Definition
Incidence
Pathophysiology
Clinical Presentation
Differential Diagnoses
Evaluation & Investigations
Treatment and Management
Complications
RECTAL THERMOMETRY
This is a gold standard in detecting a fever
Readings are affected by depth of a
measurement, local blood flow changes,
presence of stool
Axillary
thermometry
Relies on the mercury thermometer placed
over the axillary artery >4mins
Recommended by AAP as screening test
for fever in neonates
Oral thermometry
Placed in the sublingual site with tongue
depressed for 3-4mins and reflects
temperature of lingual arteries
Tympanic thermometry
Measures the thermal radiation emitted
from the tympanic membrane and ear
canal.
Also called an infrared radiation emission
detector
BIRTH TO 2 YEARS
1. RECTAL (definitive)
2. AXILLARY (screening)
OVER 2 YEARS TO 5
YEARS
1. RECTAL
2. TYMPANIC
3. AXILLARY
> 5 YEARS
1. ORAL
2. TYMPANIC
3. AXILLARY
VIRAL CAUSES
BACTERIAL CAUSES
<1 month
TORCH infections
>1 month
Enteroviruses, CMV,
EBV, HSV, respiratory
viruses (parainfluenza, influenza,
resp syncytial virus)
<1 month
1-3months
>3months
Strep Pneu, N.
meningitidis
Bundling:
Bundling can lead to a rise in skin temperature and
eventually rectal temperature. (Study 1: Cheng, 1993, Study
2: Grover, 1994)
Route of Measurement:
Tympanic/axillary dont correlate well with rectal temps
Antipyretics:
No correlation between disease etiology/severity and
response to antipyretics (Baker, 1987; numerous others)
Tactile temperatures:
Sensitivity 83%
Specificity 76% (Hooker, 1996; Graneto, 1996)
Afebrile on presentation:
6 of 63 infants 0-3 months with bacteremia/meningitis
afebrile in clinic after being febrile at home (Pantell, 2004)
Preterm
Membrane rupture: before labor onset or
prolonged>12 hours
Chorioamnionitis or maternal peripartum fever
UTI
Hypoxia or Apgar score <6
History
Associated symptoms and behaviors
Onset and duration of fever
Degree of temperature-method and anatomic
site
Medications
Environmental exposures
Similar symptoms in siblings
Birth and nursery history (STD, TORCH, GBS,
ROM)
Date of last immunizations (MMR-fever and
rash 7-10 days afterwards)
WBC - <5000
Neutrophils / Bands / Acute-phase
reactants
Antigen testing
Blood cultures
Lumbar puncture
UA/Urine culture
CXR
Stool Analysis and Culture
Antigen Testing
Strep pneumoniae
H. influenzae type b
PCR methods (HSZ, VZV, enterovirus)
Blood cultures
Gold standard
False negatives
Prior treatment with antibiotics
Inoculation of too little blood (<1ml) into the media; too much blood
may yield false negative due to ongoing killing of bacteria by
neutrophils
False positives
Improperly cleaning the skin, resulting in contamination with skin flora
LP
Indicated if the diagnosis of sepsis or meningitis is
considered
Seizures upon presentation
UA/Urine culture
20% of children with UTI have a normal UA based on
a negative reagent strip
Infants < 8w with UTI 50% will have normal UA
Best method if not toilet trained
Bladder catheterization or supra-pubic aspiration
CXR
Admit to Hospital
Further Treatment and Management by
Inpatient Team
Meningitis:
Bacterial (1.2%)
Bacteremia (2.1%):
History
Physical examination
Investigations
History:
Full term
Previously healthy
Investigations:
WBC 5,000 and <15,000
Band to neutrophil ratio <0.2 or <1500
bands/microl
Urine microscopy < 10 WBC (High power field)
CSF < 8WBC (HPF)
Stool < 5 WBC (HPF)
Normal CXR
Cool sponging
Fan therapy
Antipyretics
Paracetamol:
10-15 mg/Kg orally, IV or rectally, ever
4-6 hours
Ibuprofen:
10 mg/Kg, orally, every 6 hours
Antipyretics are used to provide comfort and
do not alter the course of infection
1.
2.
3.
4.
4.
5.
6.
Febrile seizures
What
is a non-drug approach to
alleviating fever?
Fan Therapy
Tepid sponging with comfortably
warm or tepid water, generally around
30C
Neonates
( 28days)
Young Infants
(28-90 days)
Children
History and
Physical
Examination
Obtain pertinent
medical history
from mother
regarding the
pregnancy,
delivery and early
neonatal life.
Few clues on
history and
examination to
guide therapy.
A targeted medical
examination and
history
Investigations
Complete sepsis
screen: blood,
urine and CSF
Laboratory: White
blood cell count,
Urine and stool
studies
Typical Infections
Infection in 1st
7days of life are
secondary to
vertical
transmission.
After are usually
Streptococcus
Pneumoniae,
Escherichia Coli.
Haemophilus
Influenzae.
* Vaccinations
3months to 3yrs
Neonate