Fever in

Children
Blok 26
Agustus 2014

Case 1
v 4-month-old well-appearing girl admitted for croup and

respiratory distress. Develops fever to 39.1oC

v What additional evaluation would you do at this point?

Case 2
v 10-year old boy with ALL, in induction, admitted for

febrile neutropenia. He had just received his first

dose of ceftazidime when he developed another
fever to 38.5oC, chills, and new dizziness shortly
after receiving the antibiotics.
v What would be the next steps in this patients

management?

Objectives
v To know about fever: definition, classification,

etiology and patophysiology

v To assess patient with fever.
v To determine which patients are at high risk of

developing serious bacterial infection.

v To initiate empiric therapy.

Objectives
v To know about fever: definition, classification,

etiology and patophysiology

v To assess patient with fever.
v To determine which patients are at high risk of

developing serious bacterial infection.

v To initiate empiric therapy.

Definition of Fever
v Fever: an abnormal elevation of body temperature that

occurs as part of a specific biologic response that is

mediated and controlled by the central nervous system
v 0 to 28 to 30 days of age: rectal temperature 38.0C
v Healthy one- to three-month-old: rectal temperature

38.0
v Children 3 to 36 months: rectal temperatures 38.0
v Older children and adults: oral temperatures 37.8

Classification of Fever
v Duration of fever:
v Acute ( 14 days ),
v Acute recurrent or periodic (episodic

fever separated by afebrile periods)

v Chronic (> 14 days), which is more

commonly referred to as fever of

unknown origin (FUO)

Classification of Fever
Fever
without
localizing
signs
Fever with
localizing
signs

Fever of
unknown
origin

Fever

Classification of Fever
Classification

Definition

Most frequent
etiology

Duration
of
fever

Fever with
localizing
signs

Acute febrile illness with

focus infection which could
be diagnosed by anamnesis
& physical examination

Upper
respiratory
tract infection
(URTI)

< 1 week

Fever without
localizing
signs

Acute febrile illness without

focus infection diagnosed
after anamnesis & physical
examination

Viral infection,
urinary tract
infection (UTI)

< 1 week

Fever of
unknown
origin

Fever occured minimal 3

weeks, no established
diagnosis yet after 1 week
investigation at hospital

Infection,
juvenile
idiopathic
arthritis

> 1 week

Fever with Localized Signs

Common Causes

Organ system

Diseases

Upper airway infections

Viral URTI, otitis media, tonsillitis, laryngitis,

herpetic stomatitis

Pulmonary

Bronkhiolitis, pneumonia

Gastrointestinal

Gastroenteritis, hepatitis, appendicitis

CNS

Meningitis, encephalitis

Exanthems

Campak, chicken pox

Collagen

Rheumathoid arthritis, Kawasaki disease

Neoplasma

Leukemia, lymphoma

Tropics

Kala azar, cickle cell anemia

Acute febrile illness with focus of infection, which can be

diagnosed after history & physical examination

Fever without localizing signs

About 20% all febrile episodes demonstrate no
localizing signs
Most common cause is a viral infection
Most occuring during the first few years of life

Serious infections occured in 1% cases:

serious bacteriemic infections (SBIs)
Children 3-24 months have the highest incidence
(3-4%),
aged 7-12 months demonstrating twice incidence
association with high fever >39.50C

Fever without localized signs

Common causes
Etiology

Causes

Diagnostic tools

Infections

Bacteremia/sepsis
Most virus (HH-6)
UTI
Malaria

Ill looking, high CRP, leukocytosis

Well appearing, nomal CRP, WBC
Urine dipsticks
In malarial area

FUO

Juvenile idiopathic
arthritis

Pre-articular, rash, splenomegaly, high

antinuclear factor, CRP

Post
vaccination

DTwP, measles

Time of fever onset in relation to the

time of vaccination

Drug fever

Most drug

History of drug intake, diagnosis of

exclusion

What etiologies cause

fever?
v Infectious
v Inflammatory
v Oncologic
v Other: CNS dysfunction, drug fever
v Life-threatening conditions

