The child with a fever.pptx

fever in children

1. THE CHILD WITH A FEVER Dr Sayed Ismail Professor of pediatrics

2. LEARNING OBJECTIVES Recognise ‘red flags’ in the history or examination that indicate serious bacterial infection (SBI) List the differential causes of acute, chronic and recurrent fever The initial investigations required in child presenting with fever Understand the management of common causes of fever in childhood Recognise when referral and hospital admission

3. BACKGROUND Fever is by far the commonest presenting complaint in childhood and a cause of parental anxiety Practitioners need the ability to distinguish the acutely unwell child with a potential SBI from the well child with a common viral illness. SBIs include Meningitis , sepsis, Osteomyelitis ,septic arthritis, Cellulitis, Urinary tract infections Pneumonia Enteritis .

4. Patients at high risk of SBI Infants under 2 months of age Transplant recipients Immunosuppressed children Asplenic patients

5. ACUTE PHARYNGITIS Children with viral pharyngitis are non- toxic and may present with a fever, sore throat and refusal to feed. Examination reveals an erythematous pharynx with cervical lymphadenopathy. The commonest causative agent is a common virus. Viral infection may be associated coryzal symptoms, diarrhoea or non- specifi c generalised rash. Splenomegaly, palatal petechiae and generalised lymphadenopathy suggest Epstein–Barr virus infection .

6. Group A beta- haemolytic streptococcus accounts for 15%–30% of cases. It has a rapid onset . No coryzal signs . There may be associated headache, abdominal pain, palatal petechiae, swollen and erythematous uvula and tonsillar exudates with tender cervical lymphadenopathy. Complications of GABS Suppurative : otitis media sinusitis peritonsillar and retropharyngeal abscesses suppurative cervical lymphadenitis. Non- suppurative complications : acute rheumatic fever acute glomerulonephritis.

7. ACUTE OTITIS MEDIA Children may present with fever, ear pain (non- verbal infant may pull at his or her ears), anorexia and irritability. There may be associated coryzal symptoms or vomiting or diarrhoea. With AOM, examination reveals a bulging, diffusely erythematous eardrum with loss of the light reflex and anatomical landmark. AOM is often over diagnosed. A red tympanic membrane is a common finding in children with viral upper respiratory tract infections (URTIs) and in the crying child

8. Younger age, because of an immature, short and horizontal eustachian tube Immunodeficiency Recurrent URTIS Trisomy 21 Craniofacial abnormalities including cleft palate Attendance at day care or smoking in the home . Viral agents are implicated in up to 50% of cases. Common bacterial causes include Streptococcus pneumoniae, Haemophilus infl uenzae and Moraxella catarrhalis . If associated with pharyngotonsillitis it is likely to be secondary to S. pneumoniae and if associated with purulent conjunctivitis it is likely to be secondary to H. influenzae Risk factors for otitis media include

9. Complications of otitis media include Following an episode of AOM, 70% of patients will still have an effusion at 2 weeks, 40% at 1 month, 20% at 2 months and 5%–10% at 3 months. Perforation resulting in ear discharge, which often relieves the pain Conductive hearing loss Acute suppurative labyrinthitis Facial nerve palsies Acute mastoiditis Intracranial spread of infection: venous sinus thrombosis, meningitis, subdural or extradural abscess.

10. PNEUMONIA Viruses are the most common causes of pneumonia in children < 2 years of age. In school- age children S. pneumoniae and Mycoplasma pneumoniae are most common, but in 50% of children no clear aetiology can be discerned. Typically, the child presents with fever (sometimes rigors) that is associated with a new- onset cough, which may not be productive in the early stages. Chest pain reflects the pleural involvement and abdominal pain may reflect lower lobe disease. The typical child has difficulty in breathing and systemic symptoms of anorexia, lethargy and headache. Physical examination reveals fever, tachypnoea and chest retractions The presence of consolidation is suggested if auscultation reveals diminished air entry, localised crackles, bronchial breathing and occasionally a pleural rub. The finding of wheeze is suggestive of mycoplasma infections

11. Pulse oximetry is recommended for those children with an elevated respiratory rate, to assess the need for supplemental oxygen. Pneumonia is assessed as mild to moderate in infants if: temperature is <38.5°C respiratory rate is <50 recession is mild , the infant is taking full feeds. Pneumonia is assessed as severe in infants if the following are present: temperature is >38.5°C respiratory rate >70 breaths/min moderate to severe recession ● nasal flaring ● cyanosis ● intermittent apnoea ● grunting respiration ● not feeding ● tachycardia capillary refill time ≥2 seconds.

