What age should we use for the febrile ex-premie? At what temperature does a fever become dangerous? How should we approach the unvaccinated febrile infant? How many blood cultures should we get in febrile infants?..these questions and many more will be answered on this episode of ERcast
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Interviewee: Dr. Andy Sloas
Interviewer: Dr. Rob Orman
Transcript: Dr. Justin Arambasick
Does the height of the fever affect your work up in a fully vaccinated child between 3 and 12 months – example very high fever though looks great after antipyretics? Also, does a higher fever correlate to a higher liklihood of bacteremia?
Evaluate appearance using the TICLS mnemonic
- “Tickles” (TICLS) mnemonic – Criteria to evaluate the well appearing “sick” kid
- Disposition based on initial assessment (if fever but meet TICLS criteria, probably ok to go home)
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Element
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Explanation
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Tone
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Is he/she moving around or resisting examination vigorously and spontaneously? Is there good muscle tone? |
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Interactability
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How alert is he/she? How readily does a person, object, or sound distract or draw attention? Will they reach out, grasp and play with a toy or new object, like a penlight or tongue blade?
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Consolability
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Can he/she be consoled or comforted by the caregiver or by the clinician?
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Look/Gaze
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Can he/she fix her gaze on the clinician’s or caregiver’s face or is there a “nobody home,” glassy-eyed stare?
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Speech/Cry
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Is their speech/cry strong and spontaneous? Or weak, muffled, or hoarse?
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Does height of fever influence management?
Once there’s a fever…there’s a fever. How high it goes isn’t too important.
- Bring fever down for to make child feel better
- Feeling better helps the patient stay hydrated
- Dehydration is a main reasons they will bounce back to the ER.
- Recent evidence suggests that with the advent of prevnar, there is little correlation with bactermia and height of fever
The exception to this is hyperpyrexia
- 106.7 F/41.5 C-brain proteins start to denature.
- PARENTS SHOULD BRING BACK ANY CHILD WITH A TEMP OF 106.7 F or 41.5 C
What are acceptable sources of fever?
- Bronchioloitis
- RSV
- Croup
- Apthous stomatitis
- Zoster
- HSV **
- Hand, foot and mouth **
- Viral exanthem **
- Otitis media in a child >2months **
NOTE: Some sources add these infections**
What are the 5 Main sources of fever?
Work through the LUCAS mnemonic when you cannot find a source. Never heard of the LUCAS mnemonic? That’s because we just made it up…an ERcast original.
- Lung
- Urine
- CNS
- Abdomen
- Skin
What is the likelihood of serious bacterial infection based on age?
- 1/100 at 1 month
- 1/1000 at 3 months with a set of vaccines
What are the concerns in an unvaccinated child up to 6 months with fever without a source?
There is no magic answer and there are many opinions on this topic. As is often the case, the more opinions, the less evidence there is to support a definitive pathway. One theory is to work up fevers like we used to before Prevnar and H Flu vaccination. Another is to approach this cohort as you would any other febrile infant. Below are your options.
- IF child looks good, may apply TICLS Mnemonic and check a urine and be done
- May do middle of the road and get urine with blood work
- OR Conservative with full work-up including LP
What is the correct dosing of ceftriaxone?
- 50mg/kg
- If meningitis 100mg/kg
- Most providers use cefotaxime for <1 month due to biliirubin displacement from ceftriaxone
When should steroids be used in meningitis?
- Do not give at less than 6 months
- DO use after 2 years
- Difference of opinion between 6moths -2years- most often given in this range only if severely ill or concern for adrenal insufficiency
Steroids are ok to give before during or after antibiotic administration-prefer to give before or during
Hydrocortisone is the steroid used most often in studies
- 25, 50, 100mg/kg/m squared(BSA) –calculate the BSA
- In kids, BSA is generally 0.8-1 approx 1
Steroid dosing rough estimates
- Small kids 25mg- i.e. newborn
- Medium 50mg—i.e. 1 year old
- Large 100mg- >1 year
Decadron dose
- 0.6mg/kg or max of 10mg
- Some centers use 0.15, 0.30, or 0.5 mg/kg
Who is the best person to hold the child during the lumbar puncture and what position?
- NOT THE PARENT
- Person with most experience holding the child (who can hold them still)
Method:
- One hand on upper back/neck, one on hamstring/hips
- OK to flex neck intermittently-(Not constantly-can make hypoxic). An example of this is to flex the patient to identify landmarks and place local angelsia-then relax the position and flex them again
- Sedation recommended for kids > 6-months old due to muscle development /strength
Should we order a CRP or Procalcitonin in the workup of a febrile child?
- Sloas says no. The best data shows wide sensititivity of 60-90%
How do we actually calculate ‘AGE’
And now for the big question, the one that gives us headaches and no small degree of consternation…..
When evaluating the febrile child who is an ex-premie, do we calculate their age from the time they were born or their relationship to 40 weeks (e.g. a child was born at 35 weeks and presents with a fever 8 weeks after birth, for the purposes of fever, are they considered 8 weeks old or 4 weeks old?)
4 types of age
- Gestational – how many weeks actually inside the uterus
- Post menstrual-age from date actually conceived
- Chronological age- THE ONLY THING YOU CARE ABOUT FROM IMMUNE STATUS STANDPOINT – the time since birth to the time seen in ED. Another way to think about this is the patient’s “time in the atmosphere”
- Corrected age- Used by paediatricians for growth, feeding and milestones. Corrected age = Chronological age weeks premature
**33-34 weeks is when most babies will develop normal reflexes (i.e. suck, respiratory)
What is Andy Sloas’ final word on what age to use for an ex-premie?
- CHRONOLOGICAL AGE- time in the atmosphere
Important Links
- Pediatric Fever podcast part 1 December 2011
- Andy Sloas’ PEM ED podcast
When looking for fever in men there is one very elusive source! The prostate and the rectum. I had a japanese patient who failed to tell me he had rectal pain! ( japanese are notorious for not talking about their rectum! ). I sent him home after not identifying his source of fever! The next day he was in the OR for a rectal abscess!
Lesson: always ask men if they have any pain “down there”
Sage wisdom!