IN A WELL APPEARING CHILD <3YEARS

Definition
Incidence
Pathophysiology
Clinical Presentation
Differential Diagnoses
Evaluation & Investigations
Treatment and Management
Complications

In a healthy person, this is a range that

fluctuates throughout the day. It can
vary as much as 0.5 0C to 1.0 0C.
Typically is defined as 370 C (98.6 0 F)

It can vary due to

Age: >6mths daily temp vary 1-2 0C
Time of day: max temp in late afternoon
Site

RECTAL THERMOMETRY
This is a gold standard in detecting a fever
Readings are affected by depth of a
measurement, local blood flow changes,
presence of stool

 Axillary

thermometry
Relies on the mercury thermometer placed
over the axillary artery >4mins
Recommended by AAP as screening test
for fever in neonates

Oral thermometry
Placed in the sublingual site with tongue
depressed for 3-4mins and reflects
temperature of lingual arteries

Cannot be used in unconscious and

uncooperative patients and it carries
limitations

Tympanic thermometry
Measures the thermal radiation emitted
from the tympanic membrane and ear
canal.
Also called an infrared radiation emission
detector

BIRTH TO 2 YEARS

1. RECTAL (definitive)
2. AXILLARY (screening)

OVER 2 YEARS TO 5
YEARS

1. RECTAL
2. TYMPANIC
3. AXILLARY

> 5 YEARS

1. ORAL
2. TYMPANIC
3. AXILLARY

Clinically significant fever in children <3

years is defined as the core body
temperature >380 C (100 0F) via rectal
thermometer. (Gold Standard)
Other measurements are unreliable
Axillary >37.2 0C (99.4 0F)
Oral >37.5 0C (100.4 0F)

Fever is one of the most common pediatric

presenting signs of illness in a office based
pediatric practice and is present in 19-30%
of encounters.

ACUTE FEVER <14DAYS

Viral respiratory or GI infections

Bacterial infections (otitis media,

pneumonia, UTIs)
Non infectious causes: heatstroke,
vaccines, drugs, Kawasaki disease, toxic
ingestions (anticholinergic), acute
rheumatic fever

ACUTE RECURRENT OR PERIODIC

Viral infections

Periodic fever syndrome (cyclic

neutropenia)

CHRONIC (>14 DAYS); FUO

Infectious: viral, sinusitis, pneumonia, bone

and joint infections, enteric infections
(salmonella)
Non-infectious: IBD, drugs, cancer, connective
tissue disorders (SLE, ARF, idiopathic arthritis)

VIRAL CAUSES

BACTERIAL CAUSES

<1 month

TORCH infections

>1 month

Enteroviruses, CMV,
EBV, HSV, respiratory
viruses (parainfluenza, influenza,
resp syncytial virus)

<1 month

Group B Strep, Ecoli,

L. monocytogenes

1-3months

Strep Pneu, Group B

Strep, N.
meningitidis, L.
monocytogenes

>3months

Strep Pneu, N.
meningitidis

Important info to asses: sick contacts,

immunization, antibiotic use, recent hx
previous illness
Associated signs and symptoms:
Non specific: Night sweats, chills, rigors,
headaches, muscle aches, lethargy, irritability,
refusal to feed, dehydration, seizures

Specific: system specific. EG: diarrhea, cough

A toxic appearing or septic child may manifest

with:
Signs of CNS dysfunction: lethargy, irritability
CVS impairment: cyanosis, poor perfusion,
tachcardia, tacypnea
DIC: petechiae, ecchymosis

Fever in child <3months:

Higher risk of serious bacterial infections
Exhibition of fever and poor feeding without
localizing sings of infection

This traffic light system is designed to assist

healthcare professionals in the initial
assessment and immediate treatment of
young children with fever presenting to
primary care. By assessing feverish children
for the presence or absence of particular
symptoms and signs, the traffic light system
can be used to help predict the risk of
serious illness

Bundling:
Bundling can lead to a rise in skin temperature and
eventually rectal temperature. (Study 1: Cheng, 1993, Study
2: Grover, 1994)
Route of Measurement:
Tympanic/axillary dont correlate well with rectal temps

(Craig, 2000; Craig, 2002; Jean-Mary, 2002)

Antipyretics:
No correlation between disease etiology/severity and
response to antipyretics (Baker, 1987; numerous others)
Tactile temperatures:
Sensitivity 83%
Specificity 76% (Hooker, 1996; Graneto, 1996)
Afebrile on presentation:
6 of 63 infants 0-3 months with bacteremia/meningitis
afebrile in clinic after being febrile at home (Pantell, 2004)

