Fever in the Pediatric Patient (part one)

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Fever in the Pediatric Patient (part one) Heather Wolfe, MD, FAAP Medical Director, Lutheran Children s Hospital Medical Education Participant Objectives: 1.

1 Fever in the Pediatric Patient (part one) Heather Wolfe, MD, FAAP Medical Director, Lutheran Children s Hospital Medical Education Participant Objectives: 1. Discuss pediatric fever and the concept of fever phobia. 2. Develop strategies for discussing fever with patients and families. 3. Develop strategies for the evaluation of fever in young infants. Dupont, Kosciusko Community, Lutheran, Rehabilitation, St. Joseph and The Orthopedic hospitals are owned in part by physicians.

2 You are taking call from home. It s 9:22pm. You have just gotten your toddler put back into her bed for the 4 th time. Your phone buzzes with a patient number that you call back within 5 minutes Doctor, what took you so long? My son has a high fever! Should I take him to the emergency room? Dupont, Kosciusko Community, Lutheran, Rehabilitation, St. Joseph and The Orthopedic hospitals are owned in part by physicians.

3 About 50% of after hours calls to a pediatric resident group practice were regarding fever 1 Dupont, Kosciusko Community, Lutheran, Rehabilitation, St. Joseph and The Orthopedic hospitals are owned in part by physicians.

4 What is the most important question to ask first before answering this parent? A. What is your son s temperature? B. How long has your son had fever? C. How old is your son? D. Have you given him any medicine? E. Does your son have any chronic medical issues? F. How is your son feeling? Dupont, Kosciusko Community, Lutheran, Rehabilitation, St. Joseph and The Orthopedic hospitals are owned in part by physicians.

5 What is the most important question to ask first before answering this parent? A. What is your son s temperature? B. How long has your son had fever? C. How old is your son? Answer: 4 weeks old D. Have you given him any medicine? E. Does your son have any chronic medical issues? F. How is your son feeling? Dupont, Kosciusko Community, Lutheran, Rehabilitation, St. Joseph and The Orthopedic hospitals are owned in part by physicians.

7 Under 2 months old? Yes, you should go to the ED. Skip to slide #57

8 Over 2 months old? What is your child s temperature? Any chronic medical issues? What are his other symptoms? How long has your child had fever/been sick? Have you given any medicine?

9 What is your child s temperature? Dupont, Kosciusko Community, Lutheran, Rehabilitation, St. Joseph and The Orthopedic hospitals are owned in part by physicians.

10 What is fever? Fever is: Temperature over 38.6 C or F An important sign or symptom Most common signal of illness in pediatrics Up to 1/3 of all pediatric office visits 2 Fever is NOT: Not a disease!!!!!!!! Rarely a threat Not hyperthermia Not a representation of severity of illness

11 What is fever? 98.6 F is mean body temperature in adults Established first in Body temperature normal is a range Normal range varies from person to person Younger children have higher normal body temp

12 What is fever? Hippocrates All illness is caused by imbalance of humors Fever cooks the excess humor, bringing about homeostasis 1600s: Thomas Sydenham (physician) 3 Fever is a mighty engine which Nature brings in the world for the conquest of her enemies.

13 What is fever? Insult to body (ex: viral infection) Macrophages release cytokines (pyrogens) Cytokines directly and/or indirectly affect the anterior hypothalamus Local levels of prostaglandin E 2 increase Hypothalamic set point for body temperature is increased Core temperature rises, cellular metabolism is stimulated, skeletal muscles shiver, skin vessels vasoconstrict, sweat glands stop

14 What is fever? Contrast this with Hyperthermia: Increase in body temperature over the set point (ex: overbundled infant) Sweat glands activate, blood vessels dilate leading to flushing Dizziness, headache, fatigue and confusion occur Temperature over 106 F can be lifethreatening (heat stroke)

15 What is fever? Data shows fever helps recover more quickly from viral infections 2 Integral part of inflammatory response Slows or stops growth of many microorganisms 4 Limits iron availability (many invasive bacteria require) Enhances neutrophil migration Promotes T-cell proliferation Increases interferon activity

16 What is fever? Parent: How high is too high? Doctor: It won t get that high! Homeostatic process Body releases cryogens to counterbalance the pyrogens Keeps thermostat in range Body temperature rarely gets over 106 F Temperature greater than 106 F hyperpyrexia Rare: 0.05% of children Most common cause is still viral infection 2

17 What is fever? No correlation between height of fever and serious bacterial infection 5 15,781 febrile children <5years old 7.1% had serious bacterial illness 3.4% urinary tract infection 3.4% pneumonia 0.4% bacteremia Found NO correlation between height of fever