Infectious
v Systemic
v Bacteremia, sepsis, meningitis, endocarditis

v Respiratory
v URI, sinusitis, otitis media, pharyngitis, pneumonia,

bronchiolitis

v Abdominal
v Urinary tract infection, abscess (liver, kidney, pelvis)

v Bone/joint infection
v Hardware infection
v Central line, VP shunt, G-tube

Inflammatory
v Kawasaki disease
v Juvenile inflammatory arthritis
v Lupus
v Inflammatory bowel disease
v Henoch-Schonlein purpura

Others
v CNS dysfunction
v Drug fever

Pathophysiology of Fever

Objectives
v To know about fever: definition, classification,

etiology and patophysiology

v To assess patient with fever.
v To determine which patients are at high risk of

developing serious bacterial infection.

v To initiate empiric therapy.

EVALUATION - History
v History of present illness
v degree and duration of fever, method of measurement,

and the dose and frequency of antipyretics (if any).

v Important associated symptoms that suggest serious

illness include poor appetite, irritability, lethargy, and

change in crying (eg, duration, character).

v Associated symptoms that may suggest the cause:

vomiting, diarrhea (including presence of blood or

mucus), cough, difficulty breathing, favoring of an
extremity or joint, and strong or foul-smelling urine.

v Drug history should be reviewed for indications of

drug-induced fever.

EVALUATION - History
v Factors that predispose to infection are identified.
v In neonates:
v prematurity, prolonged rupture of membranes, maternal

fever, and positive prenatal tests (usually for group B

streptococcal infections, cytomegalovirus infections, or
sexuallytransmitted diseases).

v For all children:

v recent exposures to infection (including family and

caregiver infection), indwelling medical devices (eg,

catheters, ventriculoperitoneal shunts), recent surgery,
travel and environmental exposures (eg, to endemic areas,
to ticks, mosquitoes, cats, farm animals, or reptiles), and
known or suspected immune deficiencies.

EVALUATION - History
v Review of systems:
v symptoms suggesting possible causes, including
v runny nose and congestion (viral URI),
v headache (sinusitis, Lyme disease, meningitis),
v ear pain or waking in the night with signs of discomfort

(otitis media),

v cough or wheezing (pneumonia, bronchiolitis),

v abdominal pain (pneumonia, strep pharyngitis,

gastroenteritis, UTI, abdominal abscess),

v back pain (pyelonephritis), and

v any history of joint swelling or redness (Lyme disease,

osteomyelitis).

EVALUATION - History
v A history of repeated infections (immunodeficiency) or

symptoms that suggest a chronic illness, such as poor

weight gain or weight loss (TB, cancer), is identified.
v Certain symptoms can help direct the evaluation

toward noninfectious causes; they include

v heart palpitations, sweating, and heat intolerance

(hyperthyroidism) and
v recurrent or cyclic symptoms (a rheumatoid,

inflammatory, or hereditary disorder).

EVALUATION - History
v Past medical history should note
v previous fevers or infections and known conditions

predisposing to infection (eg, congenital heart disease,

sickle cell anemia, cancer, immunodeficiency).
v A family history of an autoimmune disorder or other

hereditary conditions (eg, familial dysautonomia,

familial Mediterranean fever) is sought.
v Vaccination history is reviewed to identify patients at

risk of infections that can be prevented by a vaccine.

EVALUATION Physical Examination

v Vital signs:
v abnormalities in temperature and respiratory rate.
v In ill-appearing children, BP should also be

measured.
v Temperature should be measured rectally in infants

for accuracy.
v Any child with cough, tachypnea, or labored

breathing requires pulse oximetry.

