Febrile Illness - Emergency Management in · PDF fileeasons for paediatric presentations ......

Document ID 00707

Febrile Illness - Emergency Management in Children Children’s Health Queensland Hospital and Health Service

Executive Sponsor: Chief Executive, CHQ Custodian/Review Officer: Director, Paediatric Emergency Medicine, CHQ Version no: 1.0 Applicable To: Medical and nursing staff working in Children’s Health Queensland Approval Date: 13/02/13 Effective Date: 13/02/13 Next Review Date: 13/02/2016 Authority: Children’s Health Queensland Hospital and Health Service Approving Officer: General Manager Operations Name: Sue McKee ……………………………………… Signature Supersedes: New Key Words: Children; fever; febrile; temperature; emergency management; admission, discharge criteria, 00707 Accreditation References: NSQHS Standards: 11, 4 © State of Queensland (Queensland Health)

2013

http://creativecommons.org/licenses/by-nc-nd/2.5/au/

For permissions beyond the scope of this licence contact: Intellectual Property Officer,

email [email protected], or phone (07) 3234 1479

1. Purpose

This procedure provides clinical practice guidelines to guide clinicians involved in the emergency management of fever in children. It aims to identify those at risk of serious bacterial or other significant illness who need timely treatment, whilst avoiding unnecessary investigations in the majority.

2. Scope

This procedure relates to all Children’s Health Queensland (CHQ) staff involved in the care and management of children who present with fever as their primary complaint.

3. Procedure

3.1 Introduction

Fever is one of the most common reasons for paediatric presentations to emergency services and provides diagnostic and management challenges to clinical staff.

3.2 Fever definition and measurement

The normal mean body temperature is 37°C (range 36.2 - 38.0°C) in healthy children1. For children under three months of age, 38°C is approximately two (2) standard deviations above the mean.2 The body temperature fluctuates (by up to 1°C) with age, time of day, activity level, feeding, clothing, ambient condition and the site used for the reading 1. Core body temperature measurement (pulmonary artery or distal oesophagus) is the accepted gold standard, but is not practical in the emergency department setting. Estimation by rectal or bladder temperature is also too invasive to be routinely used in the conscious child. Commonly used alternative sites (oral, axillary, tympanic, and skin)3-5 all may underestimate core temperature by up to 1°C.

A parent’s touch has been shown to have high sensitivity but low specificity for discovering a fever.6 A practical definition of fever is any temperature ≥38°C however measured, at home or in hospital.

3.3 “Fever phobia”

Fever often causes significant anxiety for parents and healthcare workers alike. “Fever phobia” is a common phenomenon 8 and may be perpetuated by well-intentioned enquiries regarding height of the fever or repeated measurement by medical personnel. Myths and misinformation about the likely causes of fever (such as teething); what the height of the fever means; response of fever to antipyretics; and side effects such as risk of seizures, brain damage and death are commonly encountered and should be acknowledged, gently corrected where needed, and put into perspective.

Version No.: 1.0: Effective From: 13/02/2013 of 15

d

CHQ Procedure 00707 : Febrile Illness – Emergency Management in Children

Printed copies are uncontrolle

http://creativecommons.org/licenses/by-nc-nd/2.5/au/�

http://creativecommons.org/licenses/by-nc/2.5/au/

http://creativecommons.org/licenses/by-nc/2.5/au/

mailto:[email protected]

CHQ Proc00707: Febrile Illness – Emergency Management in Children

ALERT:

“Humanity has but three great enemies: fever, famine and war; of these by far the greatest, by far the most terrible, is fever” - Sir William Osler 7

3.4 Pathophysiology of fever 1,9

Fever is a physiological response most often caused by an infective process when exogenous pyrogens (e.g. bacterial toxins, antibody-antigen complexes) induce endogenous pyrogens (e.g. TNFα, IL-B1, IL-6 and interferons) resulting in an elevated body temperature. The thermoregulatory centre then raises and maintains the body temperature to the new set point. This may negatively stress some children with pre-existing cardiac, respiratory or neurological diseases, and gives most children a degree of malaise. However fever is thought to be a generally beneficial adaptive response that promotes the immune response and inhibits the invading pathogen, potentially reducing the duration of certain infections.

3.5 Epidemiology of fever

Febrile illnesses comprise approximately 20% of paediatric emergency presentations.10,11 Most (80%) have a readily identifiable source of the fever.12 Of the remaining 20%, most will have a self-limiting viral infection, however a small proportion will have a serious bacterial infection (SBI) or be febrile from conditions such as Kawasaki disease, vaccination reactions, arthritis or connective tissue disorders, malignancies, drug fever, or inflammatory bowel disease. In a large Australian children’s hospital study, 7.5% of febrile children <5 years old had a SBI; 3.4% had a urinary tract infection (UTI); 3.4% pneumonia; 0.4% bacteraemia and 0.1% meningitis.13 Pyrexia of unknown origin (PUO)14 is any fever lasting 10 - 21 days without cause identified on history, examination and basic investigations.

