Fever Control ============= þ Ibuprofen works slightly better than tylenol for fever (5 mg/kg ibuprofen vs 10 mg/kg acetaminophen). [Van Esch A, et al. Antipyretic efficacy of ibuprofen and acetaminophen in children with febrile seizures. Arch Ped Adol Med 1995;149(6):632.] Fever without a Source in Infants ================================= þ 2008 update: - now, with Prevnar (pneumococcal vaccine) and H. flu B vaccine, SBI (serious bacterial infection more likely if has had a fever for say 3 days, as meningitis much less common, now most SBIs are UTIs. E coli now most common cause of bacteremia. þ Nuchal Rigidity - Oostenbrink says nuchal rigidity is totally unreliable in little kids Oostenbrink, R., K. G. Moons, et al. (2001). "Prediction of bacterial meningitis in children with meningeal signs: reduction of lumbar punctures." Acta Paediatr 90(6): 611-7. Physicians often have to perform a lumbar puncture to ascertain the diagnosis in patients with meningeal signs, because of the serious consequences of missing bacterial meningitis. The aim of this study was to derive and validate a clinical rule to predict bacterial meningitis in children with meningeal signs, to guide decisions on the performance of lumbar punctures. Information was collected from records of patients (aged 1 mo to 15 y) consulting the emergency department of the Sophia Children's Hospital between 1988 and 1998 with meningeal signs. Bacterial meningitis was defined as cerebrospinal fluid (CSF) leucocyte count >5 cells microl(-1) with a positive bacterial culture of CSF or blood. The diagnostic value of predictors was judged using multivariate logistic modelling and area under the receiver operating characteristic curves (ROC area). In the derivation set (286 patients, years 1988-1995) the duration of the main complaint, vomiting, meningeal irritation, cyanosis, petechiae and disturbed consciousness were independent clinical predictors of bacterial meningitis. The ROC area of this model was 0.92. The only independent predictor from subsequent laboratory tests was the serum C-reactive protein concentration, increasing the ROC area to 0.95. Without missing a single case, this final model identified 99 patients (35%) without bacterial meningitis. Validation on 74 consecutive patients in 3 subsequent years (1996-1998) yielded similar results. Conclusion: This prediction rule identifies about 35% of the patients with meningeal signs in whom a lumbar puncture can be withheld without missing a single case of bacterial meningitis. For the individual patient this prediction rule is valuable in deciding whether or not to perform a lumbar puncture. Oostenbrink, R., K. G. Moons, et al. (2001). "Signs of meningeal irritation at the emergency department: how often bacterial meningitis?" Pediatr Emerg Care 17(3): 161-4. OBJECTIVE: Although signs of meningeal irritation are highly indicative of meningitis, they are not pathognomonic. In this study, we described the final diagnoses in children with signs of meningeal irritation, and we assessed the frequency of bacterial meningitis related to specific signs of meningeal irritation. METHODS: Information was collected from records of 326 patients (aged 1 month to 15 years) who visited the emergency department of the Sophia Children's Hospital between 1988 and 1998 with signs of meningeal irritation, assessed by either the general practitioner or the pediatrician. RESULTS: Bacterial meningitis was diagnosed in 99 patients (30%), viral or aseptic meningitis in 43 (13%). Other diagnoses were pneumonia (8%), other serious bacterial infections (2%), and upper respiratory tract infections or other self-limiting diseases (46 %). Presence of one of the signs of meningeal irritation assessed by the pediatrician was related to bacterial meningitis in 39%. Specific tests eliciting meningeal irritation, such as Brudzinski's and Kernig's signs, were not related