What is a fever?
An abnormal condition of the body characterised by an undue rise in temperature, quickening of the pulse and disturbance of various body functions
What is pyrexia?
Medical term denoting fever
What is hypothermia?
Defined as a core body temperature <35
How is body temp controlled and regulated?
- Neural feedback via hypothalamus
Temperature patterns based on age
Neonates may not be able to mount a hyperthermic response and may be hypothermic despite significant infection whereas older children <5yrs may have an exaggerated febrile response, high fever in even older children and adolescents suggests a serious pathological process
Who is at particular risk of fever?
- Premature infants have little or not immunity and rely on maternal antibodies (although this only happens at 30 weeks so those born before are very susceptible)
- Antibodies are also transferred via breast milk
- Newborn term infants: at risk e.g. chicken pox and herpes
- Those born through birth canal: group B strep and E.coli are present in the birth canal
- Immunodeficiencies: congenital or acquired
Bacteraemia vs septicaemia
- Bacteraemia is the presence of bacteria in the bloodstream, blood should be sterile so this is always a problem
- Septicaemia is the presence of pathogenic organisms in the bloodstream leading to sepsis
- Presence of numerous bacteria in the blood which are actively dividing, this results in a systemic response leading to organ dysfunction
- Serious illness and often fatal
- Can be complicated by circulatory collapse, respiratory depression, increased metabolic rate and vasoregulatory perfusion
Name some of the common upper resp tract infections in children
- Pharyngitis
- Tonsilitis
- Laryngotracheobronchitis
- Epiglottitis
What causes meningococcal disease?
Neisseria meningitidis
Epidemiology of meningitis
- Can affect all age groups but highest rates in children <5yrs
- High mortality and morbidity: 1/20 cases result in death and 1/5 survivors have permanent effects e.g. scars, limb loss
- Overall incidence fallen since men C vaccine
What is pyrexia of unknown origin PUO?
What it says on the tin
Causes
- Infectious
- Connective tissue disorders
- Malignancy
- Miscellaneous: drugs? Inflammatory? Sarcoidosis?
Approach to PUO
- Good hx and examination
- Measure temp
- Stop all antibiotics
- Look for common causes first
- Avoid treating empirically if possible
- If unresolved - go back to taking a history etc
What is Kawasaki disease?
- Aka mucocutaneous LN syndrome
- Multisystem vasculitis
- Typically self limiting after 12 days but cardiac complications mean treatment is required
- Aetiology unknown
- Set diagnostic criteria - not all of which need to be present if suspicion is high
- Fever >5days without any other underlying cause + 4/5 out of: bilateral non-purulent conjunctivitis, polymorphous rash, cervical lymphadenopathy, peripheral peeling/ oedema/ erythema, oral mucous membrane changes
- Consider in any child who has a prolonged fever
What can be used to decide how to manage a child with a fever?
NICE traffic light system
- A tool used to assess the risk of serious illness in children (birth – 5 years) with a fever
- Uses a list of clinical parameters to decipher whether a child falls into the following categories:
- A) GREEN: low risk of serious illness
- B) AMBER: intermediate risk of serious illness
- C) RED: high risk of serious illness
What are the criteria, according to the NICE traffic light system, that would indicate a high risk of serious illness?
RED criteria
Pale/mottled/ ashen skin
No response to social cues, appears ill, does not wake, high pitched cry
Reduced skin turgor
Age 3 months temp >38
Non-blanching rash, bulging fontanelle, status epilepticus, focal neur signs, focal seizures
A) Life-threatening illness
- Children whose symptoms or combination of symptoms suggest an immediately life-threatening illness
Action: arrange ambulance transfer to A&E
B) Red: high risk features
- Red category features but not considered to have an immediately life threatening illness
Action: urgent face to face assessment in a healthcare setting within 2 hours
What should be done if meningococcal meningitis or haemophilus influenzae meningitis is suspected?
Single STAT dose of benzylpenicillin should be administered by the general practitioner before transfer to hospital
Benzylpenicillin should be withheld if there is a known history of anaphylaxis following penicillin administration. Cefotaxime is an alternative in this case.
Management of children with a fever based on NICE traffic light criteria
A) Life-threatening illness
- Children whose symptoms or combination of symptoms suggest an immediately life-threatening illness
Action: arrange ambulance transfer to A&E
B) Red: high risk features
- Red category features but not considered to have an immediately life threatening illness
Action: urgent face to face assessment in a healthcare setting within 2 hours
C) Amber: intermediate risk
- Children with amber features but no red features – should be seen face to face in a healthcare setting
The urgency of this is judged by the healthcare professional carrying out the remote assessment
D) Green: low risk
- Children with no red or amber features, advice given to parents/ carers on how to care for the child at home
Safety netting
How is urine tested for infection in children?
- Children with a fever with no obvious cause should have their urine checked for infection - if <3yrs microscopy is used to check urine, if >3yrs dipstick urine
Fever lasting >5days - thoughts?
Consider Kawasaki’s or systemic onset juvenile arthritis
Which investigations should be performed in a child <3 months
- FBC
- Blood culture
- C-reactive protein
- Urine testing for urinary tract infection
- Chest radiograph only if respiratory signs are present
- Stool culture, if diarrhoea is present
Questions to ask when a child presents with fever
Main aim is the find the source of the fever
- Associated symptoms: cough, neck stiffness, photophobia
- Hydration
- Rash
- Travel hx
- Consider a non-infective fever: Kawasaki’s, juvenile arthritis
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Neonatal period155
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Elimination problem84
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Abnormal gait/ posture99
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Collapse and seizures12
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Examination of a child15
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Head injury1
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Failure to gain weight or height29
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Breathing difficulties48
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ENT conditions8
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Abdominal pain6
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Urogenital disorders74
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Child with chronic condition35
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Developmental delay, behavioural disorders and learning difficulty121
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Childhood cancers40
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Fever21
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Allergies, immunodeficiency and infection46
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Community child health27
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Haematological conditions15
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Paediatric cardiology62
