Pediatric Fever

Fever without a source

Most common sources

• Lungs

• Urine

• CNS

• Abdomen

• Skin

History

• Tmax (rectal)

• Resp symptoms

• Rash

• Seizures

• Urine/stools

• Pain

• Exposures

• PMH

  • Perinatal

    • Adjust age (chronologic age in weeks – [40 – gestational age in weeks])

    • Mother GBS status

    • Maternal fever/tachycardia/abdominal pain (chorioamnionitis)

    • Mother HSV

    • Birth weight/APGAR

    • Post-partum course

  • Immunocompromised (cancer, asplenia, HIV), history of infections/multiplications

  • Vaccinations

• Meds (antipyretics, antibiotics)

  • Mother's medications if breastfeeding (may pass through breastmilk)

• Allergies

Physical Exam

• Alertness (AVPU)

• ABCs

  • Airway patent/maintainable

  • Breathing (RR, O2sat, WOB, auscultation)

  • Circulation (BP, HR, cyanosis, cap refill, femoral pulses, distal pulses, auscultation)

• Temp rectal

• HEENT / hydration status

• Neuro

  • Fontanelle

  • Pupils

  • Tone/Reflexes

• Abdominal

• MSK

  • Joints

  • Ambulation (limp)

• Skin

Red Flags

• Cyanosis, poor peripheral circulation

• Petechial rash

• Inconsolability

• Parental and physician concern 

Work-up <60d if no focal infection found

• CBC, CRP

• Urinalysis and Urine culture

• Blood culture

• Consider

  • Procalcitonin

  • LP (cell count, culture, Gram stain, protein, glucose, and viral studies)

    • Optional in >1 month old and low risk (see below)

  • CXR

    • Optional if suspect bronchiolitis  OR absence of resp sx and >2 months

  • Stool culture if diarrhea

  • NPA for respiratory virus (influenza)

Low Risk Invasive Bacterial Infection (IBI)

Using previously described predictions rules (Step-by-Step and PECARN), may consider avoiding LP/antibiotics in well-appearing 29-60 day old with

• Rectal T<38.6 °C 

• UA negative (neg LE/NI with <5WBC on hpf)

• Procalcitonin ≤0.5 ng/mL

• ANC <4000/microL

• CRP <20

Note: However these labs were rapidly available <60 minutes

Work up 61-90d if no focal infection found

• Healthy, vaccinated, well-appearing, low-risk

  • UA

    • If negative, close out-patient follow-up

    • If positive, oral antibiotics with close outpatient follow-up

In >90d, rule out UTI

• • <3 years old, if fever with unclear source

  • >3 years old, consider testing if presence of dysuria, urinary frequency, hematuria, abdominal/back pain, daytime incontinence

Treatment

• Empiric IV antibiotics and fluids

  • <1 month

    • Ampicillin (100-200mg/kg/d IV divided q6h) + Cefotaxime 50mg/kg IV q8h or Gentamycin 2.5mg/kg IV q8h  or Tobramycin 6mg/kg IV q24h with dose adjustments

  • >1month, urinary findings

    • Cefotaxime 50mg/kg IV q8h

  • 1-3 months

    • Non-meningitic: Ceftriaxone 50mg/kg/day IV divided q12-24h

    • Meningitis: Ceftriaxone 100mg/kg/day IV divided q12-24h

    • Add ampicillin 100mg/kg IV q6g (3g max/dose) for Listeria or enterococcus concern

    • Add vancomycin 15mg/kg/dose IV q6h for MRSA if concern

• Consider empiric antivirals (acyclovir), especially if suspect HSV meningitis

• Antipyretic may help for prognostication and examination

  • Ibuprofen 10mg/kg TID

  • Acetaminophen 15mg/kg QID

Prolonged Fever

• Rule  out Kawasaki

• Fever ≥ 5 days (if any of the 4 below criteria present at any time during illness, diagnose on day 4 of illness)

  • Conjunctivitis (bilateral nonexudative)

  • Rash (polymorphic)

  • Adenopathy (Cervical lymph node >1.5cm)

  • Strawberry tongue (oral mucous membranes changes, also injected/fissured lips, injected pharynx)

  • Hands and feet edema (acute)/desquamation (convalescent)

• Other useful findings: Redness/crust formation at BCG vaccination site (50% will have this)

• Consider labs (WBC, platelet, AST, ALT, CRP, ESR, Urinalysis for pyuria, consider viral testing for alternative diagnoses)

• Treat with ASA and IVIG to prevent coronary artery aneurysms