Download Pediatric Fever - Global Emergency Health Medicine

An Approach to Fever without a
Source in Infants and Children
Authors:
Dr. April Kam MD, DTMH, MScPH, FRCPC
Parnian Arjmand MSc, MD Candidate
Dr. David Goldfarb MD, FRCPC
Date Created: December 2012
Global Health Emergency Medicine Teaching Modules by GHEM is licensed under
a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.
Learning Objectives
 Be able to define Fever Without a Source
(FWS)
 Develop an approach to categorizing and
managing a child presenting with fever
 Learn about some of the key red flags and
special circumstances for children
presenting with fever
Caveats…
 Need to be aware of local epidemiology
 Prevalence of infections can vary dramatically
based on geography, season, context of epidemic
 Fever Differential Diagnosis can be quite
broad– we will only cover most commonly
seen entities
 Broaden your differential, particularly in
immunocompromised children (e.g. HIV, severely
malnourished, etc.)
Caveats…(cont’d)
 In many countries the epidemiology is
changing dramatically due to newly
introduced vaccines (e.g. Hib, PCV) and
the spread of HIV
 Can often see co-infections
 e.g. Among < 5 yr olds in Nigeria with confirmed
malaria, 9% also had UTI (Okunola PO et al., 2012)
Caveats… (cont’d)
 Very little published data on the
management of fever without localizing
signs in children in the developing world
 Drug resistance rates climbing dramatically
in the developing world…
Target Audience
 Health care providers working at first level
referral centre – primary care hospital
 Basic laboratory facilities (e.g. microscopy)
and medications available
 Need to adapt to your facility based on
epidemiology, testing, and antimicrobials
available – know the local guidelines!
Main reference
 Integrated Management of Childhood
Illnesses – Management of a Child with
Serious Infection or Severe Malnutrition
 https://apps.who.int/chd/publications/referral_c
are/contents.htm
Definitions
 Fever without a Source (FWS) or Fever
without Localizing Signs (FWLS) or Fever
without a Focus (FWF):
 Rectal temperature > 38°C (> 101ºF) in an
infant or child w/ a physical exam that does not
suggest a focus of infection
Fever
 An intrinsic adaptive response that
activates the immune system
 Is controlled by the hypothalamus
 Shortens the length of disease
Etiologies