REASONS WHY BABIES 0-28 DAYS OLD ARE HIGHEST-RISK

GROUP FOR LIFE-THREATENING BACTERIAL DISEASE AND
ALWAYS GET ADMITTED
High prevalence of bacteremia and (SBI): 5% -17 %
Pathogens not community-acquired, so prevalence not
reduced in immunized populations
Immune system immature:
More susceptible to invasive disease
Unable to localize infections well
Do not demonstrate symptoms early in illness observation
Appearance and exam unreliable
*Screening tests/labs not sensitive
3-10% of bacterial disease miss by currently available
screening criteria

High Risk Criteria

Preterm
Membrane rupture: before labor onset or
prolonged>12 hours
Chorioamnionitis or maternal peripartum fever
UTI
Hypoxia or Apgar score <6

1/3-1/2 neonatal sepsis will have no risk

factors

History
Associated symptoms and behaviors
Onset and duration of fever
Degree of temperature-method and anatomic
site
Medications
Environmental exposures
Similar symptoms in siblings
Birth and nursery history (STD, TORCH, GBS,
ROM)
Date of last immunizations (MMR-fever and
rash 7-10 days afterwards)

Temperature assessment- rectal temps

best assess core temperature
Bundled infants- rectal temp >38C may
not attributable to bundling
General appearance-acute illness
observation scale
Response to antipyretics-may hinder
ability to assess the child

Toxic appearance (irritability, poor

perfusion, lethargy)
Signs of infection (omphalitis, arthritis,
cellulitis, herpes lesions)
Meningitis change in sleep pattern,
paradoxical irritability, bulging fontanelle
(late sign).

WBC - <5000
Neutrophils / Bands / Acute-phase
reactants
Antigen testing
Blood cultures
Lumbar puncture
UA/Urine culture
CXR
Stool Analysis and Culture

Antigen Testing
Strep pneumoniae
H. influenzae type b
PCR methods (HSZ, VZV, enterovirus)

Blood cultures
Gold standard
False negatives
Prior treatment with antibiotics
Inoculation of too little blood (<1ml) into the media; too much blood
may yield false negative due to ongoing killing of bacteria by
neutrophils
False positives
Improperly cleaning the skin, resulting in contamination with skin flora

LP
Indicated if the diagnosis of sepsis or meningitis is
considered
Seizures upon presentation

UA/Urine culture
20% of children with UTI have a normal UA based on
a negative reagent strip
Infants < 8w with UTI 50% will have normal UA
Best method if not toilet trained
Bladder catheterization or supra-pubic aspiration

CXR

Respiratory signs or symptoms are good

predictors of clinically significant positive CXR
findings in the group under 2 months of age
Sensitivity 93%
Specificity 73%
Crain et al. Pediatrics 1991; 88:821

Stool Analysis and Culture

Important if diarrhea present
Can be considered a focus of infection
C Reactive Protein
Acute phase reactant released by the liver
following inflammation or tissue damage.
Wide range of sensitivity and specificity that vary
by cutoff levels.
Increase until 12 hours after the onset of fever
and can rise in both viral and bacterial infections.
Pulliam PN. Pediatrics. 2001 Dec; 108(6):1275-9.

Common: Group B Streptococcus, E. coli

Less common: Listeria monocytogenes,
Enterococcus, S. aureus, other Gram
negative organisms

Empiric antibiotic treatment:

Ampicillin and cefotaxime
Or ampicillin and gentamicin

Admit to Hospital
Further Treatment and Management by
Inpatient Team

Meningitis:

Bacterial (1.2%)

Bacteremia (2.1%):

Group B Streptococci 30%

Other Bacteria:
S. Pneumoniae
E. Coli
N. Meningitidis
Salmonella
H. Flu

Urinary Tract Infection ( 4% ) E.coli

History

Physical examination

Investigations

CBC plus differential

Blood culture
Urinalysis, Urine microscopy and culture
(sterile sample)
Lumbar puncture (defer unless abnormal
urinalysis/WBC count in well appearing child)
Chest x-ray (if respiratory symptoms)
Stool microscopy and culture (if diarrhea
present)

History:

Full term

Previously healthy

Normal behaviour and feeding

Ability to return to hospital if positive culture

Investigations:
WBC 5,000 and <15,000
Band to neutrophil ratio <0.2 or <1500
bands/microl
Urine microscopy < 10 WBC (High power field)
CSF < 8WBC (HPF)
Stool < 5 WBC (HPF)
Normal CXR

If low risk criteria is met:

then discharge
only if there is adequate transportation to
return for check up to be examined daily
in the event of a positive culture, to be
readmitted.