18 What is fever? How to take temperature Oral thermometer Accuracy varies Can be affected by hot or cold foods/liquids Tachypnea Cooperation from child Axillary thermometer Most convenient and comfortable for child Less accurate than oral Tympanic thermometer Not reliable for under 6 months old Ear wax can affect Incorrect placement in ear canal Forehead thermometer---depends on who you ask Fever Strips---not accurate Pacifier thermometer---not accurate Rectal thermometer? Best approximation of core temperature Accuracy affected by poor technique, stool in rectum, poor perfusion Physically and psychologically discomforting

19 What is fever? Pearls high fever is slang Don t add a degree to the thermometer reading Tachycardia and tachypnea are common Don t forget circadian rhythms: 9-10pm!!! Swing of up to 3 F

20 Does your child have any chronic medical conditions? Dupont, Kosciusko Community, Lutheran, Rehabilitation, St. Joseph and The Orthopedic hospitals are owned in part by physicians.

21 Chronic Medical Conditions CNS disease may lead to abnormal thermoregulation Abnormal/suppressed immune system Concern for more aggressive or unusual infectious disease process Higher risk for sepsis

22 Chronic Medical Conditions Cardiovascular disease, pulmonary disease, severe anemia, underlying anatomic abnormalities, and other chronic illnesses Child may not be able to balance the increased metabolic demand Changes differential diagnosis Changes probability of serious disease More aggressive treatment of the fever

23 Chronic Medical Conditions Febrile Seizures 2-5% of children 6 Usually under 2 years old Simple febrile seizure is generalized seizure activity lasting <15 minutes and does not recur in 24 hours Recurs in 1/3 of all children No risk of brain damage or mortality Usually occurs before fever even recognized

24 What are your child s other symptoms? Dupont, Kosciusko Community, Lutheran, Rehabilitation, St. Joseph and The Orthopedic hospitals are owned in part by physicians.

25 Clinical Appearance Clinical appearance is more powerful predictor of serious illness than height of temperature Fever is only a symptom Must develop differential diagnosis based on history and clinical appearance Triage decision based on the constellation of symptoms, not body temperature

26 Clinical Appearance Occult Bacteremia 1980s: 3% of well-appearing febrile toddlers with bacteremia 3 Haemophilus influenza type B (Hib) 10-20% progression to meningitis Since widespread Hib and pneumococcal vaccine use: % bacteremia in vaccinated febrile children

27 Clinical Appearance Urinary Tract Infection 3 If no other source for fever 2%-8% risk of UTI Risk factors: female younger than 12 months, prior UTI, uncircumcised male, abdominal pain, back pain, dysuria, and suprapubic pain Must get URINE CULTURE

28 How long has your child had fever? Dupont, Kosciusko Community, Lutheran, Rehabilitation, St. Joseph and The Orthopedic hospitals are owned in part by physicians.

29 Duration of Fever: Most febrile illnesses last 3 to 5 days Healthy children with concurrent viral symptoms and no focal symptoms or concerns for serious bacterial infection should be seen in the office after 5 days of fever

30 Have you given your child any medications? Dupont, Kosciusko Community, Lutheran, Rehabilitation, St. Joseph and The Orthopedic hospitals are owned in part by physicians.

31 Should I? At what temperature do I need to give medicine? Treat the child, not the thermometer! Address the SOURCE of the fever!

32 Antipyretics Reducing fever does NOT reduce morbidity or mortality (except in child with chronic illness) 2 No decrease in febrile seizures or their recurrence 2 Reduction in fever after antipyretics does NOT distinguish serious infection 2 Child s clinical appearance after antipyretics does NOT distinguish serious infection

33 Antipyretics About 50% of parents administer incorrect doses of antipyretics 15% give supratherapeutic doses 2

34 Antipyretics Acetaminophen & Ibuprofen Inhibit synthesis of prostaglandin E 2 Insult to body (ex: viral infection) Macrophages release cytokines (pyrogens) Cytokines go to anterior hypothalamus Local levels of prostaglandin E 2 increase Hypothalamic set point for body temperature is increased Core temperature rises, cellular metabolism is stimulated, skeletal muscles shiver, skin vessels vasoconstrict, sweat glands stop

35 What do I give him? How much? How often? Acetaminophen 15 mg/kg/dose every 4-6 hours 80% of children with decreased temp in min 2 Adverse effects almost none 2 Allergic Reaction Some implication in increasing rate of asthma Inappropriate dosing Parent does not read or understand label Incorrect measuring device Use of adult preparation Toxic amount is greater than 140mg/kg

36 What do I give him? How much? How often? Ibuprofen 10 mg/kg/dose every 6-8 hours Reduces inflammation (pro or con???) Adverse effects Gastrointestinal irritability Renal complications (nephropathy) especially in face of dehydration Safety younger than 6 months not established (renal) Allergic Reaction Inappropriate dosing Parent does not read or understand label Incorrect measuring device Use of adult preparation

37 Should I alternate Tylenol and ibuprofen? My short answer: no My long answer: it probably gets the number on the thermometer down, and it might make the child feel better faster. May even decrease daycare/work absence. It is most likely safe to do.

