Here are the answers to the questions: 1. D 2. C 3. A 4. A 5. A, B 6. D 7. D 8. B

1. An Approach to Fever
in Infants & Children
DR. TAREK KOTB
MCH
BURAYDAH

2. Why Is The Topic Important?
• 20-35% of urban pediatric ED visits: – “Fever Phobia”
• 65% of children visit their pediatrician with complaint of
fever before their 2nd birthday.
• Diagnoses range from minor to life-threatening
• Multiple conflicting recommendations, guidelines, and
algorithms.

3. To Work Up or Not to Work Up?
• Do all febrile children with no obvious infection site need To be
investigated.
• Specific Questions:
• – Blood tests
• – Lumbar Puncture
• – Urinalysis / Urine Culture
• – CXR
• – Antibiotic use
• – Observation
• – Hospital admission

4. Significant Fever: Definition
Temperature of 38.0 ̊ rectally at rest:
– 0-2 months risks increase at 38.0 ̊
(the occurrence of Serious Bacterial Infection
(SBI) increases from < 1% to 5% at 38.0° C)
– 3-36 months risks increase at 39.0 ̊
Fever Without Source:
“Fever without source is an acute febrile illness in
which the etiology of the fever is not apparent after a
careful history and physical exam.”

5. • In children, fever is generally a sign of infection.
• Fever due to other causes including malignancy is rare.
• The prognosis for the most common forms of paediatric
infections is usually excellent; these infections are much more
likely to be viral
(rhinitis, pharyngitis, laryngitis, bronchitis, bronchiolitis, gastroen
teritis, exanthems) than bacterial (pneumonia, urinary tract
infections [UTIs], sinusitis, tonsillitis, otitis).

6. The medical history, physical examination
when necessary, a few additional complementary tests
usually lead to a prompt diagnosis
Reassurance Treatment

7. Neither the medical history, the physical examination, nor
complementary tests indicate a bacterial infection that can
potentially lead to serious complications.
How can a fever of viral origin be differentiated from one of
bacterial origin? Do all febrile children with no obvious
infection site need a blood culture? Should antibiotics be
administered before the results of the blood culture have
been received?

8. Bacteremia
Prevalence of Serious Bacterial Infection (SBI)
Infants 0-2 Months Old
• Febrile neonates: SBI = 13%
• Febrile infants 1 to 2 months of age: SBI = 10%
• Febrile infants younger than 3 months of age Urinary Tract
Infections account for 1/3 all bacterial diseases
Management of Fever In Infants and Children
Jeffrey R. Avner MD, M. Douglas Baker MD
Emergency Medicine Clinics of North America
Volume 20 • Number 1 • February 20

9. Bacteremia
• In a study performed in children between three and 36 months
with a rectal or tympanic temperature of 39°C or higher, the
incidence of various types of bacteremia was 1.6% .
• H influenzae was not among the isolated germs.
• Over 90% of all bacteremias are caused by pneumococcus .
• The remaining 10% are caused by various bacterial germs, such
as Neisseria meningitidis, nontyphoidal salmonella, group A
streptococcus, group B streptococcus, Escherichia
coli, Staphylococcus aureus and other more unusual germs .
Meningococcus is the most dangerous of them.

10. Bacteremia
• In the absence of treatment, bacteremias either resolve
spontaneously, persist or are complicated by other symptoms.
• The most serious complications arising from occult bacteremia
include
septicemia, meningitis, pneumonia, arthritis, osteomyelitis and
cellulitis.
• The usual prognosis for pneumococcus bacteremia is excellent.
Most cases (90.3%) resolve completely without treatment.#
• Meningococcus bacteremia is rare but high risk. In the absence of
prompt treatment, the speed at which it develops can be rapid. Any delay in
treatment can be catastrophic for the child and have serious legal
repercussions for the physician . The immediate danger arising from
meningococcus bacteremia is that it may lead to purpura fulminans, with
irreversible septic shock and death.

11. AGE
• Bacteremia appears at all ages; however, it is more frequent in
infants between the ages of three and 36 months.
•
• Before the age of three months, the incidence of bacterial
disease in febrile infants is about 10% and that of bacteremia is
between 2% and 3%.
• As a rule, bacterial infections are more serious and insidious in
infants less than three months.
• This group, particularly the neonates, is more vulnerable and is
exposed to a greater variety of causal agents; group B
streptococcus and E coli being the two main ones.
• The main danger during the neonatal period is for UTI or
meningitis

12. Temperature
• the physician’s clinical judgement is usually based on the
temperature and the general appearance at the time of the
examination, not the temperature taken at home. This applies
to all children except those younger than three months. In the
case of normal temperature at the time of the examination but a history of fever, a
sepsis examination is indicated for neonates and possibly some infants between the
ages of one and three months or if there is the slightest appearance of toxicity
• The degree of temperature is an important but misleading
indicator.
• Bacteremia is more frequent in children with a temperature of
39°C or highe .
• The absence of fever or the presence of a low grade fever does
not preclude the possibility of a serious infection .