Empirical treatment with parenteral

ceftriaxone 50mg/kg in a single dose,
because of its antimicrobial spectrum and
long duration

 If High risk criteria is present, then:

Admit to wards

Begin empirical antibiotics ( 29 -60 days

ampicillin and cefotaxine) (60-90 days
ceftriaxone)

This is directed at the underlying condition.

Warm baths ( water slightly warmer than
body temperature)

Cool sponging

Fan therapy

Antipyretics
Paracetamol:
10-15 mg/Kg orally, IV or rectally, ever
4-6 hours
Ibuprofen:
10 mg/Kg, orally, every 6 hours
Antipyretics are used to provide comfort and
do not alter the course of infection

Well appearing child 3 -36

months old

Diagnosis done by core temperature.

Done most accurately rectally.
Temperature of 38C or above is
abnormal.
Most due to Self- limiting viral
infections.
Others can be due to Occult Bacteremia,
UTI or Severe life threatening illnesses.

1.

2.

3.
4.

Observational Assessment :- Includes

Alertness, Playfulness, being consolable
when crying.
Complete History :- Must include
Immunization Status of Patient and Past
Medical History
Physical Examination
Laboratory Investigations

Unimmunized infants less than 6 months old with

rectal temperature of more than 39C
Immunized infants more than 6 months old with
a temperature of more than 40C.
WBC count of 15,000/mm3 or higher
Elevated Absolute Neutrophil Count, Band Count,
Erythrocyte Sedimentation Rate or C-Reactive
Protein.

Blood Culture is done

Organisms that are indicated
includes:- N. meningitidis, H.
influenzae type b, S. aureus, gramnegative rods.
Lumbar Puncture can be performed if
Blood Culture is positive

CBC with differential

2. Urinalysis and urine culture for suspected
cases of UTI:

In girls less than 2 years

Boys circumcised less than six months and

boys uncircumcised less than 1 year
3. Analysis of Stool if mucous or blood is
present
1.

4.

5.
6.

Chest radiograph in cases of increased

work of breathing and high WBC count
(20,000/microL )
Blood Culture if Occult Bacteremia is
suspected.
Lumbar Puncture if indicated In cases
of positive blood culture and meningitis
is suspected

Child is has a Well Appearance

Fully Immunized
Reassuring Laboratory investigations
Then treated:- 1) As an Outpatient
2) No empirical Antibiotic treatment
needed
3) Or intramuscular Ceftriaxone is
given.
4) Re-evaluation in 24 Hrs.
5) Follow up is required for 72 Hrs.

Temperature of 39C or more

WBC count of 15,000/mm3 or higher
Empirical Antibiotics treatment is
necessary.
If Positive Blood Culture
Immediate re-evaluation necessary
Repetition of Blood culture is required
Lumbar Puncture is considered
Hospitalization is considered

If co-morbidity present e.g. SCD :- If well

appearance, Blood culture should be done.
Treat with Ceftriaxone and follow as an
outpatient closely.

Dehydration- decreased urine output and

decreased activity may be early signs of
dehydration.
Quantify any changes in milk intake daily
any associated vomiting or diarrhea

Febrile seizures

In infants younger than 3 months of age,

the most commonly occurring bacterial
infection is:

A. Group B Streptococcal infection

B. Meningitis
C. Neonatal sepsis
D. Urinary tract infection

In infants younger than 3 months of age, the

most commonly occurring bacterial infection
is urinary tract infection (D)
E.Coli (75 90%)
Klebsiella sp.
Proteus sp.
Enterococcus sp
Streptococcus Group B esp. among neonates
Pseudomonas aeruginosa
The Avner & Baker article included 2 related
studies:

 What

is a non-drug approach to
alleviating fever?

Fan Therapy
Tepid sponging with comfortably
warm or tepid water, generally around
30C

Neonates
( 28days)

Young Infants
(28-90 days)

Children

History and
Physical
Examination

Obtain pertinent
medical history
from mother
regarding the
pregnancy,
delivery and early
neonatal life.

Few clues on
history and
examination to
guide therapy.

A targeted medical
examination and
history

Investigations

Complete sepsis
screen: blood,
urine and CSF

Laboratory: White
blood cell count,
Urine and stool
studies

White cell count,

Absolute
Neutrophil Count,
CRP
Urinalysis

Typical Infections

Infection in 1st
7days of life are
secondary to
vertical
transmission.
After are usually

Approximately 610% are bacterial

infections, most
often Urinary Tract
Infections.

Streptococcus
Pneumoniae,
Escherichia Coli.
Haemophilus
Influenzae.
* Vaccinations

3months to 3yrs

Neonate