by Jabeen Fayyaz
A 2-month-old female child was brought in with a history of cough and fever for 2 days. As per mother, the fever was high grade, documented as 38.5ºC with an inability to drink for the last 4 hours. There was history of an episode of cyanosis at home with coughing an hour ago. On examination, the child was looking dull and lethargic. Her vital signs were: Temp 39ºC, HR 170/ min, RR 65/ min, SPO2 89% in room air, BP 75/50mm of Hg, and Capillary refill time 4 sec. Chest on auscultation has bilateral crepitation. The child was taken immediately in the resuscitation area and was put on high flow oxygen. Reflo was 4.5 mmol/ L. The blood work up and CX-ray ordered showed right middle zone consolidation. IV antibiotic, Cefotaxime was administered. The child was kept on IV fluids and cardiac monitoring. The child was admitted to the high dependency unit.
Fever is one of the most common reasons for the Pediatric Emergency Department (PED) visits. It accounts for almost 10% to 25% of PED visits annually. Febrile illness in children is caused mostly by viral infections, but a significant proportion, especially in children who are less than 3 months old, are caused by serious bacterial infection (SBI). As an ED physician, the goal is to identify this population at risk and to promptly manage them.
SBI has been reported to affect 6-10 % of infants who are younger than 3 months and 5-7% of children who are between 3-36 months of age. Therefore, you should always be very careful when evaluating a child with fever under 3 years old. The infant’s immune system is relatively immature during the first 2 to 3 months of life. This puts them in a very high risk group.
SBI can even be found in the presence of viral infection concomitantly, 5% of patients with confirmed viral sources having urinary tract infections or other SBIs. Infants and children presenting with a fever and signs of a viral illness should have investigations to confirm the viral etiology, but should also be assessed for other sources of bacterial infections. Details of this approach can be found in Policy Clinical Guideline.Children with an apparent focus or are sick looking are easy to manage. However, it is very challenging and many gray zones in managing the well-appearing infants and children with febrile illness without any source in the chaotic ED environment. Febrile illness in children results in significant parental anxiety. Management decisions about febrile children are further complicated by the fact that parents and physicians weigh the risks and costs differently.
In a study (Byington 2004), common sources of bacterial infection in children less than 90 days were found UTI, bacteremia, soft tissue infection, meningitis, and pneumonia.
Fever is defined as temperature ≥38°C measured rectally or tympanic/axillary temperature of approximately 37.5°C. If parents state that fever is documented at home by a thermometer, it should be considered as fever recorded in the ED and should be evaluated in the same manner. Another important consideration mainly in neonates is hypothermia. Neonates may respond to SBI with hypothermia rather than hyperthermia, so they need to be evaluated carefully for any other sign of toxicity.
Normal temperature ranges in children measured by different method
|Measurement method||Normal temperature range|
|Rectal||36.6°C to 38°C (97.9°F to 100.4°F)|
|Ear||35.8°C to 38°C (96.4°F to 100.4°F)|
|Oral||35.5°C to 37.5°C (95.9°F to 99.5°F)|
|Axillary||34.7°C to 37.3°C (94.5°F to 99.1°F)|
Temperature in children can be measured at the axilla, rectally, orally or via the ear (tympanic). Younger children (<5 years old) cannot manage the glass thermometers because it can break easily. Therefore, this method is not recommended for this age group. To check the temperature in newborns and young children, axillary measurement is an acceptable method. However, children under 2 years of age may need confirmation with a rectal temperature. Rectal temperature is considered the gold standard. Bundling a young child may increase the skin temperature but not the core temperature. It should also be considered in neonates and children less than 2 years of age where other methods are not reliable. Studies have shown a good correlation between the tympanic temperature and rectal temperature, especially in children more than 2 years of age. On the contrary, axillary temperatures have a lower correlation. If there is any doubt about a child’s temperature, rectal temperature measurement should be considered for confirmation. Rectal temperature should be avoided in neutropenic and immunocompromised children.
Recommended methods to measure temperature by age
|Birth -2 years||First Choice||Rectal (for exact temperature)|
|Second Choice||Axillary (to check for fever)|
|Between 2 and 5 years||First Choice||Rectal|
|Older than 5 years||First Choice||Oral|
History and Physical Examination Hints
The detailed history and physical examination are the most vital in the assessment of the febrile child. It is critical to pay attention to the history provided by parents for documented fever at home as studies have shown it is moderately accurate; further evaluation should always be carried out because a subjective fever at home may be the only indicator of a possibly serious bacterial infection in a child who is afebrile in the ED.
Focused history on fever characteristics should be asked, as it may provide useful clues. There is an increase in the rate of pneumococcal bacteremia with a rise in temperature, especially in young children. Studies suggest that the incidence of SBI is higher in patients who have higher temperatures. The duration of the fever at the time of ED presentation does not help to predict occult bacteremia. The response to antipyretic medications does not predict bacterial or viral infection. Other important data to be considered include associated signs and symptoms, underlying medical conditions, exposure to ill contacts, and immunization status.
In the exam, evaluate the quality of the cry? High pitched, or weak in effort? Does the child appear fearful of the doctor, nurse? It is normal to see healthy young children’s fear of strangers. Therefore, if you expose to a child who lies on the exam bed and not interacting things around him or not showing his/her fear, then you need to think about more serious illness on those. Examination of skin is very important. So, skin color, cyanosis or jaundice, rashes should be evaluated. Although the skin may give a clue about the degree of hydration, tears during crying, moisture on the oral mucosa/lips and tongue should be checked. For the neonate, “gentle” palpation of the anterior fontanelle indicates current the fluid status. If the fontanelle is sunken, this shows hypovolemia/dehydration.