38 Antipyretic Use Combined Antipyretics 7 Temperature change after one hour 15mg/kg acetaminophen.95 celcius (1.71 Fahrenheit) 5mg/kg ibuprofen.92 celcius (1.66 Fahrenheit) 15mg/kg acetaminophen + 5mg/kg ibuprofen 1.22 celcius (2.2 Fahrenheit)

39 Antipyretic Use Combined Antipyretics 8 Study of 464 children age 6 to 36 months Done in 2006 Pediatric community ambulatory centers Israel (used slightly different dosing from standard American dosing guidelines) Followed temperature, stress score, and amount of antipyretic received

40 From: Antipyretic Treatment in Young Children With FeverAcetaminophen, Ibuprofen, or Both Alternating in a Randomized, Double-blind Study Arch Pediatr Adolesc Med. 2006;160(2): doi: /archpedi Table Title: Primary Outcome Measures of Treatment by Group Date of download: 1/6/2017 Copyright 2017 American Medical Association. All rights reserved.

41 Antipyretic Use Combined Antipyretics Adverse effects 2,7,8,9 Promotes fever phobia Increased potential for inaccurate dosing/overdosing Renal complications increased Acetaminophen metabolized in liver, but excreted in urine Ibuprofen blocks production of renal prostaglandin Acetaminophen may accumulate in the renal medulla Ibuprofen inhibits glutathione production Glutathione detoxifies the toxic metabolite of acetaminophen. 6 Then acetaminophen can cause tubular necrosis and renal toxicity

42 Antipyretics Aspirin Associated with Reye s Syndrome Don t use it Be careful of slang use of term aspirin

43 Physical Cooling cool bath, sponging Very commonly used without conferring with you Does not lower the thermostat May increase discomfort of child Cooling begins Hypothalamus senses widening of set point from actual temperature Muscular shivering and increase in metabolic rate (tachypnea & tachycardia) Child uncomfortable, as soon as cooling procedure done temperature rises back to set point

44 Physical Cooling Integral to treatment of hyperthermia (along with hydration) Works well in neurologically impaired child with abnormal homeostasis Could use in the uncommon times you need to get the temperature down Works well in combination with antipyretics body cools while waiting for drug to lower the set point

45 Alcohol baths 18% of parents say they have used for fever 1 Uncomfortable Systemic absorption of alcohol can be an issue

46 Antipyretic Pearls Don t forget OTC cough & cold preparations often contain acetaminophen or ibuprofen Instruct parents on use of appropriate measuring device Proper handling & storage of medication >80% of ED visits for medication overdoses in children are unsupervised ingestions 2 Most common single drug overdose is acetaminophen 2

47 Fever phobia First described in literature in 1980 by Schmitt 10 Parent s responses: 46% feared permanent brain damage 58% said temperature over 102 F was high 16% thought temperature could go over 110 F if not treated 63% worried lots that fever would harm their child 56% gave antipyretics for normal temperatures

48 Fever phobia Blame Measles!! Day 1: fever to 104 F, cough, runny nose Day 3 to 7: measles encephalitis in 1/ Seizures, delirium, coma 15% die 25% intellectual disability 11

49 Fever phobia 20 years later 1,2 44% said temperature over 102 F was high Compared to 58% 7% thought temperature could go over 110 F if not treated Compared to 16% About 50% of parents believe temperature <100.4 F to be fever 25% of caregivers give antipyretics for temp <100 F Checked temperature more often, gave antipyretics more often (even for normal temperatures), and initiated sponge bathing more often 85% of parents reported waking child from sleep to give antipyretics!!

