Fever resident survival guide (pediatrics)

Resident Survival Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Marufa Marium, M.B.B.S[2]

Synonyms and keywords:

Fever resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Fever in Children is exceptionally recurrent presenting complaints in pediatric department or emergency department or primary care comprising of 15-25%. Most of the parents has immense concern regarding this complaints. Physiologic thermoregulatory elevation of body core temperature above the standard quotidian temperature may termed as fever. As an ancient presenting complaints fever is thought to be an evil spirits by most of the ancient civilizations for example Egyptian, Greek, Mesopotamian etc. There were various ideology regarding fever as the Roman used to worship a God of fever, whereas in the middle age, by Persian famous scholar Avicenna, fever was explained as increased temperature produced by heart diffusing throughout the whole body. 'The Medical renaissance' removed the confusion by describing fever as a physiologic response of an infection in eighteenth century. A number of factor influences fever for instances Chronological age, stage of activity, durational variations(lower body temperature in morning, and higher in late afternoon), food intake etc. The body core temperature is estimated from different parts of body. American Academy of pediatrics has provided information on the accuracy of rectal temperature in infants under four years. But due to its uneasiness of patients oral temperature is the most preferred method in usual population whereas in children under 5 years axillary temperature is sensitive in clinical settings. The mechanism of fever comprises of several components, it includes-Toxic insult/ Infection / inflammatory mediatiors → Macrophage/endothelial cells → Pyrogens(Exogenous: LPS from Gm- organism/ Toxin from Microorganism and EndogenousIL-6/IL-1/IFN-a/TNF-a/Ciliary neurotropic factor/Muramyl Dipeptidase/Enterotoxins) and Cryogens(IL-10, Hormones like MSH, CRH, Neuropeptide Y, Bombesisn, Thyroliberin) → endothelial cells of Hypothalamus → PGE2 → Cyclic AMP → Elevation of Thermoregulatory set point → Heat conservation and production by → fever. The most common cause of fever is infection of any variety like bacterial, viral, fungal, parasitic, other causes are due to malignancy, autoimmune, medications etc.

Causes

Life Threatening Causes

Life-threatening causes of fever includes red flag symptoms or signs (Impaired intake of food, Fussiness, Irritability, Inconsolable crying, Lethargy, Poor moto stimuli response, pallor or cyanosis or or ruddiness mottling of skin, tachycardia, tachypnea, Delayed CRT/ Hypovolemia with reduction in urine output, Bulging fontanelle, Petechial or purpuric or blanching rash, Nuchal rigidity, Rigors, Drooling, tripod position, Vomiting) along with high body core temperature that may result in death or permanent disability within 24 hours if left untreated.

• Sepsis
• Toxic Shock Syndrome
• Scalded Skin Syndrome
• Meningitis
• Pneumonia
• Influenza
• Stevens-Johnson syndrome/ Toxic Epidermal Necrolysis
• Acute Rheumatic Fever
• Typhoid Fever
• Malaria, Dengue, West Nile Fever
• Encephalitis
• Osteomyelitis
• Septic Arthritis
• Mastoiditis
• Retropharyngeal Abscess
• Kawasaki Disease
• UTI
• Orbital Cellulitis
• Central line associated fever

Common Causes

• Infectious causes are bacterial, viral, parasitic, fungal whereas noninfectious causes include autoimmune disease, malignancy, drug fever, congenital cause.
• Infectious:
  • Bacterial: Tonsillitis, abscess, sinusitis, tuberculosis, cellulitis/erysepelas, endocarditis, pyelonephritis, Shigellosis/bacilary dysentry, staphylococcal food poisoning, V.Parahemolyticus/ V.vulnificus/V.Cholerea infection, mycoplasma, listeriosis, brucellosis, bartonella, leptospirosis etc.
  • Viral: Adenovirus, RSV, CMV, EBV, HIV, HSV, Hepatitis virus, Parvo Virus, Enterovirus, Measles Virus, Mump Virus, Parainfluenza, Noro virus etc.
  • Fungal: Cryptosporidium, Candia, Blastomycosis, Histoplasmosis, Pneumocystis Jiroveci.
  • Parasitic: Malaria, Toxoplasmosis, Amebiasis, Ehrlichiosis, Q fever, Leishmaniasis, Helminthiasis, Lyme disease, Rocky Mountain spotted fever.

Non-infectious:

• • Malignancy / Hematologic: Leukemia, Lymphoma, Sickle cell anemia, hemophilia, cyclic neutropenia, Langerhans cell histiocytosis.
  • Genetic / Congenital: Familial Mediterranean fever, TNF associated periodic fever syndrome, Neonatal Onset multisystem inflammatory disorder (NOMD), Familial cold autoinflammatory syndrome, familial dysautonomia.
  • Autoimmune: Systemis juvenile idiopathic arthritis/still disease, granulomatosis with polyangitis, behcet disease, polyarteritis nodosa, henoch-scholen purpura, antiphospholipid antibody syndrome, SLE, sarcoidosis, hyperthyroidism, benogn giant cell lymhnode hyperplasia/castleman disease, , juvenile dermatomyositis.
  • Other: Diabetes incipidus, pancreatitis, serum sickness, drug fever etc IG4 related disease, factious fever, hypothalamic dysfunction.

