Assessing the febrile child-Consider...

1. How is fever IDed in kids?
1. Parents usually know
2. In hospital
  1. < 4 weeks old
    1. electronic thermometer in the axilla
      1. axillary temps underestimate body temp by 0.5 deg C
  2. 4 weeks- 5 years
    1. electronic or chemical dot thermometer in axilla or infrared tympanic thermometer
2. How old is child?
1. febrile infants < 3 months old
  1. present with non-specific features
    1. fever/temp instability
    2. poor feeding
    3. vomiting
    4. resp distress
    5. abdo distension
    6. jaundice
    7. neutropenia
    8. hypo/hyperglycaemia
    9. shock
    10. irritabilty
    11. lethargy, drowsiness
    12. in meningitis
      1. tense/bulging fontanelle
      2. head retraction (opisthotonos)
  2. often have bacterial infection
    1. can't be IDed on clinical exam alone
  3. uncommon to have viral infections
    1. due to passive immunity from mum
  4. if clear cause of fever not IDed
    1. septic screen
      1. blood culture
      2. FBC incl differential WCC
      3. CRP
      4. Urine sample
      5. consider if indicated
        CXR
        lumbar puncture
        rapid antigen screen on blood/CSF/urine
        meningococcal & pneumococcal PCR on blood/CSF
        PCR for viruses in CSF
        esp HSV & enterovirus
    2. immediate iv Abx therapy
3. Any risk factors for infection present?
1. illness of other family members
2. unimmunised
3. if a specific illness is prevalent in community
4. recent travel abroad
  1. malaria
  2. typhoid
5. contact w/ animals
  1. brucellosis
6. increased susceptibility from immunodef
  1. usually secondary
    1. post splenectomy
    2. nephrotic syn
    3. increased susceptibility to encapsulated orgs
      1. Strep. pneumoniae
      2. Haem. influenzae
      3. Salmonella
  2. primary immunodef
4. How ill is child?
1. Red flags i.e. urgent ix & rx needed
  1. < 3 months old
    1. fever > 38 deg C
  2. 3-6 months
    1. > 39 deg C
  3. colour
    1. pale
    2. blue
    3. mottled
  4. level of consciousness reduced
  5. neck stiffness
  6. status epilepticus
  7. focal neurological signs or seizures
  8. significant resp distress
  9. bile-stained vomiting
  10. severe dehydration or shock
5. Is there a rash?
1. rashes often come w/ febrile illness
2. characteristics of rash & other clinical features can help make diag
  1. e.g. meningococcal septicaemia
6. Is there a focus for infection?
1. examination may ID a focus of infection
2. If no focus IDed
  1. could be prodromal phase of viral illness
  2. could be serious bacterial infection
    1. UTI
    2. septicaemia
Mx
1. if not seriously ill
  1. give parents clear instructions to manage
    1. tell abt features that would make them bring kid to dr
2. significantly unwell & no focus of infection
  1. septic screen
  2. Ix and obs
3. seriously unwell
  1. paraenteral Abx
    1. 3rd gen cephalosporin
      1. 1-3 months old
        cefotaxime
        in case septicaemia or meningitis
        ampicillin
        in case Listeria
      2. > 3 months old
        cefotaxime
        ceftriaxone
4. antipyretic mx
  1. child should not be underdressed
  2. consider antipyretic agents
    1. children w/ fever who appear distressed or unwell
      1. paracetamol
      2. ibuprofen
    2. do not give if child otherwise well

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