EVALUATION Physical Examination

v Child's overall appearance and response to the

examination are important.

v A febrile child who is overly compliant or listless is of more

concern than one who is uncooperative.

v An irritable infant or child who is inconsolable is also of

concern.
v The febrile child who looks quite ill, especially when the

temperature has come down, is of great concern and

requires in-depth evaluation and continued observation.
v Children who appear more comfortable after antipyretic

therapy do not always have a benign disorder.

Age is important
v >10 % of well-appearing young infants with a

temperature >38C has a serious bacterial

infection or meningitis
v Only <2 %of well-appearing older infants and young

children with a temperature >39C (manifest

bacteremia}

Serious Bacterial Infec1on (SBI) Syndromes

Pneumonia
Meningi,s
Bacteremia
Osteomyeli,s
Urinary tract infec,on
Bacterial Gastroenteri,s
Sepsis

Allen C: Fever without a source in children 3 to 36 months of age.UpToDate CDROM 18.2,2010

Smitherman HF,Macias CG : Evaluation and management of fever in the neonate and young infant (< 3mo of age),UpToDate
CDROM 18.2,2010
Tolan RW :Fever Without a Focus , http://www.medscape.com, 2009

ETIOLOGY Serious Bacterial Infection

(SBI)
Common Bacterial Etiology of SBI
Streptococcus pneumoniae Streptococcus agalactiae
Neisseria meningitidis
Haemophilus influenzae type b
Listeria monocytogenes
Eschericia coli

Allen C: Fever without a source in children 3 to 36 months of age.UpToDate CDROM 18.2,2010

Smitherman HF,Macias CG : Evaluation and management of fever in the neonate and young infant (< 3mo of age),UpToDate
CDROM 18.2,2010
Tolan RW :Fever Without a Focus , http://www.medscape.com, 2009

Source: Jornal de Pediatrica - Vol. 85, No. 5, 2009

Yale Observa1on Scale (YOS) degree of Illness

Indica,ons Assessment of febrile child ages 3-36 months
Predicts serious infec,on (Occult Bacteremia)
Quan,es "Toxic Appearance" in children

Observa1on Items

1 (Normal)

3 (Moderate
Impairment)

5 (Severe
Impairment)

Quality of cry

Strong with normal tone

or contentment without
crying

Whimpering or sobbing

Weak cry, moaning, or

high-pitched cry

Reac1on to parent
s1mula1on

Brief crying that stops or

contentment without
crying

IntermiJent crying

Con1nual crying or
limited response

Color

Pink

Acrocyano1c or pale
extremi1es

Pale or cyano1c or
moJled or ashen

State varia1on

If awake, stays awake; if

asleep, wakes up quickly
upon s1mula1on

Eyes closed briey while

awake or awake with
prolonged s1mula1on

Falls asleep or will not

arouse

Hydra1on

Skin normal, eyes

normal, and mucous
membranes moist

Skin and eyes normal

and mouth slightly dry

Skin doughy or tented,

dry mucous membranes,
and/or sunken eyes

Briey smiling or alert

briey (<2 mo)

Unsmiling anxious face

or dull, expressionless, or
not alert (<2 mo)

Response (eg, talk, smile) Smiling or alert (<2 mo)

to social overtures

Risk SBI : Score < 10 (2.7%) , Score > 16 (92%)

Yale Observa1on Scale (YOS) degree of Illness

Indica,ons Assessment of febrile child ages 3-36 months
Predicts serious infec,on (Occult Bacteremia)
Quan,es "Toxic Appearance" in children

A total score of less than 11 signifies a less than 3% probability of serious illness.
A total score 11-15 signifies a 26% probability serious illness
A total score of greater than 15 signifies 92 % probability of serious illness

Laboratory evaluation
v What would you do if the patient has device (VP

shunt, tracheostomy, gastrostomy tube) or central

line?
v CBC with differential
v Blood culture
v CSF (tap VP shunt)

Laboratory evaluation
v What would you do if the patient has a high risk for

sepsis?

v Immunocompromised
v Transplant recipient
v Oncology patient
v CBC with differential
v Blood culture
v Urinalysis and urine culture