13. Fever Pitfalls
• 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 don’t correlate well with rectal temps
(Craig, 2000; Craig, 2002; Jean-Mary, 2002)
• 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)
( * No comment on whether or not antipyretics were
given)

14. General appearance of the febrile child
An alert and active child with a healthy appearance, who
is:-
 well hydrated,
 smiles,
 cries vigorously but is easily consoled;
 who watches the physician’s movements,
 seeks his parents’ hand or their soothing eyes
and does not cause worry.
These signs are reassuring and usually indicate a benign
febrile state.

15. General appearance of the febrile child
1.Quality of cry
2.Reaction to parents’ stimulation
3.State variation
4.Colour
5.Hydration
6.Response to social overtures
(Yale criteria for febrile children between three and 36
months)
(up to Each criterion is given a score of either 1 (normal), 2
(moderate impairment) or 3 (severe impairment). A child with a
score of 10 or less is unlikely to have a serious illness (less 2.7%).
A child with a score of 16 or more has a great probability of
serious illness 92.3%). Data from reference(McCarthy PL, Sharpe
MR, Spiesel SZ, et al. Observation scales to identify serious illness in febrile
children. Pediatrics. 1982;70:802–9

16. General appearance of the febrile
child
1.Infant appears generally well
1.Infant has been previously healthy
2.No evidence of skin, soft tissue, bone, joint or ear
infection
3.Laboratory values:White blood cell count between 5000
and 15,000/mm
3
4.Bands 1500/mm
3
or less
5.Centrifuged urine sediment 10 leukocytes/field (×40) or
less
6.Stool smear 5 leukocytes/field (×40) or less – for infants
with diarrhea
(Rochester criteria for febrile children between 30 and 90
days}

17. Leucocytosis
• Bacterial infections are more likely than viral infections
to have a leukocytosis count of 15,000/mm3 or more, but
because viral infections are much more frequent than
bacterial infections, the majority of febrile children with
a high leukocytosis count have a viral infection.
• In healthy children from one to three years of age, the
normal white cell count varies between 6000 and
17,500/mm3;
• in children one month of age it varies between 5000 and
19,500/mm3 (36).
• It is rightly possible to wonder why the risk level for
bacteremia has been set at 15,000/mm3

18. leucocytosis
• The percentage and absolute number of total neutrophils
are more precise and useful than those of unsegmented
neutrophils (bands) ------- why ?
• Children between three and 36 months of age with an
absolute neutrophil count greater than 10,000
cells/m3 are at higher risk of occult pneumococcal
bacteremia: 8% compared with 0.8% for those with an
absolute neutrophil count less than 10,000 cells/m3.
• Conclusion : White blood cell count results can be
confusing for physicians when there is an obvious
discrepancy between the number of leukocytes and the
child’s general condition.

19. OTHER MARKERS OF INFECTION
ESR
CRP
IL8
PROCALCITONIN
CRP AND ESR NON SPECIFIC
PCT has the greatest sensitivity (85%) and specificity (91%) for
differentiating patients with systemic inflammatory response syndrome (SIRS)
from those with sepsis, when compared with IL-2, IL-6, IL-8, CRP and TNF-
alpha.[3] Evidence is emerging that procalcitonin levels can reduce unnecessary
antibiotic prescribing to people withlower respiratory tract infections
Conclusion: It is likely to make the decision more confusing
when there is a discrepancy between the general appearance
of the child and the C-reactive protein result and/or white blood
cell count.

20. CHEST X-RAYS
• An unexplained and persistent fever can be the only
manifestation of pneumonia.
• When faced with high fever and leukocytosis greater
than 20,000/mm3, the physician should suspect
pneumonia .
• Up to 26% of children younger than five years old with an
unexplained fever of 39°C or higher and leukocytosis
20,000/mm3 or higher, who have no respiratory
symptoms, may have a pneumonia that can only be
detected by a chest x-ray.
• In the absence of respiratory symptoms, chest x-rays
are usually normal.

