How to approach a child with fever

Warunee Punpanich, MD Pediatric Infectious Division Queen Sirikit National Institute of Child Health

The kids in our classroom are infinitely more significant than the subject matter were teaching them! Meladee McCarty

What is normal core body temperature?

Normal core temperature : 37C (98.6F) + 0.8 diurnal variation = 0.6 - 1.1C maximum temperature

~ 4 - 6 pm.

 Oral - axilla temp < 1C Rectal - oral temp < 1C (generally 0.4C (0.7F) higher than oral readings)1 Tympanic membrane ~ oral temperature (not reliable for < 3 year old children): underestimate core temp by 0.5 C
Axillary temp underestimate core temp 1 C Lower esophageal temp > core temp The standard definition of fever is a rectal temperature of > 100.4F (38.0C). A life-threatening event occurs in approximately 1% of children presenting to an acute care setting with fever.2
1. Harrisons Internal Medicine 2. http://www.emedicine.com/EMERG/topic377.htm

Pathophysiology of fever

Raising of the hypothalamic set point in CNS

Infection, CNT disease, Malignancy Reduced by antipyretic & physical removal of heat ASA overdose, hyperthyroidism excessive environmental temperature malignant hyperthermia ectodermal dysplasia, heat stroke anticholinergic drug poisoning

Heat production exceeding heat loss

Defective heat loss

Mechanism of fever production

Exgenous Pyrogens Viruses Endotoxin Bacteria Ag-Ab complexes Fungi Drugs

Antigen+ Sensitized T-Cells

Phagocytic Leukocytes Monocytes Macrophages Neutrophils

Interleukin-1 lymphocyte-activating

Interleukin-1 endogenous pyrogen

Interleukin-2
Proliferation of Helper T-Cells

T-Cell

Preoptic Anterior Hypothalmic Nuclei

Prostaglandins

Fever

Interleukin-1

Phospholipids phospholipase A2
Arachidonic acid Cyclo-oxygenase Endoperoxides Leukotrienes lipogenase

Prostacyclins

Prostaglandins (PGE-2) Fever

Thromboxanes

Metabolic and physiologic response

1. HR increase ~ 15 BPM/1C 2. Metabolic Rate 10-12%/1C 3. Insensible water loss : 300-500 ml/m2/day 4. Electrolyte & nutritional consequence

Classification of fever according to etiologic diagnosis

Endogenous Cause
- Infection & Inflammation - Malignancy - CNT Disease Tissue injury - Hereditary : FMF, Ectodermic dysplasia - Metabolic Dz - Kawasaki - Endocrine - CNS (thermoregulatory center) - granulomatous Dz

Exogenous cause
- Drug : cocaine, amphotericin, ATB - Vaccine - Biologic agent : GM-CSF, IL, IFN - Factitious fever

Clinical classification of fever

1. Fever with localizing sign
2. Fever without localizing sign (FWLS)
self-limited fever with localizing sign fever of unknown origin

3. Fever with nonspecific sign 4. Fever of unknown origin

uncommon presentation of common disease Infections (30-50%) CNT disease (10-20%) Neoplasm (5-10%) Miscellaneous (10-20%) Unknown (10-25%)

Fever w/o localizing sign

Occult bacteremia occurs with an incidence of 3-5% in children younger than 24 months with fever. Studies in the 1980s-1990s showed the rate of occult bacteremia was as high as 5%. In the 21st century, studies show a decline in the rates to as low as 0.5-1%.

This change is most likely due to the increasing rates of pneumococcal vaccinations.

http://www.emedicine.com/EMERG/topic377.htm

Diagnosis & Evaluation of Acute febrile illness including FUO

History taking :

-Characteristic of fever : onset, duration, pattern

-Associated symptoms -Assessment of risk factors : - Host, Agent, Environment (animal-contact, recent travel, raw meat consumption (tularemia), vaccination etc.) - Hx of pica: Toxocara (visceral larva migrans) or Toxoplasma gondii

Diagnosis & Evaluation of Acute febrile illness including FUO

PE : -general assessment

-level of fever
Risk of bacteremia BT < 39C : 1.2% 39.5C : 6.2% then ( 0.5C : Risk 2% > 41C : 26%

Diagnosis & Evaluation of Acute febrile illness including FUO

PE : -Sweating: The continuing absence of sweat suggests dehydration, anhidrotic ectodermal dysplasia, familial

dysautonomia, or exposure to atropine.

source of infection : eye & eye ground, TM, sinuses, skin sign, CNS, PR, corneal reflex, DTR, Iodine test

Diagnosis & Evaluation of Acute febrile illness including FUO

Additional PE in case of FUO - nailfold capillary abnormalities that are associated with connective tissue diseases such as juvenile dermatomyositis and systemic scleroderma - failure of pupillary constriction due to absence of the sphincter constrictor hypothalamic dysfunction - lack of tears, an absent corneal reflex, or by a smooth tongue with absence of fungiform papillae familial dysautonomia

Nailfold capillary pattern in rheumatic diseases. A, Normal nailfold capillary pattern in a healthy child, with a homogeneous distribution and uniform appearance of capillary loops. B, The nailfold capillary pattern in a child with juvenile dermatomyositis that shows dropout of capillary end-loops, resulting in a wide band of avascularity. Dilated, tortuous capillaries are also seen, some with terminal bush formation that is found in patients with juvenile dermatomyositis, with scleroderma, and with Raynaud phenomenon that may progress to scleroderma

Clinical identification of a toxic child (Yale acute illness observation scales)