3.6 Serious bacterial infection (SBI)

SBI includes UTI, pneumonia, meningitis, bacteraemia, osteomyelitis, septic arthritis, skin and soft tissue infection or bacterial enteritis; though only the first four (4) are likely to present in an occult fashion with significant frequency.

UTI

This is a relatively common infection in febrile children <5 years. In the 1st year of life, 6.5% girls and 3.3% boys (1.2% of circumcised vs. 8% of uncircumcised males) will have a UTI. In the 2nd year, the rates become 8.1% girls & 1.9% boys15 and decrease thereafter. UTI is also the most common SBI causing fever without focus, at approximately 5%.16

Pneumonia

About 3 - 4% all febrile children under 5 years13 and approximately 5% with fever without a focus17 have pneumonia, though most will be viral in origin. Increasing pneumococcal immunisation may continue to decrease the incidence of bacterial pneumonia due to the commonest bacterial agent, Streptococcus pneumoniae.

Bacteraemia

The incidence of occult bacteraemia has fallen from over 10% to <0.5%12,18 of febrile children aged three (3) months to three (3) years. This is largely due to effective immunisation against Haemophilus influenzae type b (HIB) & Streptococcus pneumoniae. Rates are higher (approximately 2 - 10%) in non and pre-vaccinated children depending on age. Meningococcaemia occurs in only 0.02% of young febrile infants <2 - 3 months,19,20 but approximately 15% of these may not appear ill-looking.21 Other common pathogens, particularly in infants <6 months, include Salmonella species (which may be associated with diarrhoea) and E. Coli (which may accompany UTI).16


d






Printed copies are uncontrolled

Meningitis

The incidence of meningitis is generally very low,13 but more common in younger infants. A recent study found a bacterial meningitis rate of approximately 0.7% in febrile infants < 2 months old.22

4. Assessment

A well-taken history and thorough clinical examination should aim to identify:

a. children who have a focus of infection that may then be investigated and treated , and

b. children for whom no infective focus may be found and who may require further investigations and/or empirical treatment according to their risk of SBI.

Factors that may assist in risk stratification include:

child’s age immune status - incomplete immunisations, immunocompromise signs of toxicity current or recent use of antibiotics presence of concerning signs and symptoms (eg. petechial rash)

5. Age

Several meta-analyses15,23,24 have shown that febrile young infants <3 months have a high risk of SBI (7-24%). This risk is greatest in the neonatal period and decreases progressively with increasing age. Young infants are more likely to present with non-specific features (they lack the hypothalamic and immune system maturity to localise the infection) and can deteriorate rapidly25. In addition to the pathogens seen in older children, Group B Streptococcus, E. Coli, Herpes Simplex virus, Listeria monocytogenes infections are more common in this period. Detecting other viral infections (e.g. RSV) lowers but does not remove the risk of SBI (7% vs. 12.5% for SBI (mainly UTI) in one (1) large study.22 More recently a study26 found the incidence for SBI in infants one to three (1 - 3) months decreased significantly if they had bronchiolitis, however the UTI rate was still 4%. A systematic review27 supported the use of screening for UTI in bronchiolitic children aged one to three (1-3) months as this was the only SBI with significant incidence (3.3%).

Children aged three (3) months to three (3) years have a lower risk of SBI and have their immunity boosted with vaccinations. Occult bacterial infection is most commonly UTI, pneumonia or bacteraemia. In this age group, the presence of a recognisable viral syndrome (including bronchiolitis) predicts a very low incidence of bacteraemia (0.2%).28

Older children (>3 years) have mature immune systems, are better able to verbalise and localise symptoms and are at lower risk of SBI.

6. Immunisations & Immune status

The risk of occult bacteraemia (OB) and SBI has fallen in the last 20 years with the advent of several vaccines, in particular the Haemophilus influenzae type b (HIB) and pneumococcal (PC) immunisations. Recent studies suggest that OB rates have fallen to <0.5% in immunised children 3 - 36 months with fever without focus.12,18 HIB has all but been eliminated as a cause of bacteraemia and serious invasive infection.24 Streptococcus pneumoniae remains responsible for the majority of current cases of OB, but is thought to cause invasive disease in less than 5% of these.29 It is expected that there may be a further decrease in OB incidence as the 7-valent conjugate pneumococcal vaccine is replaced on the National Immunisation Program with a 13-valent one that covers most of the remaining invasive serotypes. After two (2) of the usual three to four (3 - 4) doses of these immunisations (usually achieved by four (4) months of age in Australia), there is >95% protection30 In addition the national program has increased herd immunity, which further reduces the risk to all children.