Infection
Infection
Infection
Other causes much less likely




Inflammation – e.g. Kawasaki disease
CNS disorder – e.g. Hypothalamic dysfunction
Metabolic
Iatrogenic: drugs, immunizations
4 Major Categories for child
presenting with fever
 Fever due to infection without localized
signs – i.e. FWLS (no rash) in > 2 mo
 Fever due to infection with localized signs
(no rash) in > 2 mo
 Fever with rash in > 2 mo
 Special Situations/Red Flags
 Young infant (7 days - 2 months) – high risk
serious bacterial infection
 HIV infection
 Severe Malnutrition
Differential Dx of FWLS (no rash)
Diagnosis of fever
In favour
Malaria (only in children
exposed to malaria
transmission)
•
•
•
•
Septicemia
• Seriously and obviously ill with no apparent cause
• Purpura, petechiae
• Shock or hypothermia in young infant
Typhoid
•
•
•
•
Seriously and obviously ill with no apparent cause
Abdominal tenderness
Shock
Confusion
Urinary tract infection
•
•
•
•
Incontinence in previously continent child
Vomiting with no diarrhea
Crying on passing urine or increased frequency
White blood cells, bacteria or nitrites on micro/UA
Fever associated with HIV
infection
• Signs of HIV infection (see red flags)
Blood film or rapid test positive
Severe anemia
Enlarged spleen
Jaundice
Differential Dx of Fever with
localizing signs (no rash)
Diagnosis of fever
In favour
Meningitis
•
•
•
•
Otitis media
• Red immobile ear-drum on otoscopy
• Pus draining from ear
• Ear pain
Mastoiditis
• Tender swelling above or behind ear
Osteomyelitis
• Local tenderness
• Refusal to move the affected limb
• Refusal to bear weight on leg
Skin and soft tissue
infection
•
•
•
•
LP positive
Stiff neck
Bulging fontanelle
Meningococcal rash (petechial or purpuric)
Cellulitis
Boils
Skin pustules
Pyomyositis (purulent infection of muscle)
Differential Dx of Fever with
localizing signs (no rash) – cont’d
Diagnosis of fever
In favour
Pneumonia
•
•
•
•
•
•
Viral upper respiratory
tract infection
• Symptoms of cough/cold (e.g. rhinorrhea)
• No systemic upset
Throat abscess
• Sore throat in older child
• Difficulty in swallowing/drooling of saliva
• Tender cervical nodes
Sinusitis
• Facial tenderness on percussion over affected sinus
• Foul nasal discharge
Cough with fast breathing
Lower chest wall indrawing
Fever
Coarse crackles
Nasal flaring
Grunting
Differential Dx of Fever with rash
Diagnosis of fever
In favour
Measles
•
•
•
•
•
•
Typical rash
Cough, runny nose, red eyes
Mouth ulcers
Corneal clouding
Recent exposure to a measles case
No documented measles immunization
Viral infection
•
•
Mild systemic upset
Transient non-specific rash
Meningococcal infection
•
•
•
•
Petechial or purpuric rash
Bruising
Shock
Stiff neck (if meningitis)
Relapsing fever
(borreliosis)
•
•
•
•
•
Petechial rash/skin haemorrhages
Jaundice
Tender enlarged liver and spleen
History of relapsing fever
Positive blood smear for Borrelia
Typhus
•
•
Epidemic of typhus in region
Characteristic macular rash
Dengue Hemorrhagic
Fever (or other HFs)
•
•
•
•
•
•
Bleeding from nose or gums, or in vomitus
Bleeding in stools or black stools
Skin petechiae
Enlarged liver and spleen
Shock
Abdominal tenderness
Special Situations/Red Flags
 Young infant – 7 days to 2 months
 HIV infected child
 Severely malnourished child
Young infant 7 days – 2 months
 Presume Serious Bacterial Infection
 e.g. Pneumonia, sepsis, meningitis
 Show less specific signs
 Can present with Fever or Hypothermia
 Irregular breathing, jaundice, apnea, grunting, seizure,
vomiting, abdominal distension, lethargy, anorexia
HIV infected or potentially infected
 HIV infected children have higher risk of sepsis and
opportunistic infections
 Signs common to HIV infected infants:
 Recurrent infections, oral thrush, chronic parotitis,
generalized lymphadenopathy, hepatosplenomegaly,
persistent/ recurrent fever lasting >7 days, neurological
dysfunction, Herpes Zoster, HIV dermatitis
 More specific signs: pneumocystic pneumonia, esophageal
candidiasis, lymphoid interstitial pneumonia, shingles or
Kapsosi sarcoma
 Signs common to both HIV infected and non-infected infants:
chronic otitis media, persistent diarrhea, failure to thrive
Severe Malnutrition
 Definition - edema in both feet or severe wasting
and weight for height < -3 SD or <70%
 Assume that all severely malnourished children
have an infection (regardless of presence of
fever) and treat with antibiotics
 On exam look for: dehydration, pallor, signs of
HIV infection/ local infection, fever, ulcers, skin
changes of kwashiorkor
HISTORY AND PHYSICAL
History
 Duration of fever
 Residence in or recent travel to an area with Plasmodium
falciparum (malaria) transmission
 Skin rash
 Stiff neck or neck pain
 Headache
 Pain on passing urine (generally child ≥ 3yr)
 Ear pain – e.g. pulling on pinna
 Immunizations
History (cont’d)










