Younger patient (28 60 days) with high fever Ill, but non-toxic, appearing or any other concern while observing
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Toxic 3 to 36 Months Old

Toxic appearing? Concern for sepsis or meningitis? Treat empirically
Ceftriaxone 100 mg/kg IV up to 4G OR Vancomycin 15 mg/kg IV up to 500 mg AND Cefotaxime 50 mg/kg IV up to 2G

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3 to 36 Months Old
Well appearing with clear source of fever: Treat and send home with follow-up Patient has a source but appears toxic: LP, antibiotics and admit Well appearing but no clear source of fever; Debatable approach depends on immunization status
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Why Treat in Pre-HiB and Pre-Prevnar Era?

Patients who received oral antibiotics later identified with OPB had fewer serious bacterial infections (3.3% vs. 9.7%). Meningitis developed in 0.8% vs. 2.7%, respectively.

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Nontoxic 3 to 36 Months Old Not Immunized

< 24 months old with 39 C (102.2 F) fever without a identifiable source needs further work-up 24-36 months old, 39.5 C (103 F) used because risk of bacteremia increases to 2.1% from 0.7% with fever 39 C to 39.4 C.
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Nontoxic Un-immunized 3 to 36 Months Old

Labs recommended in those without a source:
Blood culture CBC Cath U/A and urine culture (as indicated) CXR for tachypnea, retractions, focal abnormalities, room air SaO2 < 95%

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Nontoxic Un-immunized 3 to 36 Months Old

If urine or CXR is positive, treat with appropriate antibiotics for UTI or pneumonia If ANC > 10k (or WBC > 15k), send blood culture then give ceftriaxone 50 mg/kg IV/IM Follow-up with ED or PCM in 24 hours to check culture results, reassess the patient and consider need for further antibiotic treatment.

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Impact of Pneumococcal Vaccine

S. pneumoniae = leading cause of most bacterial upper respiratory tract infections (i.e. pneumonia, sinusitis, OM), meningitis and occult bacteremia in the U.S. Pneumococcal vaccine is dramatically dropping rates of invasive disease
has changed emergency care of the febrile child !
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Nontoxic Immunized* 3 to 36 Months Old

> 95% infants with serotype specific antibodies after 2 doses Prevnar Herd immunity / lower invasive disease After 2 doses HiB and Prevnar vaccines, UTI alone is primary concern if no source * At least 2 doses each of HiB and Pneumococcal vaccines
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3 to 36 Months Old
Advise parents/caretakers to return immediately if the child is worse Follow-up in the appropriate clinic/PCM office if not improving or for culture results

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3 Years Old and Up

After a careful history and physical to identify possible fever causes, treatment should be tailored to specific causes only. In the well-appearing child without a source, no further evaluation is indicated. Occult serious bacterial infection in children over 3 years is extremely low.
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3 Years Old and Up

Treat fever with anti-pyretics:
Acetaminophen 15- 20 mg/kg every 4 hours and/or Ibuprofen 10 mg/kg every 6-8 hours

Advise parents to return immediately if the child is worse and to follow-up with his/her PCM if not improving.

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Special Cases
Any child with a complicated or significant medical history should be treated conservatively. Clinical judgment must be used. Febrile children with sickle cell disease under age 4 are usually admitted.

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Summary
Treatment of the febrile infant and young child depends on: Appearance Fever Age Past Medical History Immunization Status
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Summary
Bloodwork rarely helpful Do complete History and PE Ensure appropriate admission Arrange close F/U or return to ED Always tell the parents to return if the child is getting worse!

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