1. Quality of cry
2. Reaction to parent stimulation 3. State variation 4. Color 5. Hydration

6. Response to social overtures

Mccarthy et al : Pediatrics 1982;74:802

 Incidences of serious illness are 2.7% for a score of 10 or less, 26% for a score of 11-15, and 92.3% for a score of 16 or more (McCarthy, 1982).
For quality of cry, 1 = strong or no cry; 3 = whimper or sob; and 5 = weak cry, moan, or high-pitched cry. For reaction to parents, 1 = brief cry or content, 3 = cries on and off, and 5 = persistent cry. For state variation, 1 = awakens quickly, 3 = difficult to awaken, and 5 = no arousal or falls asleep. For color, 1 = pink; 3 = acrocyanosis (cyanosis of the extremities); and 5 = pale, cyanotic, or mottled. For hydration, 1 = eyes, skin, and mucus membranes moist; 3 = mouth slightly dry; and 5 = mucus membranes dry and eyes sunken. For social response, 1 = alert or smiles; 3 = alert or brief smile; and 5 = no smile, anxious or dull.

Although high scores correlate well with ill appearance and higher rates of SBI, low scores cannot be used to exclude SBI.

Laboratory Investigation
1. CBC
Risk of bacteremia 5 times if total leukocyte > 15,000 2. ESR, CRP increase in bacterial infection, CNT Dz, neoplasm ESR > 100 : suggestive of Kawasaki Tuberculosis CNT D2 Malignancy Newborn : normal CRP have high NPV (99%) 3. Specific laboratory investigation : culture, X-ray, TT, serology

Management of FWOLS
Age < 3 months : 10-15% serious bacterial infection 5% bacteremia Clinical : Toxic ---> Admit + septic W/U + empiric ATB Nontoxic ---> assessment : CBC, ESR, CRP

Lab assessment - Low Risk : Culture ---> ceftriaxone+F/U - High Risk : Admit + empiric ATB

Age 3-36 month : 4% occult bacteremia

Clinical : Toxic Admit + septic W/U + empiric ATB Nontoxic level of body temperature

BT < 39C observe & F/U within 48 hr. BT > 39C Laboratory assessment : CBC, ESR, CRP Admit + culture + empiric ATB Culture & F/U 48 hr.
Lab assessment : Low Risk F/U High Risk Admit + C/S +empiric ATB

Low risk criteria for febrile infant

(Rochester Criteria for serious bacterial Illness in febrile infant) Clinical criteria
Previous healthy Nontoxic clinical appearance No focal bacterial infection

Laboratory criteria
WBC 5,000 15,000, Band < 1500, Normal ESR Normal UA (WBC < 5/HPF) When diarrhea present : < 5 WBC/HPF in stool

*LP : certainly is not required in all febrile children, but should be reserved for those in whom there is any clinical suspicion of CNS involvement (esp. in children < 12 month)

Harper MB. Update on the management of the febrile infant. Clin Ped Emerg Med 5:5-12. 2004

Fever of Unknown Origin

Definition
Prolong fever FUO : BT > 38.5C > 2 wk : prolong fever of indiscernible cause despite careful initial evaluation

Classic FUO (Adult) : Fever lasting for 3 wk after 1 wk of hospitalization

COMMON CAUSES OF ACUTE FUO IN THAI PATIENTS

Scrub typhus (7.5%)

Influenza (6.0%) Dengue fever (5.7%) Murine typhus (5.3%) Bacteremia (3.0%)

Typhoid fever (1.9%)

Chikungunya (1.1%) Leptospirosis (1.1%) Melioidisis (0.9%) JE infection (0.6%)

A. Lelarasmi 1992

Practical point in evaluation of acute FUO

History taking :
1. Duration of fever usually < 3 week in infections etiology

2. Age group DF, DHF rarely seen in > 40 yr Rickettsial disease and leptospirosis : beyond infancy Typhoid : late childhood/young adolescent
3. Place scrub typhus & malaria : rural dengue, murine typhus, leptopirosis : urban

4. Season Influenza, DHF, Leptospirosis: common in rainyseason & winter rare in summer GI - transmitted disease : common in summer 5. Family history Dengue & Lepto : outbreak or epidemic prone 6. Myalgia If markedly tender suggesting Leptospirosis, staphylococcal septicemia, Trichinosis & Gnathostomiasis

Physical examination : look for :1. Eschar : Scrub typhus Thai tick typhus
2. Rash : generalized rash Evidence against leptospirosis, malaria & enteric fever 3. Subconjunctival hemorrhage (& uveitis) : highly suggestive of leptospirosis & Rickettsia

Laboratory Assessment
1. CBC

- WBC if < 3,000 suggesting Dengue infection > 15,000 suggesting Leptospirosis (severe form) - platelet if decrease suggestive DHF, leptospirosis (severe form of leptospirosis with thrombocytopenia usually have WBC elevation)
- Malarial pigment

2. Serum creatinine > 2 mg/dl 20% of leptospirosis elevate Cr. 3. Evidence of aseptic meningitis leptospirosis / Rickettsia 4. Weil-felix test, IFA or IIP for Rickettsia leptospira titer

5. Stool C/S, BM C/S for typhoid

6. Sterile pyuria : TB kidney & Kawasaki

IF no any diagnostic clue at all,

1. Repeat PBS for malaria 2. Empiric treatment with cotrimoxazole for typhoid

fever
3. If not improve Doxycycline which effective for : Lepto, Scrub, murine typhus, Mycoplasma defervescence within 48 hr.

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