to a higher frequency of bacterial meningitis than neck stiffness and the tripod phenomenon. In children < or =1 year, bacterial meningitis is more frequently related to presence of irritability and a bulging fontanel. CONCLUSION: Bacterial meningitis is present in 30% of children with signs of meningeal irritation. Presence of meningeal irritation as assessed by the pediatrician is related to bacterial meningitis in 39%. A better prediction of bacterial meningitis was not achieved by using more specific tests for signs of meningeal irritation. þ Yale Observation Scale - attempt to quantify "looks sick." 1. Indications 1. Assessment of febrile child ages 3-36 months 2. Predicts serious infection (Occult Bacteremia) 3. Quantifies "Toxic Appearance" in children 2. Interpretation 1. Score = 10 1. Incidence serious illness: 2.7% 2. Score = 11-15 1. Incidence serious illness: 26% 3. Score >16 1. Incidence serious illness: 92.3% 3. Scoring 1. Quality of Cry 1. Strong or No cry: 1 2. Whimper or Sob: 3 3. Weak cry, Moan, or high pitched cry: 5 2. Reaction to parents 1. Brief Cry or Content: 1 2. Cries off and on: 3 3. Persistent cry: 5 3. State variation 1. Awakens quickly: 1 2. Difficult to awaken: 3 3. No arousal or falls asleep: 5 4. Color 1. Pink: 1 2. Acrocyanosis: 3 3. Pale, Cyanotic, or Mottled: 5 5. Hydration 1. Eyes, skin, and mucus membranes moist: 1 2. Mouth slightly dry: 3 3. Mucus Membranes dry, eyes sunken: 5 6. Social Response 1. Alert or Smiles: 1 2. Alert or brief smile: 3 3. No smile, anxious, or dull: 5 4. References 1. McCarthy (1982) Pediatrics 70:802 2. McCarthy (1985) Pediatrics 76:167 3. McCarthy (1987) J Pediatr 110:26 þ Empirical oral or IM antibiotics - do have a "modest" effect to to decrease persistent bacteremia and meningitis. [Rothrock SG, Harper MB, Green SM. Do oral antibiotics prevent meningitis and serious bacterial infections in children with S. pneumoniae occult bactermia. Pediatrics 1997;99:438-444.] - continued fever doesn't differentiate between those with and without serious infections. [Bonadio WA, et al. Relationship of temperature pattern and serious bacterial infections in infants 4 to 8 weeks old 24 to 48 hours after antibiotic treatment. Ann Emerg Med 1991;20(9):1006.] Abstract: þ Recommended ED management: - [Bell LM, Albert G, Campos JM, Plotkin SA. Routine quantitative blood cultures in children with H flu or S pneumoniae bacteremia. Pediatr 1985;76:901-904.] IF 39.4C (103F) or more for 4 days or less AND IF 24 months age or less AND IF looks well (alert, quiet), THEN: WITH otitis media consider blood culture and PO antibiotics. WITH NO FOCUS of infection: Blood culture; +/- CBC; CXR if RR 45 or more, or cough; urine culture for males 12 months or less, and females 4 years or less (clean catch or cath). Rx: none for most. if has LP and is normal and well enough to go home, consider Ceftriaxone IM and F/U 24-36 hours. þ Fever and Infant Age - More serious in younger infants (under 4/6/2 weeks) - small boys, uncircumcized, have a high rate of UTIs [Lin et al. Urinary tract infections in febrile infants younger than eight weeks of age. Pediatrics 2000;105:e 20.] - Philadelphia protocol doesn't work under one month of age, looks as though this really is the age under which you really can't tell if they are sick. [Baker MD, Bell LM. Unpredictability of serious bacterial illness in febrile infants. Arch Pediatr Adolesc Med 1999;153:508-11.] þ Occult Bacteremia - 1-3% develop morbidity - 25% will clear without treatment - 50% will develop serious bacterial infection (pneumonia, meningitis, etc.) - clinical impression in 3-36 months unreliable. - Temp > 39 or > 39.5 associated with occult bacteremia. - Temp reduction with antipyretic makes no difference in incidence of occult bacteremia (but may make clinical exam much better) - WBC > 10-15K - Band/PMN > 0.2 picked up a few cases - > 24 months, occult bactermia