Laboratory evaluation
v What would you do for an infant 2 months of age?
v CBC with differential
v Blood culture
v Urinalysis and urine culture
v Lumbar puncture

Laboratory evaluation
v Who needs a urinalysis and urine culture?
v Circumcised males < 6 months
v Uncircumcised males < 1 year
v Females < 2 years
v Immunocompromised patients
v Patients with history of UTI/pyelonephritis

Laboratory evaluation
v Who needs a lumbar puncture?
v Neonates 2 months
v Ill-appearing
v Altered mental status

v What tests do you send?

v Gram stain and culture
v Cell count and differential
v Protein and glucose
v Extra tube for additional studies
v Enteroviral PCR, HSV PCR, CA encephalitis project

Laboratory evaluation
v Consider CRP, ESR
v Consider PT/PTT, fibrinogen
v Consider chest x-ray
v Consider nasopharyngeal DFA
v For immunosuppressed patients consider:
v Viral PCR studies (ie CMV, EBV, HHV6)
v Additional imaging (ie ultrasound, CT scan)

Objectives
v To know about fever: definition, classification,

etiology and patophysiology

v To assess patient with fever.
v To determine which patients are at high risk of

developing serious bacterial infection.

v To initiate empiric therapy.

Which patients are high-risk for

serious bacterial infection?
v Neonates
v Transplant recipients
v Bone marrow
v Solid organ

v Oncology patients
v Undergoing therapy, mucositis, central line
v Most chemotherapy: nadir ~ 10 days after rx

v Asplenic patients, including sickle cell

Objectives
v To know about fever: definition, classification,

etiology and patophysiology

v To assess patient with fever.
v To determine which patients are at high risk of

developing serious bacterial infection.

v To initiate empiric therapy.

Treatment for non-high risk

patients
v May not need empiric antibiotics
v Consider the following issues:
v Is patient clinically stable?
v Are the screening laboratory studies suggestive of

infection?

Yale Observation Scale

A total score of less than 11 signifies a less than 3% probability of serious illness.
A total score 11-15 signifies a 26% probability serious illness
A total score of greater than 15 signifies 92 % probability of serious illness

Treatment for patients with

central lines
v Ceftriaxone
v Vancomycin

Treatment for neonates 2

months
v If < 28 days old
v Ampicillin AND cefotaxime OR
v Ampicillin AND gentamicin
v Consider acyclovir

v If 29-60 days old

v Ceftriaxone Ampicillin OR Vancomycin
v Until CSF results are known (cell count, protein,

glucose), initiate therapy with meningitic dosing

regimen

Treatment for febrile neutropenia

v Broad-spectrum antibiotics with Pseudomonas

coverage

v Ex: use ceftazidime or piperacillin-tazobactam

v Consider double coverage for possible resistant

Pseudomonas

v Ex: add amikacin or tobramycin

v Consider gram-positive coverage (central line,

skin infections)

v Ex: add vancomycin

v Consider anaerobic coverage (mucositis,

typhlitis)

v Ex: use piperacillin-tazobactam or add clindamycin

Take home points

v Infections are the most common cause of

fever in children
v During assessment of a child with fever, pay

close attention to vital sign changes, overall

appearance, and potential sites of infection
v Closely monitor for clinical decompensation

after antibiotic administration, particularly in

patients at high-risk of developing sepsis

References
v Baraff LJ. Management of fever without source in infants and

children. Ann Emerg Med. 2000. 36:602-14.

v Meckler G, Lindemulder S. Fever and neutropenia in pediatric

patients with cancer. Emerg Med Clin N Am. 2009.

27:525-44.

v Palazzi EL. Approach to the child with fever of unknown

origin. UpToDate. 2011

v Palazzi DL. Etiologies of fever of unknown origin. UpToDate.

2011.

v Tolan R. Fever of unknown origin: A diagnostic approach to

this vexing problem. Clin Pediatr. 2010;49:207-13.