What was the temperature and how was it measured?
Level of activity prior and after onset of fever
Infection(s) during pregnancy or at birth
Ill contacts or recent travel history
Oral intake
Presence of lethargy/ irritability
Presence of cough/ vomiting
Urination frequency/ abdominal pain/ back pain/ new onset of
incontinence (e.g. UTI)
Protection of the affected area in deep soft tissue/ bone infection
Underlying medical conditions (e.g. sickle cell disease, urinary tract
reflux, etc.)
History (cont’d) - Immunizations

It is particularly important to know if Hib, pneumococcal, meningococcal
and/or yellow fever vaccines have been given and are up to date




Nearly all low income countries have now rolled out Hib vaccine
> 18 countries in developing world have also recently introduced
PCV
6 countries in sub-Saharan “meningitis belt” have just introduced
new meningococcal A conjugate vaccine
Rapid increase in number of children vaccinated against yellow
fever with assistance GAVI
 Vaccination with the above conjugate vaccines (i.e. Hib, PCV)
dramatically reduces the risk of occult bacterial infection in
children presenting with fever without localizing signs
Physical Examination
 Always fully undress child
 General appearance (alert, playful, irritable, consolable,
lethargic)
 Oxygen saturations (if available)
 Stiff neck
 Hemorrhagic skin rash - purpura, petechiae
 Skin infections - cellulitis or skin pustules
 Discharge from ear/red immobile ear-drum on otoscopy
 Severe palmar/conjunctival pallor
 Refusal to move joint or limb
 Local tenderness
 Fast breathing
Physical Examination
 Toxic-appearing:




Lethargic: decreased level of consciousness/ poor eye contact, failure
to interact with environment or parents
Poor perfusion and cyanosis
Hypo/ hyperventilation
Woods, CR.
Purpura may be present
Epiglottitis
(supraglottitis):
Clinical features
and diagnosis.
In: UpToDate,
Basow, DS
(Ed),
UpToDate, Walt
ham, MA, 2012.
Physical Examination
 Watch for signs of raised intracranial
pressure:






