The Febrile Infant

BY:

DRA.Fatma .s.al zahrani

The Febrile Infant

Definition: Temperature >/= 38 C (100.4 F ) Rectal temp closely correlates with core body

temperature Ear/Axillary/Sticker temps are unreliable. Temps vary depending upon time of day

The Febrile Infant

Fever Without A Source

(FWLF)

Acute febrile illness in which the etiology of the fever is not localized after the history and physical examination.

The Febrile Infant

Pathogenesisof fever:

Pathogens → cytokine release →resets thermoregulation of hypothalamus→ maintains a higher body temperatur

Infants < 3 months less likely to have fever

The Febrile Infant

What to do?

Obtaining detailed History Age Parents report of wellbeing Parents report of specific symptoms Height and presence of fever Risk Factors (Prematurity,Immunocompromised) Epidemiologic Factors (Sick contacts)

The Febrile Infant

Physical Exam Give anti pyretic to relax the child if irritable

or in pain Perform throughu physical examination. Look for evidence of serious illness Meningeal signs may not be apparent < 18mo

The Febrile Infant

Approach

1)The high risk age is:

0 – 28 days 28 – 90 days 3 – 36 months

The Febrile Infant

2)Toxic Appearing A clinical picture consistent with the sepsis

syndrome: Lethargy Poor Perfusion Hypoventilation Hyperventilation Cyanosis

The Febrile Infant

3)Lethargy:

Poor eye contact &poor interaction with parents and people arround

The Febrile Infant

Assessing Risk

Rochester Fever Criteria

Yale Observation Scale (Clinical)

The Febrile Infant

Rochester Criteria for Febrile Infants Ages 60 – 90 Days

Criteria Well appearing/Full term No skeletal, soft tissue, skin, or ear infections Previously healthy WBC 5000 – 15,000 Bands <1500 UA: WBC’s < 10/hpf If diarrhea: fecal Leukocytes <5/hpf Interpretation Well appearing febrile infant risk: 7-9% All Rochester Criteria present: < 1%

The Febrile Infant

Yale Observation Scale 3 - 36 Months Quantifies “Toxic Appearance” Quality of Cry Reaction to parents Arousability Color Hydration Social Response Interpretation: Risk increases with higher scores

The Febrile Infant

Low Risk Infants Previously Healthy/Full term No focal Bacterial Infection on PE Good social situation Nontoxic clinical appearance Negative lab screening: WBC 5000 – 15,000 < 1500 Bands Normal UA < 5 WBCs/hpf in stool if diarrhea present

The Febrile Infant

Management: Infants 0 – 28 Days ALL infants should be admitted , with full

sepsis workup (Blood, Urine, CSF) Empiric parenteral antibiotic therapy pending

negative cultures.

The Febrile Infant

Management:

Infants 0 – 28 Days

Most common bacterial organisms

(Group B Strep,E. Coli,Listeria)

Antibiotic coverage Ampicillin and Gentamicin OR Ampicillin and Cefotaxime

The Febrile Infant

Management:

Infants 28 – 90 Days Febrile Infant Toxic OR Nontoxic High Risk OR Low Risk Inpatient OR outpatient

The Febrile Infant

Management:a)Infants 28 – 90 Days Low Risk Outpatient Full sepsis work up and empiric parenteral antibiotic coverage (Ceftriaxone IV/IM)

Follow up within 24 hours If CSF cx (+), admit for IV Abx treatment If Blood cx (+) i) febrile/ill for IV Abx ii) afebrile/well, may consider oral Abx outpt Rx

If Urine cx (+), i)febrile/ill for IV Abx, ii) afebrile/well, consider oral Abx outpt Rx

The Febrile Infant

Management:

Infants 28 – 90 Days

Admit Low Risk if: Immature/Unreliable Parents Unsure of follow up No home telephone Lack of Transportation

The Febrile Infant

Management:

Infants 28 – 90 Days

Nontoxic High Risk Admit Full sepsis work up +/- empiric parenteral antibiotics

Most Common Organisms Late onset Group B Strep Strep. Pneumoniae H. Flu N. Meningitidis

The Febrile Infant

Management:

Children 3 – 36 Months Fever without source accounts for 14% of

outpatient visits Mean probability of occult bacteremia 4% Higher risk of bacteremia with temps >39C Sensitivity of clinical evaluation greater

(89-92%) in this age group

The Febrile Infant

Management:

Children 3 – 36 Months

Nontoxic, Temp > 39 C (102.2 F)

Lab work not indicated if presumptive diagnosis is URI, or sick contacts with URI

- CBC w Diff, Blood Cx

-CXR indicated if signs of LRI, WBC > 15, Temp > 104- urine culture (catheter or suprapubic) is gold standard

UA/Urine cx if males < 6 months and females < 2years

The Febrile InfantManagement:Children 3 – 36 Months Most Common Organisms Strep. Pneumoniae H. Flu N. Meningitidis Strep. Pyogenes Staph Salmonella

The Febrile Infant

AntibioticTreatment:

-Children 3 – 36 Months

Nontoxic, Temp > 39 C (102.2 F) WBC > 15,000 UA (+) Can treat with Abx without LP in this age Group optional)

The Febrile Infant

Treatment:Children 3 – 36 Months Ensure follow up If Blood cx (+) i) febrile/ill f0r admission & IV Abx

ii) a febrile/well, consider outpt oral Abx

Most studies indicate that treatment with parenteral

Abx associated with least risk of further sequelae If Urine cx (+) i) admit if febrile/ill for IV Abx

ii) a febrile/well, consider outpt oral Abx

The Febrile Infant

Summary

Guidelines is one way to assist physicians in managing infants and children with fever without a source .They are flexible and management may be individualized according to the case.