Also here is the link to the shownotes and podcast of Best Case Ever 27: Pediatric Shock.
The value of treating the fever in the ED besides patient comfort and minimizing dehydration, is so that the child can be re-examined when afebrile to help risk stratify for SBI and to counsel the parents. If the child’s vital signs and clinical picture continue to be worrisome after their fever has been corrected, then SBI should be suspected. However, if, after normalizing the temperature, the child has normal vital signs and is clinically ‘well’, then SBI is less likely and the parents can be reassured that fever itself is not dangerous.
Temperature Corrected Heart Rate and Respiratory Rate
Heart Rate increases by approx 10 beats/min and Respiratory Rate by 5 breaths/min for every Celsius degree (1.8 degree of Fahrenheit) of fever >38°C.
For example, if the temperature is 40°C and HR 144 -> subtract 2×10 -> corrected HR 124
If the child has tachycardia after being corrected for fever, consider other contributors (pain, crying, early compensated shock). Check perfusion, ask about urine output, and have a high degree of suspicion for dehydration and sepsis.
Normal Pediatric Vital Signs
Age Heart Rate (beats/min) Blood Pressure (mm Hg) Respiratory Rate (breaths/min) Premie 120-170 55-75/35-45 40-70 0-3 mo 100-150 65-85/45-55 35-55 3-6 mo 90-120 70-90/50-65 30-45 6-12 mo 80-120 80-100/55-65 25-40 1-3 yr 70-110 90-105/55-70 20-30 3-6 yr 65-110 95-110/60-75 20-25 6-12 yr 60-95 100-120/60/75 14/22 12 > yr 55-85 110-135/65/85 12-18
Hypotension is a Late Sign of Pediatric Septic Shock
- Be very cautious in setting of tachycardia and DO NOT WAIT for hypotension to make diagnosis of septic shock.
- A pediatric patient with hypotension and sepsis is a pre-arrest patient.
Acetaminophen vs Ibuprophen for Fever Reduction
Studies suggest that ibuprophen may be superior to acetominophen for treating pain and fever in children. Using both in combination of ibuprophen and acetominophen in an alternating pattern may be more effective, however the complex dosing associated with combination therapy increases potential for errors. A dosing handout can help – prompt parents to record times and dosages given.
Recommend no more than 3 doses of 10mg/kg of ibuprophen/24h and 4 doses of 15mg/kg of acetaminophen/24h, and emphasize keeping the child hydrated, to reduce risk of drug toxicity. Some experts suggest only giving antipyretics on a prn basis for fever, rather than on a schedule, so as to avoid potential complications with scheduled dosing (liver complications have been reported in children on q4h acetominophen, and renal complications have been reported in children on q6h ibuprophen). There is no good evidence that these medications prevent febrile seizure.
Is the Parent’s Touch Accurate at Predicting Fever?
The parent’s touch has been shown to be fairly accurate for identifying children with fever. Therefore a child without a measured fever at home but brought in for “tactile fever” should still receive the same history and physical assessment as the febrile child, even if they are afebrile in the ED.
Particularly important, is whether antipyretics were given, and the duration of fever. If the child is <3 months of age and is afebrile in the ED, observe them for several hours to document normal feeding and a normal exam, repeating the rectal temperature to verify that it remains normal. Educate the parents how to do this at home, and to come back if a fever is measured after they leave.
Fever in a child is a common emergency department presentation. About 20% will have fever without an identifiable source, and a small but significant number of these children will have an occult, serious bacterial infection (SBI)(1).
UTIs are the most common occult SBI (2), especially in children <2 years of age, but other causes include pneumonia, early meningitis, and septisemia [as well as skin and joint infections].
By definition, fever is an oral temperature >38°C, or rectal temperature >38°C. Take a rectal temperature in toddlers, infants and neonates; axillary and tympanic temperatures are less accurate for core temperature.
Guidelines by age for fever and the septic workup
Our experts recommend using chronological age (how many days since the child’s birth, rather than adjusted gestational age) to help guide decision making for septic workup. *However premature infants with a complex hospital course are already high-risk patients, so these babies usually require more thorough investigations.
A full septic workup including LP is recommended for babies under 28 days, because they have the highest risk of SBI. This includes routine blood work and culture, urinalysis and culture, and lumbar puncture (cell count, protein, glucose, culture, gram stain and culture, and viral studies).
Which infants should receive acyclovir for meningitis? If you suspect meningitis based on physical, or LP results (especially in <14 days), start acyclovir. HSV also causes pneumonitis and hepatitis, so also check for these if you are suspicious of HSV meningitis.
For infants 29 days to 90 days, use the low-risk criteria (see below). If they are well appearing, with no obvious source of infection, no complex past medical history, normal laboratory criteria (WBC count, normal urinalysis, and normal stool white count if diarrhea is present?), they can usually be sent home if they have reliable parents and good availability for follow up in 24h. These infants have a chance of SBI of about 1.5%, usually UTI, so make sure urine is sent also for culture.
The above are simply excerpts from the outstanding show notes of podcast 48. Be sure and review the complete set of notes at Episode 48 – Pediatric Fever Without A Source from Emergency Medicine Cases