Bulging fontanelle
Poor feeding, Vomiting
Headache, Irritability
Papilledema
Lethargy, Seizures
Cushing’s triad: hypertension, widened pulse
pressure, bradycardia
Management: Fever in 2 month
– 3 year GROUP
Fever 2 months – 3 years
 The first step is to determine if the child is
toxic looking i.e. septic
 If the patient is septic, do septic work up and
start antibiotics, fluids, and provide oxygen
Fever 2 months – 3 years
 In the non-septic child, the second step is
to determine if the fever is due to an
infection with or without localized signs by
doing a detailed history and physical
 If a focus is found, treat accordingly
 If no focus is found, investigate as FWLS or
Fever without a source
Fever 2 months – 3 years
 Example of an institutional algorithm for
FWLS in the 2 m – 3 year age group
developed for Botswana referral hospital
(where there is very low/no malaria, no
typhoid, no dengue) is provided on the next
page
Algorithm: Fever without a Source – Ages 2 months to 3 years
Definition: Child between 2 months and 3 years with an axillary temperature > 37.5 and
no obvious source of infection after a thorough History and Physical
*Normal Rates
Child Appears Toxic
• Lethargic (not interacting with
caregivers/environment)
•Poorly perfused (cap refill > 2sec)
•Hypoventilating or tachypneic for age
Yes
No
Child is HIV positive, CD4 <25% or unknown or
child is HIV Exposed and HIV status unknown
No
Yes
T > 38.5 axillary
Yes
No
Tests: Blood Cx or FBC and then
Blood Cultures only if WBC > 15,000
UA and Cx: if Male < 6 mo, Female <
2 yr or T > 40
CXR: if dyspnea, cough/rales
LP: if < 15 mo, or associated with
seizure and does not meet criteria for
simple febrile seizure
•No diagnostic test
•Paracetemol 15mg/kg/dose
•Discharge home
•Return if fever > 48 hrs or seems
more sick
•NO Antibiotics
Age
Respiratory
2-12 months
<50/min
Heart
<160/min
1-2 years
<40/min
<120/min
2-5 years
<40/min
<110/min
6-8 years
<30/min
<110/min
Sepsis evaluation
•Blood Culture
•Urinalysis and Culture
•CBC
•LP if indicated by symptoms
•Consider malaria smear if indicated
Admit to Ward
Start empiric antibiotics- Cefotaxime
50mg/kg/dose 6 hourly
Treatment:- If any diagnostic tests are suggestive of a source for infection treat according to protocol for that diagnosis .
However, if no tests are indicated or all test are normal AND If FBC or WBC > 15,000 THEN -> Amox/Clav for 48 hours
If FBC or WBC < 15,000 then do not give antibiotics
ALL children regardless of whether they are given abx NEED: F/U in 48 hours if still febrile or at any time if they appear
more sick & Paracetemol 15 mg/kg/dose
Management – Presumed
Septicemia
 Treatment
 Give benzylpenicillin IV (50 000 units/kg every 6 hrs)
or ampicillin 50 mg/kg IM every 6 hrs) plus
chloramphenicol (25 mg/kg every 8 hrs) for 7 days
 If significant drug resistance to these antibiotics among
Gram-negative bacteria, follow the local guidelines for
management of septicaemia  may be a thirdgeneration cephalosporin such as ceftriaxone (80
mg/kg IV, once daily over 30-60 minutes) for 7 days
Management – Presumed
Septicemia (cont’d)
 Supportive care
 If a high fever of ≥ 39°C (≥ 102.2°F) is
causing the child distress or discomfort, give
paracetamol (15mg/kg/dose every 4 hours,
maximum 5 doses/day )
 Fluid intake and nutritional management
 Manage complications including seizures,
hypoglycemia, electrolyte abnormalities
Investigations for FWLS –
Depending on availability
 Blood smear or rapid diagnostic test (RDT) for
malaria (if endemic)
 LP if signs suggest meningitis (with no signs of
raised intracranial pressure, in stable patient)
 Blood culture in suspected sepsis
 Full Blood Count
 Urinalysis/Microscopy
 CXR – if pneumonia is suspected
Management: FEVER in
7 day – 2 month old GROUP
Management 7 day to 2 month old
 Investigations:




Check glucose
Do Cultures – Urine and Blood
Do an LP
CXR if available
 Management: Oxygen, Fluids, Antibiotics
Management 7 day to 2 month old
 Ampicillin (50 mg/kg IM/IV every 6 hrs for 2
days) then oral amoxicillin (15 mg/kg every 8
hrs for 5 days) OR oral ampicillin (50mg/kg
PO every 6 hrs on an empty stomach for 5
days)
 plus IM gentamicin (7.5 mg/kg once daily) for
a total of 7 days of therapy
 You may continue IV Ampicillin beyond 2 days
if child continues to appear unwell
Management 7 day to 2 month old
(cont’d)
 If S. aureus is known to be an important
cause of neonatal sepsis locally, or signs
suggestive of severe staphylococcal
infection (e.g. skin pustules), give IM
cloxacillin (50 mg/kg every 6-8 hrs
depending on age) plus IM gentamicin (7.5
mg/kg once daily)
Management 7 day to 2 month old Suspected or Confirmed Meningitis
 Give IM ampicillin (50 mg/kg every 6-8 hrs
depending on age) plus IM gentamicin (7.5
mg/kg once daily). An alternative regimen
is IM ampicillin plus IM chloramphenicol (25
mg/kg every 6 hours).
 Chloramphenicol should not be used in
premature infants and should be avoided in
infants in the first week of life
 Some centres use third generation
cephalosporins
MANAGEMENT: SEVERE
MALNUTRITION
Investigations may include
 Glucose (mandatory)
 Labs: Hb/ Htc if severe pallor
 Electrolytes (generally hypokalemic)
 Blood culture
 TB investigations
 HIV testing, etc.
Management of child admitted with
severe malnutrition
 Multidimensional management in two
phases of stabilization and rehabilitation
[see chapter 7 in the WHO manual]
Management of child admitted with
severe malnutrition
 All severely malnourished children
receive