12. In 30% of children with UTI, vesicoureteric refl ux (VUR) is present. VUR is a developmental anomaly of the vesicoureteric junction. There is often a positive family history. There are five described grades of VUR. Grade I: reflux without dilatation into distal ureter Grade II: reflux with dilatation into proximal ureter Grade III: reflux into renal pelvis with dilatation Grade IV: further dilatation and distortion of calyces Grade V: hydronephrosis

13. MENINGOCOCCAL DISEASE Meningococcal disease has two main clinical presentations: meningitis and septicaemia , which often occur together. Septicaemia is more common and more dangerous. It is more likely to be fatal when it occurs without meningitis. Not all children with meningococcal disease present with a fever. The presentation of early meningococcal disease can be difficult to differentiate from common viral illnesses. 50% of children presenting to their primary care physician with meningococcal disease are sent home on their first visit. These children are more likely to die

14. Meningitis can present with severe headache, neck stiffness, photophobia, decreased level of consciousness or seizures. Positive Kernig and Brudziniski signs Septicaemia can present with a rash, tachycardia, tachypnoea, cool peripheries, prolonged capillary refi ll time, hypovolaemia , limb or joint pain, abdominal pain or decreased level of consciousness.

15. The presentation in infants is very non- specific There may be a history of poor feeding, irritability, a high- pitched cry, abnormal tone, lethargy, a tense and bulging fontanelle and/or cyanosis. Some children may complain of painful feet and be reluctant to walk The onset of the rash in meningococcal disease occurs at a median of 8 hours after the start of the illness in infants. The presence of purpura is highly predictive of meningococcal disease and should be considered an emergency requiring prompt evaluation and treatment. Purpura fulminans is a severe complication of meningococcal disease occurring in approximately 15%–25% of those with meningococcemia. It is characterised by the acute onset of cutaneous haemorrhage and necrosis due to vascular thrombosis and disseminated intravascular coagulopathy.

16. Long- term complications of meningococcal disease include: ● Hearing loss ● Neurological impairment including learning, motor and neurodevelopment defi - cits and epilepsy ● orthopaedic damage including amputation, growth plate damage and arthritis ● post- necrotic tissue/skin loss ● renal impairment ● psychiatric and behavioural problems.

17. EXAMINATION Assess the overall appearance of child by observation : toxic or well looking? Assess for signs of meningism Vital signs including temperature should be recorded Expose the child fully and perform a head- to- toe examination Ear, nose and throat: otitis media, pharyngitis, stomatitis, cervical lymphadenopathy Joint exam: swelling, erythema, paresis Skin exam: rash, erythema, tenderness Respiratory exam: signs of respiratory distress, wheeze, crepitations Gastrointestinal exam: abdominal tenderness, masses

18. Recognising the sick child (Toxicity) The ABCD can also be used to assess toxicity where ‘A ’ is for arousal, alertness or decreased activity, ‘ B ’ is for breathing difficulties (tachypnoea, increased work of breathing), ‘C’ is for poor colour (pale or mottled), poor circulation (cold peripheries, increased capilliary refill time) or cry (weak or high pitched), ‘ D’ is for decreased fluid intake (less than half normal) and/or decreased urine output (fewer than four wet nappies per day). The presence of any of these signs places the child at high risk for serious illness

19. Red flags ABCDE A Alerness B Respiratory distress C Signs of impending shock D Seizures , Altered level of consciousness , Meningism E Petechiae rash

20. DIFFERENTIAL DIAGNOSIS Common causes Viral URTIs : Cough, runny nose Pharyngitis : Sore throat, refusal to feed, erythematous pharynx, cervical lymphadenopathy Otitis media : Irritable, vomiting or diarrhoea, pulling at ear, may present without fever, otorrhoea, associated coryzal symptoms Viral exanthems : Coryzal symptoms, rash, lymphadenopathy Viral pneumonia : Temperature usually <38 Gradual onset ,bilateral crepitation , wheezing Viral gastroenteritis : Vomiting, watery diarrhoea, dehydration, absence of blood per rectum

21. Serious bacterial infections UTIs Very non- specifi c presentations, may present without fever, failure to thrive, malodorous urine, poor feeding, vomiting, jaundice, family history of VUR Bacterial pneumonia : Tachypnoea, signs of respiratory distress, localised crepitations Meningococcal disease : Toxic, poor perfusion, lethargy, apnoea , bulging fontanelle, high- pitched cry, hypotonia, listlessness, poor feeding, seizures, fever or hypothermia, vomiting, cool peripheries Encephalitis : Altered level of consciousness, seizures, headaches, irritability Septic arthritis and osteomyelitis Paresis, abnormal position of limb, pain elicited on passive movement, swelling Cellulitis Localised erythema, increased temperature Bacterial gastroenteritis Vomiting, bloody diarrhoea Septicaemia Toxic, poor perfusion, hypotension, altered level of consciousness Orbital cellulitis Erythema of eyelids, pain on eye movement, reduction in visual acuity, proptosis

