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 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.]