A broad-spectrum antibiotic
 Ampicillin (50 mg/ kg IM/IV 6-hourly for 2 days) then oral
amoxicillin (15 mg/ kg 8-hourly for 5 days) OR oral ampicillin (50
mg/kg IM/IV for 5 days) over a total of 7 days
 Gentamicin (7.5 mg/kg IM/IV) once daily for 7 days
If child fails to improve within 48 hours: add chloramphenicol
(25 mg/kg IM/IV 8-hourly) for 5 days
 Local antibiotic regimen may be different
due to different resistance rates
Management of child admitted with
severe malnutrition
 Measles vaccine if child > 6 mo (not
immunized) or > 9 month
 Delay vaccination if in shock
MANAGEMENT: COMMON
INFECTIONS
Diagnostic Criteria for Urinary Tract
Infections
 Clinical signs:





Malodorous urine/ hematuria
Abdominal tenderness/ suprapubic pain
Vomiting, irritability, diarrhea
Fever > 38 °C for over 24 hrs
Dysuria, vaginitis/ vulvalitis
 Labs:
 Urinalysis from suprapubic aspirate or transurethral catheter
 Leukocyte esterase
 Nitrite
 WBC
 Culture
Treatment of Urinary Tract
Infections
 For Oral agents, be aware of local
susceptibilities – treatment include:
 Amoxicillin/Clavulanate, First generation
cephalosporins, Quinolones
 If <6months, or septic, require admission
and IV Ampicillin & Gentamicin
Other Common Infections

Malaria (seehttp://apps.who.int/medicinedocs/documents/s19105en/s19105en.pdf for
details)
 Varies by severity, endemic species, and resistance patterns
 Antimalarial treatment:
IM/IV Artesunate first line for severe malaria due to P. falciparum in
most regions (pre-referral rectal artesunate an option)

Measles
 Two doses of Vitamin A to all children; immediately on diagnosis
and within 24 hours
Other Common Infections

Typhoid
 Chloramphenicol (25 mg/ kg every 8 hours) for 14 days
 If systemic signs/ upset: benzylpenicillin (50 000 units/ kg every 6
hours) for 14 days in addition to chloramphenicol (dosed as above)

Ear infections


Acute otitis media - Amoxicillin (50 mg/kg PO TID) X 7 days
Chronic suppurative otitis media – wicking and topical antibiotic such as
chloramphenicol drops if available
Summary
 FWS: fever without a specific source in an acutely ill, temp
(rectal) > 38ºC (100.4ºF)
 Infection is the most common etiology of FWS
 There are four categories of infants presenting with fever: young
infant with serious risk of bacterial infection, infectious fever
without rash, fever due to infection with localized signs, and fever
with rash
 Management strategies vary depending on geographical area,
access to resources, presentation, and infant age
 Red flags to watch out for: severely malnourished infant, infant
with signs of HIV and young infant (7 days to 2 months)
General References
 MANAGEMENT OF THE CHILD WITH A SERIOUS
INFECTION OR SEVERE MALNUTRITION
Guidelines for care at the first-referral level in
developing countries. WHO. 2000
 IMCI UTI guidelines: Urinary Tract Infections in Infants
and Children in Developing Countries in the Context
of IMCI
http://whqlibdoc.who.int/hq/2005/WHO_FCH_CAH_05
.11.pdf
Credits
 Dr. April Kam MD DTMH MScPH FRCPC
Assistant Professor, Pediatric Emergency Medicine
Department of Pediatrics, McMaster Children’s Hospital
 Parnian Arjmand MSc MD Candidate
McMaster University
 Dr. David Goldfarb MD FRCPC
Assistant Professor, Infectious Diseases
Department of Pediatrics, McMaster Children’s Hospital
Adjunct Senior Lecturer, University of Botswana