Pediatric Fever

By Jeremy Faust, MD

ERcast with Dr. Rob Orman and guest PEM specialist Dr. Andrew Sloas
Pediatric Fever Part 2. Link:

Question: Does height of fever increase risk that you’re dealing with Serious Bacterial Infection?
Answer: Old studies (poorly controlled, according to Dr. Sloas) mostly were done looking at Strep
Pneumococcus showed some possible correlation. Since Prevnar, the studies show no significant correlation.  Overall, the answer today seems to be that the older literature is not valid because the data were flawed and the pathogen that was being studied is largely not a concern in the United States..
More useful is to ask: Is the kid well-appearing?

Question: Does height of fever have a correlation to bacteremia?
Answer: seems not to. In modern era with the vaccines we currently have, there does not seem to be any data supporting this idea.

Question: Should we control all pediatric fevers?
Answer: Pros and Cons. In favor of controlling fever: child feels better and more likely to hydrate which is one of the main goals of supportive care. Against treating (or aggressive treatment) is the concept that fever is an immune defense helpful in killing infectious agents.

Question: How high of a fever is too high?
Answer: 106.7 F (41.5 C) fever is the level at which there is genuine risk of denaturing of brain protein (from adult data). In this situation, goal is to lower fever 1-2 degrees per hour

Question: When sending a child home from the ED, what threshold should you give parents for bringing child back to ED?
Answer:
Child <6 weeks old, child should return to ED with temp of 100.4
Child >8 weeks old, less aggressive threshold of 102.2 can be used as a cutoff.
Any child with a fever approaching 106.7 F (or 41.5 C) as per above.

Question: In terms of risk stratification, when is the correct time to assess a child, before or after anti-pyrexis?
Answer: There is no good data since Philadelphia, Rochester, and Boston studies on bacteremia. So, Dr. Sloas states that assessing the child prior to anti-pyrexis would be the more conservative approach.

Question:  What is the approach to a high fever with no immediate obvious source?
Answer: LUCAS! In a classic moment in #FOAMed (Free Open Access Meducation), during this podcast Rob Orman coined this mnemonic for pediatric fever sources based on Dr. Sloas’ answer to this question. LUCAS stands for: L=Lung, U=Urine, C=CNS, A=Abdomen, S=Skin. Of course there are other sources like blood (and you do not want to miss endocarditis), sinus infections, and if the patient has any lines or medical equipment, that is always a concern as a possible source.

Question: How likely is a serious bacterial infection at 1 and 3 months?
Answer: At 1 month of age, likelihood of SBI is 1/100. At 3 months of age, likelihood is 1/1000, assuming vaccines.

Question: What are “acceptable” sources for pediatric fever?
Answer: Brionchiolitis, RSV, Croup, aphthous stomatitis, Herpes Zoster, HSV, Hand/Foot/Mouth Coxsackie virus, enterococcus, viral exanthems, otitis media (if >2 months of age). Side note on otitis: Philadelphia, Rochester and Boston studies excluded soft tissue infections including otitis.

Question: Do you need to change your practice towards Fever of Unknown/Unclear Origin in well-appearing child <6 months old who is not vaccinated?
Answer: Look hard for a source as you would prior to Prevnar era. In this case, data from Rochester and Philly (pre-Prevnar) is still applicable: Dr. Sload advises that you can do everything (including LP) because you just have to be thorough. A “middle of road approach” would be: CBC and urine (modified Rochester would give you 92% sensitivity for occult bacteremia). Least invasive strategy: only check urine. Dr. Sloas also states that it is at times like this when it might be good to talk to parents about vaccines and address concerns. Also, in cases of unvaccinated children, If you don’t have Pediatric Emergency Medicine specialists in your shop but there is one nearby, it’s ok to transfer to them if you are concerned your hospital does not have a lot of experience with cases such as these.