50 Fever phobia

51 Fever phobia

52 Fever phobia

53 Fever phobia

54 Fever phobia

55 Fever Phobia Moral of the story: Emphasize fever as a SYMPTOM, not a disease!

56 Fever Pearls Treat the child, not the thermometer (emphasize comfort) Address the cause of the fever (emphasize additional signs of serious illness) Discuss fever as part of anticipatory guidance Don t give fever prophylaxis for vaccinations Teething does not cause fever

57 Now, back to that 4 week old Infants less than 2 months old have immature immune response Have not received vaccinations Can be difficult to assess clinical appearance

58 Fever in Young Infant Fever in <2 months 3 10% have serious bacterial infection 3% have bacteremia or bacterial meningitis Fever in <2 months & well-appearing 12 About 1% have bacteremia About 0.4% have meningitis Only 58% of febrile infants with bacteremia or bacterial meningitis appeared ill 13

59 Fever in Young Infant What if they have obvious viral symptoms? 6-7% of febrile infants with demonstrated virus have concurrent bacterial infection 12

61 Fever in Young Infant Rates of Bacteremia/Bacterial Meningitis in Febrile Infants by Age days: 4.1% days: 1.9% days: 0.7%

62 Fever in Young Infant Automatic: CBC with manual differential Blood culture Urinalysis and URINE CULTURE (cath specimen) +/- Lumbar Puncture RSV & influenza swabs (seasonal) Blood HSV PCR CXR if respiratory signs/symptoms

63 Fever in Young Infant If : <30 days old Clinically ill-appearing Underlying medical condition WBC >15,000-20,000 Abnormal urinalysis (+leukocyte esterase or WBC) Then, more likely to have serious bacterial infection: Full work-up with lumbar puncture & HSV testing Antibiotic and Antiviral therapy

64 Fever in Young Infant <30 days old Ampicillin (50mg/kg/dose every 6 hours) Cefotaxime (50mg/kg/dose every 6 hours) Acyclovir >30 days old Ceftriaxone (100mg/kg/dose every 24 hours) Acyclovir

65 Fever in Young Infant What really happens in outpatient practice? study >3000 infants <50% had full evaluations Equally high sensitivity to guideline results 2016 study 1380 febrile, previously healthy infants 32.3% had no bacterial cultures drawn Full sepsis evaluation for: 59% for 7-28 day olds 25% for day olds 5% for day olds No infant returned with bacteremia or meningitis 1% returned with UTI

66 Fever in Young Infant Occurs in 1.4% of infants 7-90 days old 12 Any one pediatric provider may not encounter 1 well-appearing febrile infant with bacterial meningitis ever! What affects decision? Scientific Evidence Experiential bias Personal habits Patient convenience

67 Fever in Young Infant If <2 months and fever, must have emergent medical evaluation CBC, blood culture, UA, and Urine cx ALWAYS done?hsv PCR (blood) for all? Lumbar puncture, CXR, viral studies based on clinical appearance and risk Antibiotic treatment based on risk

68 References 1. Crocetti M, Moghbeli N, Serwint J. Fever Phobia Revisited: Have Parental Misconceptions about Fever Changed in 20 Years? Pediatrics. 2001, Vol 107/Issue Sullivan J, Henry C, Farrar, Section on Clinical Pharmacology and Therapeutics. Fever and Antipyretic Use in Children. Pediatrics. 2011, Volume 127/Issue Avner J. Acute Fever. Peds in Review. 2009, Vol 30/Issue Adam, H. Fever: Measuring and Managing. Pedsinreview. 2013, August, Volume 34/Issue De S, Williams GJ, Teixeira-Pinto A, et al. Height of Fever Does Not Predict Serious Bacterial Infection. AAP Grand Rounds. 2015, Vol 34/Issue Subcommittee on Febrile Seizure. Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child with a Simple Febrile Seizure. Pediatrics. 2011, Volume 127/Issue Erlewyn-Lajeunesse MDS, Coppens K, Hunt LP, et al. Randomised controlled trial of combined paracetamol and ibuprofen for fever. Arch Dis Child. 2006; 91: Sarrell E, Wielunsky, Cohen. Antipyretic Treatment in Young Children with Fever. Arch Pediatric Adolescent Medicine. 2006;160(2): McIntire, SCRubenstein, RCGartner, JDJrGilboa, Nellis. Acute Flank Pain and Reversible Renal Dysfunction associated with Nonsteriodal Anti-inflammatory Drug Use. Pediatrics. 1993; Schmitt BD, Fever Phobia: Misconceptions of Parents about Fevers. Am J Dis Child. 1980;134: Centers for Disease Control and Prevention. CDC 24/ Baker M, Avner J. Management of Fever in Young Infants: Evidence Versus Common Practice. Pediatrics. 2016, Volume 138/Issue Pantell RH, Newman TB, Bernzweig J, et al. Management and outcomes of care of fever in early infancy. JAMA. 2004;291(10):

Fever in Children. Dr Shane George Staff Specialist - Emergency Medicine & Children s Critical Care Gold Coast University Hospital

Fever in Children. Dr Shane George Staff Specialist - Emergency Medicine & Children s Critical Care Gold Coast University Hospital Fever in Children Dr Shane George Staff Specialist - Emergency Medicine & Children s Critical Care Gold Coast University Hospital Update on Children s services @ GCUH Dedicated Children s Pod in the Emergency