Fever in Babies. Too much testing or not enough testing? Martin E. Weisse, M.D. Pediatric Infectious Diseases

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1 Fever in Babies Too much testing or not enough testing? Martin E. Weisse, M.D. Pediatric Infectious Diseases

2 Disclosures I have nothing to disclose

3 Learning Objectives At the end of the talk, participants should be able to 1. Recognize different models for evaluating febrile babies 2. Develop a plan for addressing fever in infants and children

6 Occult bacteremia in outpatients

7 McGowan etc June 21, 1973 N Engl J Med 1973; 288:

8 Untreated, unsuspected bacteremia with: N % meningitis % focal infection S. pneumoniae % 10.5% H. influenzae 15 20% 60% N. meningitidis 11 36% 63.6% Woods AJDC 1983;137:544 Dashefsky J Peds 1983 Sullivan PEDS 1987

14 Rates of pneumococcal disease in children < 5 years

15 Occult bacteremia in outpatients

16 Strategies to treat suspected cases of bacteremia High risk groups Low risk Groups (Rochester criteria, etc)

17 Fever as Predictor of Bacteremia Temp (F) McGowan Teele Waskerwitz < 102 2/212 (0.9) 0/ /122 (4.1) 19/459 (4.1) /150 (8.7) *** 17/292 (5.8) /112 (8.0) *** > 105 1/16 (6.2)

18 High Fever and Bacteremia T (Celsius) N % / / >41 15/58 26 McCarthy. Pediatrics 1977;59:663

19 WBC as Predictor of Bacteremia Baraff,Pediatr Annals Aug 1993 Study Ages Temp ( o C) N WBC < 15k WBC >15k Teele 1-24 > Murray 3-24 > Schwartz 2-36 > Carrol 6-24 > Jaffe 3-36 > Bass Bass 3-36 > TOTAL

20 low risk vs non-toxic Probability of bacterial infection in infants < 90 days of age Low risk Nontoxic Toxic SBI 1.4% 8.6% 17.3% Bacteremia 1.1% 2.0% 10.7% Meningitis 0.5% 1.0% 3.9% Baraff LJ. Pediatr Infect Dis J 1992;11:

21 Social Smile and Bacteremia Present n=250 Absent n=262 p value Gender 49% female 44% female 0.26 Age (mo) WBC (x 1000) Temp Fever duration Bacteremia 26 of of Bass, Wittler, Weisse. Pediatr Infect Dis J 1996

24 Management of Infants and Young Children with Fever without Source Baraff, Larry J, MD. Pediatric Annals; Vol. 37, Iss. 10, (Oct 2008):

emergency department management of febrile infants 56

25 Febrile Infant CPG at 21 Children s Hospitals Association of clinical practice guidelines with emergency department management of febrile infants 56 days of age. Aronson Pl, et al J Hosp Med Jun;10(6):

26 Traffic light system for identifying risk of serious illness National Institute for Health & Care Excellence 2013 National Guidelines, London

27 Sick vs Not Sick Focus vs No Focus Well vs Unwell

28 15 m/o boy 3 days of fever Previously well- normal development 3 day history of fussiness, fever UTD on vaccines - Prevnar x 3 No focus on exam

29 What work-up would you do? A. UA & UC B. CBC, UA & UC C. CBC, BC, UA & UC D. Reassurance, watchful waiting

30 Same patient, but also RSV (+) A. UA & UC B. CBC, UA & UC C. CBC, BC, UA & UC D. Reassurance, watchful waiting

31 CBC H/H 9.5/28.9 WBC 7.5 (31p45b21l) BC: S. pneumoniae type 6A CSF WBC: 3625 Glucose: 32 Protein: 284

32 Bilateral frontal infarcts T2 DWI

33 10 m/o boy 1 day of fever Previously well- normal development Seen in ER with 1 day of fever, 12 hour so vomiting, loose stool UTD on vaccines - Prevnar x 3 No focus on exam

34 What work-up would you do? A. UA & UC B. CBC, UA & UC C. CBC, BC, UA & UC D. Reassurance, watchful waiting

35 CBC H/H 10.1/30.5 WBC 28.3 (71p2b21l) BMP 137/ / 17 16/ Fluid Bolus x 2 139/ / 16 14/.03

36 Admitted to Pediatric ward around 7 a.m. On rounds at 10:30, parents and baby were sleeping, so they were not interrupted Intern mentions that since WBC was elevated, maybe we should get a BC and give a dose of Ceftriaxone. Attending and SR remark that the guidelines state that CBC was not even recommended, and WBC is no longer a discriminator.

37 What would you do? A. Continue to watch clinically B. Send a blood culture, do not give antibiotics C. Give antibiotics, no BC is needed D. Send a blood culture and give ceftriaxone

38 At 1:30 p.m. parents called nurse to room Child was having extensor posturing A code was called Intubated, BC drawn, Vanc/Ceftazidime started CT scan showed herniation Blood culture grew S. pneumo (non-vaccine strain)

42 Hospital Pediatrics Vol 2, Issue 2, 2012

43 The emerged themes were fear of complications by 18 (75%), perception that LP was unnecessary by 5 (21%), and distrust of the motives behind the request for consent. Fear of paralysis and conviction that LP is unnecessary encompassed 80% of the causes for refusal. Eleven families (46%) stated that nothing would have made them consent, and 10 (42%) would agree only if the child looked unwell or deteriorated.

45 Let s divide the risk people are worried about into two components. The technical side of the risk focuses on the magnitude and probability of undesirable outcomes: paralysis, other complication, poorly performed procedure, discomfort of their child. Call all this hazard. The non-technical side of the risk focuses on everything negative about the situation itself (as opposed to those outcomes). Is it voluntary or coerced, familiar or exotic, dreaded or not dreaded? Are you trustworthy or untrustworthy, responsive or unresponsive? Call all of this outrage.

46 My recommendations 0-30 days- Temp 38 Complete work-up for all babies Blood, Urine CSF HSV PCR and Acyclovir for babies with seizures, skin lesions, CSF lymphocytosis, elevated ALT/AST days- Temp of 38.3 Toxic- Full evaluation Unwell- Urine and WBC Well- Urine

47 My recommendations 3-6 month- Temp of 39 Toxic- Full evaluation Unwell- CBC, BC, Urine Well- Urine > 6 months, fully immunized- Temp of 39.5 Non-Toxic- CBC, Urine Well- Urine or nothing >6 months, under-immunized- Temp of 39.5 CBC, BC, Urine

48 What if there is a focus on exam? Is a Recognizable Viral Syndrome a focus? NB: Vomiting is not a focus, it is a RED FLAG

49 < 3 mo

Evidence-based Management of Fever in Infants and Young Children

Evidence-based Management of Fever in Infants and Young Children Shabnam Jain, MD, MPH Associate Professor of Pediatrics Emory University Medical Director for Clinical Effectiveness Objectives Understand