Hot Stuff: The Febrile Child

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1 Hot Stuff: The Febrile Child Dr. Shannon MacPhee, Department of Emergency Medicine, Division Head Pediatric Emergency Medicine. IWK Health Centre. Dalhousie University November 2017

2 Know when to suspect a serious bacterial infection as the cause of fever in the otherwise healthy child Fever myths Fevers with rashes

3 I have no actual or potential conflict of interest in relation to this program. I also assume responsibility for ensuring the scientific validity, objectivity, and completeness of the content of my presentation.

4 Re-setting of hypothalamic temperature setpoint Controlled physiologic process within benign limits When body is below the setpoint, body will generate internal heat through shivering and minimize heat loss through vasoconstriction

5 WBC activity Activation of T lymphocytes Interferon MAY inhibit viral or bacterial function

6 30% of all pediatric acute care visits are for fever

7 Fever with localizing symptoms Fever of unknown origin (Fever > 2wks) Higher incidence of noninfectious causes Very different infectious differential Fever without focus/source (FWS)

8 Temperature was high on the fever bug How do you define fever? What is the best method to take temperature?

9 Rectal 36.6 C to 38 C Tympanic 35.8 C to 38 C Oral 35.5 C to 37.5 C Axillary 34.7 C to 37.3 C

10 CPS Position Statement: Temperature Measurement in Pediatrics, 2013 Age Recommended technique 0-2 years 2-5 years RECTAL (definitive) Axillary (screening) Axillary or tympanic Rectal used for definitive only >5 years Axillary or tympanic Oral for definitive Definitive measurements are only needed in select circumstances e.g. neonate or immunosuppression

11 Rectal temperatures traditionally gold standard Affected by depth of measurement and presence of stool Rectal perforation in less than 1 in 2 million measurements (Arch Dis Child, 1992)

12 18 month old previously healthy child should have an axillary temperature. Although rectal is likely safe, it is unnecessary in this scenario to obtain a gold standard temperature.

13 14 day old baby girl brought to the ED with a fever Feeding well Healthy full term baby. Normal pregnancy and birth. Group B Strep test was negative. Well looking baby T39.9R,HR146,RR 46,BP 80/40,Sats 99% Normal exam

14 The baby looks ok so we could send her home BUT

15 12% of febrile infants less than 1 month old without source will have Serious Bacterial Infection (SBI) Most common bugs: Group B Strep Eschericia coli Listeria monocytogenes Enterococcus

16 Serious Bacterial Infection in 12% Urinary Tract Infection 8.6% Bacteremia 3.2% Meningitis 1.3% Cellulitis 0.8% Bacterial gastroenteritis, septic arthritis and pneumonia 0.3% Kadish, Clinical Pediatrics, 2000

17 Neonates have immature immune systems and infections are not contained the way they are are in adults. An infection in the urine can quickly spread to the blood and the spinal fluid, for example.

18 Even for very experienced pediatricians, we can t pick the sick child out of a line up and the screening bloodwork and urine tests don t help either.

19 All babies who are less than one month old with a fever need cultures of the blood, urine and cerebrospinal fluid culture All babies with a fever less than one month of age are admitted with intravenous antibiotics (Ampicillin and Cefotaxime)

25 Kids older than 3 months rarely get a bloodstream infection Herz et al Pediatric Infectious Disease Journal ,133 blood cultures on children 3-36 months 0.95% positive

26 Blood work not indicated for previously healthy, vaccinated and well appearing 3-36 month old children unless fever > 5 days

27 The presence of another clinically obvious source of infection reduces risk of UTI by one-half. Overall rate of UTI in febrile kids under 2 is 5% Highest risk groups: Girls (especially under 12 months) Uncircumcised boys Fever for more than 2 days Temperature >39 C White race Gorelick, PEC, 2003 Gorelick, Arch Dis Child, 2000 Baraff, Annals of Emerg Med, 2000

28 Get a urine test if : 2 days of fever in a girl, an uncircumcised boy who has no other source of infection.

29 Pediatric Urine Collector (PUC) or Bag Urine is a screening tool We measure signs of the body fighting off infection and would expect to see white cells and nitrites in a urine sample. Trouble is we have white cells all over our body. So this is only good if it s negative.

33 Helps you relax and most importantly helps you forget the experience.

Options include: Cefixime, Cephalexin, Clavulin, Trimethoprim-sulfamethoxazole, Cefprozil Long list of antibiotics that will work we choose the one that is the narrowest in spectrum, the cheapest in

34 Options include: Cefixime, Cephalexin, Clavulin, Trimethoprim-sulfamethoxazole, Cefprozil Long list of antibiotics that will work we choose the one that is the narrowest in spectrum, the cheapest in cost and the easiest to give based on taste and dosing interval) ¹American Academy of Pediatrics Clinical Practice Guideline: Urinary Tract Infections 128, Number 3, September 2011 Diagnosis and Management PEDIATRICS Volume

36 7 months old Chicken pox x 3 days Today Crying constantly Fever Area of redness around one of the spots Taken to after hours clinic Prescribed antibiotics and sent home The doctor did not even take her out of the stroller to examine her

37 On arrival home was limp and unresponsive Taken to ED On arrival in ED: T 39.4, HR 168, RR 44, Sat 94% Difficult to arouse Mottled, cap refill 5 sec Area of erythema on chest

38 Further information?? BP 70/35 What is her diagnosis? Septic Shock Next steps? Fluid Resuscitation Antibiotics Sepsis protocol

39 Emergency Management Fluids, fluids, fluids: received Normal Saline 20 ml/kg x 3, no improvement Pressors started (tighten the blood vessels and increase the blood pressure). Pressors started were epinephrine and dopamine. Intubated (to protect airway) Admitted to intensive care unit

40 Thea had Group A Strep Sepsis. Rates of Group A Strep sepsis have decreased since have chicken pox vaccination, but this is a well known complication.