unlikely (nontoxic children) - cause: Pneumococcus - 85%; H flu - 10%; meningococcus - 1-2% (this study done prior to H flu vaccine, though) - studies: PCN vs. nothing: Carroll; Amoxil vs. placebo: Jaffe; Augmentin vs. ceftriaxone: Bass; amoxil vs. ceftriaxone: Fleish. Antibiotics seemed to lower fever quicker, but no difference in sequelae. Fleish is flawed due to throwing out several cases. þ Low Risk Criteria: "Rochester" criteria - physical findings of ear, soft tissue, or skeletal infection - WBC <5000 and <15000 - Bands < 1500 - no UTI by UA [Dagan R, Powell KR, Hall CB, Menegus MA. Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis. J Pediatr 1985;107(6):855-860.] - Added later: <25 WBC, hemoccult negative, on stool exam if diarrhea [Dagan R, Safer S, Phillip M, Shachak E. Ambulatory care of febrile infants younger than 2 months of age classsified as being at low rist for having serious infections. J Pediatr 1988;112(3):355-360.] - An additional study of more than 1000 infants confirmed the above. [Jaskiweicz JA. Febrile infants at low risk for serious bacterial infection - An appraisal of the Rochester criteria and implications for management. Pediatrics 1994;94:390.] - But another found a couple of failures in the neonatal age group: [Ferrara PC. American Journal of Emergency Medicine 1997;15:299-302.] - This editorial recommends admission and full septic workup for those under 28 days, and an LP for infants that you might give IM ceftriaxone and discharge (to avoid partially-treated meningitis). þ "Philadelphia protocol" - [NEJM 1993;329:1437-41.] þ Bandemia as indicator of meningitis þ Uselessness of the CBC? - Even with high WBC and abnormal diff, most infants without obvious source still have nonserious viral illnesses. [Kramer MS et al. Role of the complete blood count in detecting occult focal bacterial infection in the young febrile child. J Clin Epidemiol 1993; 46(4):349.] - Should you get a CXR if high WBC and asymptomatic? Probably not. Below study had problems because some kids in it had tachypnea or appeared ill. [Bachur RB, Perry H, Harper MB. Occult pneumonia: empiric chest radiographs in febrile children with leukocytosis. Ann Emerg Med 1999;33:166-173.] þ Ceftriaxone for febrile infants - criteria: WBC < 20K; CSF WBC < 10 x 10^6; negaive urinary LET; good parental supervision and followup available - 50 mg/kg IM stat and on re-exam at 24 hours. [Baskin MN, O'Rourke EJ, Fleisher GR. Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. J Pediatr 1992;120(1):22-27.] - IM Ceftriaxone works better than PO amoxicillin [Fleisher FR, Platt R, The occult bacteremia study group/Childrens' Hospital, Harvard Medical School, Boston; SAEM abstract #38; Ann Emerg Med 1992;21(5):600.] - Those given IM cefriaxone rather than nothing did better: + more likely to be clinically better (32% vs. 86%) + more likely to be febrile (75% vs. 28%) + more likely to be hospitalized (67% vs. 22%) þ Ceftriaxone for Otitis: þ UTIs: - unrecognized UTIs common in girls under 2 years and boys under 6 months, so always check if no other source. [Young PC. The management of febrile infants by primary-care pediatricians in Utah: comparison with published practice guidelines. Pediatr 1995; 95:623-627.] which is based on practice guidelines published in [Baraff LJ, Bass JW, Fleisher GR, et al. Practice guidelines for the management of infants and children 0 to 36 months of age with fever without source. Pediatr 1993; 92:1-11.] - Uncircumcized boys younger than 8 weeks have a high incidence of UTIs [Lin et al. Urinary tract infections in febrile infants younger than eight weeks of age. Pediatrics 2000;105:e 20.] - spun urine in hemocytometer is much better for diagnosing UTI compared to standard UA; C-reactive protein and ESR about as good as a UA. [Lin et al. Urinary tract infections in febrile infants younger than eight weeks of age. Pediatrics 2000;105:e 20.]