FIRE: Focused Initial Rapid Evaluation

Focused Initial Rapid Evaluation is done following several criteria or guideline to identify and quantify the risk in febrile infants/children and clinically manage patients according to risk. The criteria or guidelines are:

• Rochester criteria (Infants up to 60 days of age)
• Philadelphia criteria (Infants from 29-60 days of age)
• Boston criteria(Infants of 28-89 days of age)
• The 2007 NICE traffic light system
• 'Red features' of 2013 NICE traffic light system
• The Dutch college of general practitioner guidelines
• Yale observation scale
• A pneumonia rule
• A meningitis rule

After evaluation with these criteria and guidelines, extensive clinical examination, Continuous monitoring, laboratory findings, parental reassurance and guidance, safety measurements aids adjunctive diagnostic approach in evaluation febrile infants/children.

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of fever in infants and young children according the the American Academy of Family Physician guidelines.

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Fever in children.

{{familytree | | | | | | | | | | | | B01 | | | | | |B01=Physical Examination: •General appearance: Restlessness/ Irritable/lethargic/Inconsolable crying/fussiness?
• Skin: decreased or normal turgor/ pallor/cyanosis/Mottling/ruddiness/rash?
• HEENT: Headache/Dizziness/Bulging fontanelle/nuchal rigidity/rigors/rhinorrhea]]/otorrhoea/earche/erythematous tympanic membrane/orbital cellulitis/tender sinus point?
• CVS: Dysrhythmia/Tachycardia?
• Respiratory: Tachypnea/ Hypoxemia, Compensatory hypoventilation, Wheezing, stridor, rhonchi, crackles, [[increased or decreased fremitus Pulmonary microatelactasis, Increased V/Q mismatch
• GI: Nausea/vomiting/diarrhea?
• GU: Urine output, frequency?
• CNS: Confusion, loss of consciousness/Mental obtundation, Neuromuscular excitability/Muscle cramps, Poor motor stimuli response, Tremor, tingling and numbness in extremities, Weakness? }}

History: • H/O Familial Mediterranean fever/TNF associated periodic fever syndrome/Neonatal Onset multisystem inflammatory disorder (NOMD)/Familial cold autoinflammatory syndrome/familial dysautonomia? • Recent or current Antibiotics/Sulfa containing drug/diuretics/antiepileptic medication/antidepressant/digoxin/steroid]] use?

Younger than 29 days?

yes: • Blood Test (CBC with differential count, blood culture) • Urine test (Urine analysis, urine culture) • Lumber punture • Stool test (stool analysis, fecal WBC count) • Chest radiography

NO Red flags present and more than 29days of age then • Blood Test (CBC with differential count, blood culture) • Urine test (Urine analysis, urine culture) • Lumber punture • Stool test (stool analysis, fecal WBC count) • Chest radiography

more than 29 days and Red flags present? yes, then inpatient management • Blood Test (CBC with differential count, blood culture) • Urine test (Urine analysis, urine culture) • Lumber punture • Stool test (stool analysis, fecal WBC count) • Chest radiography

Broad spectrum antibiotic for generalized cause

Broad spectrum antibioticfor UTI

• Ceftriaxone • Cefotaxime

• Cefotaxime

'Empiric antibiotic (Ceftriaxone, cefixime, azythromycin, amoxicillin) and if No good outpatient follow up

Empiric antibiotic (Ceftriaxone, cefixime, azythromycin, amoxicillin) and if Yes good outpatient follow up

• Inpatient monitoring

• Close outpatient monitoring

Ampicillin

Gentamicin

Cefotaxime

Treatment

Shown below is an algorithm summarizing the treatment of Fever in children.

Fever in children

symptomatic management

Antimicrobial management

• Hydration •IV fluid •Tepid sponge • Airway, breathing, circulation maintenance

Acetaminophen, NSAIDs

Steroid, Immunoglobulins, antiepileptic medications for other inflammatory or immunologic cause or seizure

According to blood, urine, stool culture

Aspirin in Kawasaki disease

Broad spectrum antibiotic and then narrowed down according to culture and sensitivity

Rule out bacterial cause

Bacterial: Ampicillin, gentamicin, cefotaxime, cefixime, vancomycin

Antiviral, anti fungal, Anti parasitic medications according to causal agent

Do's

• Monitoring and Maintenance of hydration by physicians, nurses, parents.
• Careful evaluation for identifying the 'red flags'.
• Stress factors of catabolism triggers fever, so these should be evaluated and avoidance of it will prevent recurrence of fever.
• Dosage and concentration of medications should be measured with the greatest care according to pediatric dose.
• Using a standardized delivery device for application of medication on children.

Don'ts

• Bath with cold water, inappropriate dressing (over or under) are not recommended.
• Don't use aspirin except for Kawasaki disease.
• Higher Acetaminophen and NSAIDs dosage is not are not recommended.
• Combination therapy with acetaminophen and Ibuprofen are not encouraged.