22. Prolonged fever Infections Epstein–Barr virus, malaria, Lyme disease, Rocky Mountain spotted fever, bacterial endocarditis, tuberculosis, rheumatic fever, cat scratch disease, HIV, abscesses, systemic fungal infection Inflammation Systemic juvenile idiopathic arthritis, systemic lupus erythematosus, Kawasaki’s disease Neoplasia Leukaemias , lymphomas, metastases, solid organ tumours

23. Recurrent fever (occurring at regular intervals) PFAPA syndrome (periodic fever, aphthous ulcers, pharyngitis, cervical lymphadenopathy) Fevers occur every 21–28 days Cyclic neutropenia Fevers occur every 21–28 days Relapsing fever Fevers occur every 14–21 days Familial Mediterranean fever Fevers occur every 7–21 days Hyperimmunoglobulinaemia D syndrome Fevers occur every 14–28 days Epstein–Barr virus Fevers occur every 6–8 weeks

24. INVESTIGATIONS

25. Sepsis work up Notes : Automated blood culture systems can now identify most bacterial pathogens in <24 hours. Most recently, nested multiplex polymerase chain reaction (PCR) testing of positive blood cultures can identify bacterial pathogens and antimicrobial resistance genes in approximately 1 hour Similarly, multiplex meningoencephalitis panels can provide results on CSF for 14 potential CSF pathogens in 1 hour, rapid viral PCR and multiplex respiratory viral testing

26. Notes Tepid sponging should be discouraged. Parents often use cool water and cause peripheral vasoconstriction of the skin, thus preventing heat loss through the skin Anxious parents may present early to their family doctors with their febrile child. If no cause is apparent, explain that symptoms may evolve over the following hours. Some children with sepsis will present with a normal or even low temperature therefore do not assume that all septic children will be febrile. not all fever is reflective of infection. Clinical conditions such as Kawasaki’s disease and collagen vascular disease present with fever and symptoms evolve over time

27. Fever and rash Do not assume that all rashes are part of a viral syndrome. Doctors need to be familiar with specific rashes inclusive of erythema multiforme, erythema nodosum and those that reflect bacterial infections

28. Fever in the child with incidental neutropenia . Pitfall: the finding of neutropenia in the child with fever may reflect severe sepsis; however, if the child is not clinically septic, careful follow- up is advised, as a percentage of these children will present with leukaemia within a few months. Fever in the child diagnosed with a malignancy who is neutropenic. Treat this child with intravenous antibiotics promptly while awaiting culture reports (follow clinical protocol for antibiotic regimens). Th is is a clinical emergency.

29. Treatment of fever Parents often focus on fever reduction as the sole goal of addressing the needs of the febrile child; however, for the doctor, fever most often reflects the presence of an illness, so the aetiology is the primary focus, and subsequently the focus is on fever treatment. The two most common medications used to reduce fever are paracetamol and ibuprofen. Both are effective in fever reduction, and combined treatment or alternating treatment is more eff ective than single treatment

30. Treatment of specific conditions Sick infant less than 2 months of age Full sepsis work up Low threshold for hospital admission See last slides

31. Pharyngitis

32. Acute otitis media Most cases of otitis media are viral in origin and will resolve spontaneously in 10–14 days . Antibiotic is giver for infant less than 6 month and severe cases watchful waiting is a more prudent approach for older children (offer antibiotic treatment if no improvement after 3 days). A percentage of children will develop persistent otitis media with effusion, which may impair their speech development because of associated hearing deficit, and these children require referral to ENT specialist. Ventilation tubes (VTs) offer a temporary solution for these children Patients who have VTs inserted should not be restricted from swimming.

33. Pneumonia

34. Urinary Tract Infections In a child with a UTI, ensure that there is a positive urine culture to guide antibiotic treatment. Ensure: high fluid intake Avoidance of constipation Regular voiding: at least five times a day Complete bladder emptying Recommend good perineal hygiene: girls should wipe from front to back, avoid soap, bubble bath, and shampoo in the perineal area and wear cotton panties. Cranberry juice has been shown to have a modest effect in the reduction of UTI frequency .

35. Antibiotics for UTI

36. FOLLOW- UP

37. Under 2 months of age with a fever, there should be a very low threshold for referral to hospital Fever with petechiae WHEN TO REFER?

38. Clinical Practice Guideline: Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old

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