21. UTIs
• Repeated spells of fever or normal tympanic membranes
following several alleged bouts of otitis media should lead the
physician to suspect UTI .
• The diagnosis of a UTI must be confirmed by a culture;
• Thus, febrile infants less than three months of age should either
be catheterized or have a bladder tap.
• Older febrile children who are not toilet-trained and who have a
risk factor for a UTI, such as UTI symptoms, UTI past
history, known renal anomalies, toxic appearance or who have
positive urine analysis by bag specimen should be
catheterized .
• Febrile infants older than three months of age who are not
toilet-trained and are at low risk of UTI should have a bag
specimen taken initially

22. EMPIRICAL ANTIBIOTIC THERAPY
• may reduce the number of serious bacterial complications
• it does not prevent meningitis
• It has not been formally proven that the absence of treatment has
ever been the direct cause of a serious accident
• The scientific data are contradictory and unclear.
• The choice of antibiotics can also be debated.
• Oral antibiotic therapy cannot prevent the risk of meningitis, but it can
delay its diagnosis
• Too liberal a use of ceftriaxone will most likely lead to an increase in
the number of resistant strains of bacteria
• Ceftriaxone is not a panacea, nor is it total risk insurance. It is an
expensive drug that is administered intravenously or intramuscularly in
a painful way.

23. EMPIRICAL ANTIBIOTIC THERAPY
• The widespread use of pneumococcal immunization in the near
future will likely reduce the morbidity and mortality associated
with pneumococcal bacteremias . This will decrease the
difference in outcome between the different approaches:
observation in comparison to the approach of empirical
treatment for all patients or based on an elevated white blood
cell count
• Efficacious and widespread use of pneumococcal immunization
will likely favour the observational approach based on clinical
judgement

24. CASE MANAGEMENT STRATEGIES

25. Home care instructions
Educate parent about appropriate wt-based med dose with
return demonstration
When discharged from ED follow up with primary care
provider within 24 hrs
When discharged from inpatient follow up with primary care
provider in 1-2 days
Reasons to call provider or return to ED

26. CONCLUSIONS
• There are no sufficiently reliable markers of bacterial
infection.
• The physician must therefore practice medicine that is
fraught with empiricism, but also based on sound
scientific arguments and on his or her own personal
experience.
• The child’s general appearance, temperature and
leukocyte count are the best evaluation criteria.
• Practice guidelines never entirely compensate for a lack
of clinical judgement.

27. Let us practise
• 1. In infants younger than 3 months of age, the most
commonly occurring bacterial infection is:
• A. Group B Streptococcal infection
• B. Meningitis
• C. Neonatal sepsis
• D. Urinary tract infection

28. Q2
• 2. Which statement about temperature measurement in
infants less than 3 months of age is accurate?
• A. Bundling (swaddling) causes elevation in skin
temperature, but not in rectal temperature
• B. Fever that lowers quickly after antipyretic medication
indicates a less severe infection than a fever that is less
responsive to medication
• C. Temperature of 38.0°C (100.4°F) is defined as fever
• D. Tympanic measurement is closely correlated with
rectal measurement

29. Q3
• 3. The following asymptomatic infants come to the
emergency department with fever of unknown source.
Who will definitely have a lumbar puncture?
• A. 1 month old
• B. 5 month old
• C. 7 month old
• D. All of them

30. Q4
• For a young infant with fever of unknown source, the
nurse should notify the physician for which abnormal lab
finding?
• A. ANC of 2,000
• B. ANC of 9,000
• C. WBC of 4,000
• D. WBC of 11,000

31. Q5
• A 3 week old infant presents with fever and cough. He
has no signs of respiratory distress and has been healthy
since birth. The nurse anticipates which of the following
orders?
• A. Blood culture
• B. Chest x-ray
• C. Lumber puncture
• D. All of the above

32. Q6
• A fully immunized 6 month old uncircumcised male infant
presents with cough, decreased feeding, temperature of
39.0°C (102.2°F) and a diagnosis of clinical bronchiolitis.
, the nurse anticipates which of the following orders?
• A. Blood culture
• B. Cath UA and culture
• C. Lumbar puncture
• D. RSV viral study

33. Q7
• A 2 year old presents with a fever of 39.1°C, is difficult to
arouse, and eating poorly. Based on the Pediatric Fever
Clinical Practice, the nurse anticipates which of the
following orders?
• A. Blood culture
• B. Cath UA and culture
• C. Lumbar puncture
• D. All of the above

34. Q8
• A 3 month old is discharged from the ED after work up
for fever of unknown source. The nurse’s parent teaching
should include the importance of a follow up
appointment with the baby’s primary care provider at:
• A. 24 hours
• B. 2-3 days
• C. 1 week
• D. Next well baby check at 4

35. Q9
• Fever of unknown origin is most dangerous in the following age
groups:
• A. 0-3 years
• B. 5-7 years
• C. 10-12 years
• D. 15-17 years

36. Finally
•Evaluation & management of fever of unknown source in
infants and
young children is challenging
 History & physical exam may provide few clues to guide
therapy
 Findings may be nonspecific
 Social interaction skill is limited
 Clinical scoring systems identifying those at low risk of
SBI have varying degrees of reliability in the very young.
(Avner &
Baker, 2002)

37. Thank you