Question: What are the doses for suspected pediatric bacteremia?
Answer: Ceftriaxone dose: 50 mg/kg for non-meningitis and 100 mg/kg if you suspect meningitis.
Many use cefotaxime for neonates <1 month of age (related to bilirubin interaction with ceftriaxone)

Question: Does antibiotic dose matter? In the early 1980s a study looked at blood concentration over
time for various Rocephin doses. That’s how the doses above were derived.

Question: Should very young patients get steroids if there is confirmed meningitis?
Answer: The very young mostly should not receive steroids. Anyone under 2 years with confirmed meningitis would probably not get steroids unless concern for adrenal insufficiency. Controversial between age 2-5. Certainly a five year old with confirmed meningitis would be indicated for steroids (plus antibiotics of course!)

Question: When giving steroids for meningitis (generally hydrocortisone), what is the doing scheme?
Answer: Stress doses hydrocortisone as follows:
Newborn: 25 mg/kg/meter-squared (Body Surface Area)
Up to a year old : 50 mg/kg/meter-squared
Over a year old: 100 mg/kg/meter-squared

Question: For a child receiving Decadron as the choice of steroids for meningitis, what would be the dose?
Answer: 0.6 mg/kg with a maximum of 10 mg although some places are using lower doses.

Question: When doing a lumbar puncture, should I have the parents hold the child?
Answer: No. The best person to hold the child is in fact not the parent but rather the most experienced person in Emergency Department. Often this will be a nurse or a technician.

Question: What is the best positioning for a pediatric lumbar puncture?
Answer: one hand on upper back / lower neck, other on buttocks/hamstring. Your goal is to get hips perpendicular to table with no movement except inspiration. (Dr Sloas adds: No mercy! Crunch them and watch for hypoxia. Be careful not to flex the kid too much because literature shows this is when
pediatric patients are more likely to get hypoxic. To alleviate this, give breaks between preparation, numbing, and actual puncture. EMLA is an acceptable adjunct to local anesthesia but should not be used in place of subcutaneous lidocaine because once the LP needle is in, you need the subcutaneous lidocaine to keep the child pain free below the surface and minimize the child from withdrawing to pain.

Question: What is the role for sedation for pediatric lumbar punctures?
Answer: Once the child is 6 months old, they can really move! So that is a cutoff many use.

Question: What medications are good for sedation for a lumbar puncture?
Answer: Ketamine and Propofol. A combination of these medications can provide excellent procedural sedation for a minute or two and if you have experience with these medications, you can well control the length of sedation. Fentanyl and Versed in small amounts can be a good combination as well but Dr. Sloas advises to use very small amounts of Ketamine.

Question: What is the role of CRP or pro-calcitonin in pediatric fever/sepsis work-up?
Answer: According to Dr. Sloas, not too helpful at this time. The problem is that the sensitivity in different studies has varied from 60-90% which is too wide to know the real sensitivity.

Question: What is the utility of blood cultures in kids?
Answer: As a practical matter, most commonly, one set of cultures is drawn, especially younger babies.
The issue is that positive cultures are so frequently false positives, can also get a sense of which positive cultures might be false just as in adults especially after a few days. No evidence here though. However, an Academic Emergency Medicine paper from 2009 showed false positive: true positive ratio in
children <60 days old was 6:1 (caveat: the study included at-risk babies with underlying lines which might have increased that ratio more than would have been seen in a healthier baseline population. The study also did not factor in immune status which might have been lower in the study population).

Question: In premature infants, how do old do you consider a patient? Are they aged in terms of membranes being open? Post-conceptual age? Post-partum age?
Answer: In the ED, Chronological Age (time since delivery, i.e. “time in the atmosphere!”) is the only thing you care about because this is what matters from an immunological status. In non-ED settings though the Corrected Age (Time since delivery – # of weeks premature) can be used for monitoring of developmental milestones (And yes, some babies will have a negative Corrected Age!). But when assessing immune status, Dr. Sloas recommends using chronological age, especially if baby is up-to-date on all vaccines.

Question: At what gestational age does a pre-mature infant start acting like a normal neonate?
Answer:  32-34 weeks gestation is magic time when fetus starts acting like baby. Suck reflex comes down and respiratory drive goes up.

 

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