41 Sepsis is a leading cause of death in infants and children 6 million deaths per year worldwide in infants and children 60-80% of deaths in children in developing countries is from sepsis

42 Sepsis occurs when chemicals released into the bloodstream to fight infection trigger inflammatory responses throughout the body. This inflammation can result in a number of physical responses that can damage multiple organ systems causing them to fail. If sepsis progresses to septic shock, blood pressure drops dramatically, which may lead to death.

43 US National database 28.2 million ED visits < 18 yrs annually 95,055 severe sepsis 0.34% of pediatric ED visits Bimodal age distribution 32% < 1 yr 24% yrs National estimates of emergency department visits for pediatric severe sepsis in the United States. Singhal et al. 2013

44 Mortality 9% Causative Organism found in ~40% Staph 7% Gram neg 5% Strep 3% Meningococcus 0.5% Trends in the Epidemiology of Pediatric Severe Sepsis. Watson et al. Ped Crit Care Med 2013

46 HR Decompensated Compensated BP TIME

48 Partnerships:

58 4 year old boy Non immunized Recent trip to the UK Returns to Halifax Fever, cough, red eyes, runny nose for 4 days Miserable Taken to chiropractor x 2 Comes to ED on a busy night and you finally see him after he has been in the ED for 6 hours.

59 Public Health Image Library, CDC

60 Incubation: 6-19days Starts with fever, cough, coryza and conjuctivitis Koplik spots (Day 2) Morbilliform rash-confluent face (Day 4) spread from head down-takes 3-4 d Nature Reviews Micro

61 Public Health Image Library, CDC

62 8 million deaths per year worldwide (Sem Ped Neur 2012) Vaccine preventable Most deaths due to complications: Pneumonia Encephalitis Higher case fatality for < 5 years, poverty, outbreaks, secondary case in household Wolfson, 2009

63 Paramyxo virus Spreads through aerosolized droplets Infectious droplets in your waiting room for 2 hour period One of most communicable infectious disease >90% household attack rate Not spread by those who are immune

64 R 0: basic reproduction number i.e. average number 2 0 infectious cases produced by a single index case in completely susceptible pop From Dr. Noni MacDonald, ID

65 Primary measles encephalitis Fever, headache, altered mental status, seizures, ataxia and weakness 10-15% death rate 25% serious disability Acute postinfectious measles encephalomyelitis Sensory loss, Ataxia, back pain Autoimmune demyelination Weeks to months after measles infection or vaccination Measles inclusion body encephalitis Altered mental status, medically refractory seizures, motor deficits 75% death rate in 2-3 weeks Immunocompromised kids Subacute sclerosing panencephalitis Behaviour problems, dementia, myoclonus, cerebellar ataxia, necrotizing retinitis, cortical blindness Diffuse cortical atrophy Fatal 2-20 years post measles

67 2 year old girl with fever for 3 days and mild nasal congestion. Parents already called 811 twice, been to a walkin clinic, and visited the IWK ED Records show a negative urinalysis and microscopy from 0200h this morning at ED Mom s main concern is that the fever is not responding to acetaminophen or ibuprofen. She is worried her child will get brain damage.

68 Your thorough physical exam reveals a well appearing child with no signs of meningitis. She looks well and there is no focus on exam aside from mild rhinorrhea. She attends day care.

69 Poirier, Clinical Pediatrics, caregivers, Pediatric ED settings Median temperature to cause harm % Very concerned about potential harmful consequences of fever % Very concerned when fever not reduced by antipyretics % who wake children from sleep to administer antipyretics % who administer ibuprofen more than every 6 hours 40.6 C 73% 88% 77% 40%

70 Seizure 32% Death 18% Brain damage 15% Passing out 6% Infections 3% Shock 2.2% Blindness 1.9%

72 Meta-analysis 11 articles Majority of published research indicates that response to antipyretics cannot be used as a predictor of significant bacterial illness

73 Is this helpful? Could it be harmful?

74 Heterogeneity of studies Reduction of temperature :no statistical or clinical significance. Comfort: Unclear effect Side effects : not sufficiently powered to detect toxicities or side effects Not recommended in light of possible dosing errors and lack of harm due to pyrexia

75 Inquire about parents concerns and address specific fears directly Fever is a symptom and not a disease Antipyretic treatment is optional. Routine temperature checking and night waking for antipyretics is unnecessary Recommend against alternating agents of antipyretics

76 Unwell looking febrile child if they are lethargic, confused or irritable, if their skin is cool or mottled, or if they have breathing troubles or specific symptoms such as a stiff neck. Fever with a rash that doesn t blanch needs to go to the ED Fever that has no explanation after 2-3 days even if they look ok Special populations: Any baby less than 3 months Any child who has had recent surgery Immunocompromised child with fever. Common conditions include: Chronic steroid / immunosuppressant therapy Chemotherapy related immune suppression Sickle Cell Disease / Asplenia Known B or T cell immune deficiency Any children with a central line or other medical devices

77 Fever is a normal physiological response Fever phobia is common No need for alternating doses of antipyretics. You re likely to need a urine sample if you are under 36 months and have a fever with no obvious source. Sepsis is a dysregulated body response to infection that damages organs and can lead to death. Immunization prevents against serious diseases in children.

Fever in the Newborn Period

Fever in the Newborn Period 1. Definitions 1 2. Overview 1 3. History and Physical Examination 2 4. Fever in Infants Less than 3 Months Old 2 a. Table 1: Rochester criteria for low risk infants 3 5. Fever