An assessment of the child’s overall appearance is critical. Although there is an imperfect correlation between physical examination findings and serious bacterial illness, ill-appearing children are more likely than well-appearing children to have serious bacterial infection, and most well-appearing children do not have serious bacterial infection.
Toxic appearence includes lethargy with poor perfusion (delayed capillary refill, cold hands and feet, pale or mottled skin) or cyanosis or respiratory distress findings. Grunting is considered one of the most important signs to identify a sick child and may indicate an impending respiratory failure.
Assessment of Clinical Condition in Children on Physical Examination
|Alertness/ Activity||Strong cry or not crying / smiles / stay awake/ normal response to social cues||Drowsy / decreased activity / poor smile/response to social cues/ irritable||Wakes only with prolonged stimulation/ unable to arouse/ weak cry / high pitched cry/ continuous cry/ bulging fontanelle /grunting|
|Breathing||Normal work of breathing||Nasal flaring||Chest indrawing /RR more than age specific rates/grunting|
|Color / Circulation||Normal lips, skin, tongue color||Pale per caregiver||Pale / mottled / blue / ashen|
|Fluid/ Urine output||Normal skin and eyes/ moist mucus membranes||Poor feeding in infants / dry mucus membranes / reduced urine output||Reduced skin turgor / bilious vomiting|
|Others||New lump >2 cm||Appears very unwell to health care professional|
The physical examination may reveal focal infection, and if so the need for additional testing decreases. For example, the children who have clinically obvious viral illness such as croup, chicken pox have lower rates of bacteremia than the children who have no obvious infection source. Except for neonates and young infants, if a child has a nontoxic appearance, a more selective approach can be undertaken. When a child has an identifiable cause, the treatment and disposition should generally be tailored to this specific infection.
NICE green light system.
Emergency Treatment Options
Airway, breathing, circulation (ABC) is the priority for all patients. Supplemental oxygen or advance airway measure can be necessary. Open intravenous access to draw blood samples, fluid infusion, and medications. Monitor the patients’ vitals. Early treatment of fever is important. This gives the patient comfort as well as optimal physical examination condition for the physician.
Acetaminophen and ibuprofen both can be used. They can overlap during the treatment period to control fever. Some studies favor acetaminophen because of its fast effect. Other studies found that combination of acetaminophen and ibuprofen is very effective regime. Recommended doses are acetaminophen 15 mg/kg and ibuprofen 10 mg/kg.
Empiric antibiotic regimes should also be considered
- Age 0-28 days: ampicillin + gentamicin or a third-generation cephalosporin
- Age 29-56 days: Ill appearing children can receive same regimen above. The children who can discharge home do not need empiric antibiotics.
Ceftriaxone is a preferred agent by some clinicians before ED discharge.
- Age 2-24 months: Empiric antibiotic therapy is not indicated for well-appearing children if there is no defined bacterial source and will be managed as outpatients.
Finding venous access, waiting the lab results and availability of the antibiotics are couple obstacles to apply timely antibiotics to children with fever.
Toxic appearance, need for monitoring, need for fluid treatment, poor social condition, follow up chance for the next day with the primary physician are factors affecting admission decisions. However, admission is warranted for febrile infants 28-56 days old regardless of the above factors.
If the patient meets all of the following low-risk criteria, they may be discharged home.
- Full-term birth
- Not hospitalized longer than the mother
- No toxic appearing
- Not received antibiotic within 48 h
- No dehydration
- No lethargy
- No irritability
- No wheezing
- No infections in the ear, skin, soft tissue, skeletal
- No focal infection source
- No hyperbilirubinemia
- No underlying or chronic illness
- No previous admissions
- CSF – WBC < 8/hpf
- WBC – 500-15000/mm3, PMNL < 0.2
- Urine WBC <10/hpf
- No infiltration on chest x-ray
- Fecal leukocytes < 5/hpf
Red Flags to be explained to parents at the time of discharge. The parents should be instructed to follow-up after 24-48 hours as per clinical condition in the primary health care system. A detailed account of danger signs should be explained to parents and if possible given a handout. It should be emphasized to them that if they notice or observe any of the following, they should come back to the ED immediately as it indicates worsening of the child’s condition:
- Have breathing difficulty
- The lips, tongue or nails appear blue
- Crying continuously and inconsolable
- Refuse to eat or drink or appear too sick to eat or drink
- Vomiting whatever eating
- Has headache
- Has stiffness
- Develop skin rash
- Has severe abdominal pain
- Anything that worried parents from his baseline
Links To More Information
- CDEM Curriculum – Pediatric Fever- https://cdemcurriculum.com/pediatric-fever/
- REBEL EM – The Challenge of Fever in Kids – http://rebelem.com/the-challenge-of-fever-in-kids/
- LITFL – NICE fever guidelines for kids – https://lifeinthefastlane.com/nice-fever-guidelines-for-kids/
- EM cases – Episode 48 – Pediatric Fever Without A Source – https://emergencymedicinecases.com/episode-48-pediatric-fever-without-source/
- DFTB – A NEW APPROACH TO FEBRILE INFANTS – https://dontforgetthebubbles.com/step-by-step-a-new-approach-to-febrile-infants/
- DFTB – FINDING THE FEVER – https://dontforgetthebubbles.com/finding-fever/
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