If a child has a congenital immune deficiency syndrome, sickle cell disease, HIV, asplenia, cancer, nephrotic syndrome, intracranial shunt, cochlear implant, immunosuppressive therapy or is indigenous then there is a greater risk for SBI.


7. Clinical appearance and toxicity

Well-appearing children over one (1) month of age are less likely to have a SBI than those who appear toxic (92% if toxic, 26% if looking ill, 3% if well-appearing - using Yale Observation Score (YOS) in children under age two (2) years).31 More recent studies 32 have cast doubt on the utility of the YOS and recognise the difficulties in differentiating toxic and well-appearing infants. A number of SBI risk assessment protocols in young infants (Rochester, Boston, and Philadelphia protocols)19,20,33.34 include a ‘well appearance’ criterion in addition to laboratory tests.

The National Institute for Health and Clinical Excellence (NICE) guidelines combine features of specific serious disease with general appearance into a ‘traffic light’ based assessment to help determine risk.35 Clinical features that may help to identify serious infection in children include:32,36

Drowsiness Breathing difficulty or tachypnoea Cyanosis or pallor Poor peripheral perfusion Feeding <50% normal Decreased activity <4 wet nappies in 24 hours Seizures Petechial rash Parental concern or clinician instinct. 8. Petechial rash and fever (Figure 1)

SBI incidence (predominantly meningococcal disease) has been estimated to be 2 - 8% in children with fever and petechiae.30 If the child is unwell (i.e. abnormal vital signs, poorly perfused, or having altered mental state) or if the rash is purpuric (>2mm lesions) and not consistent with typical Henoch-Schonlein purpura (HSP), then the child should be managed presumptively for meningococcal disease with resuscitation as required and a 3rd generation cephalosporin whilst investigations are carried out. Well-appearing children with petechiae caused by local pressure or only in the distribution of the superior vena cava (eg. following coughing/vomiting) may be discharged with early review. In all other cases blood tests should be performed (full blood count, C reactive protein, blood culture). If the FBC and CRP are within normal limits and the child remains well during a 4-hour period of observation, then discharge with early review is again appropriate, otherwise admission with or without antibiotics should be undertaken.37-39

Figure 1: Fever and petechial rash flowchart

Adapted from: Royal Children’s Hospital, Melbourne, ‘Fever and petechiae flowchart’39


d







8.1 Fever height, duration and response to antipyretics

The height of the temperature has been used in many management algorithms to risk stratify febrile children. Whilst there is evidence that higher temperatures are associated with increased risk of SBI 40,41 the significance and degree of risk may be less clear in today’s immunised population. In addition, viruses such as influenza routinely cause fevers >40°C, with SBI’s being responsible for only a small proportion of high fevers encountered. Also, SBI’s such as sepsis and meningitis may present without significant fever. Thus, it is the presence of a fever that is important to note and the height of fever should not be used as the primary discriminating management decision variable.

The duration of the fever 42 and response to antipyretics 7 have failed to show any ability to differentiate severe from mild illness or bacterial from viral infection.

INVESTIGATIONS

Most tests used to investigate febrile children have only moderately good sensitivities and specificities. Investigations may be used to help make a diagnosis, determine antibiotic use and duration, or risk stratify certain patients when no focus of infection is found. In the case of a PUO, more extensive investigations may be warranted, but will not be discussed further here.

Urinalysis, microscopy and culture,43-46

UTI is the most prevalent SBI in febrile young children and testing for one should be performed in symptomatic children or in febrile children <3 years. A recent AAP Clinical Practice Guideline on diagnosis of UTI in young children has recommended screening on the basis of risk. In practice, the majority of children, in particular infants will not fall into their low risk category and will require testing.

Dipstick urinalysis or urine microscopy may be used to screen urine samples for UTI. A diagnosis of UTI is likely (positive likelihood ratios of >20) when:

both the leucocyte esterase and nitrite tests are positive in children ≥2 years or bacteria are seen on a Gram stain.

A presumptive diagnosis of a UTI can then be made and empirical antibiotics commenced while the sample is being cultured and tested for sensitivities.

UTI may be confidently ruled out (negative likelihood ratio of 0.19) when both leucocyte esterase and nitrite are negative on dipstick testing in patients over two (2) years of age. If not, a sample for microscopy and culture should be obtained.

The method of urine collection is also important and different methods vary by potential delays, invasiveness, and contamination rates.

Supra-pubic bladder aspiration (SPA) has the lowest contamination rate, but is invasive and has a success rate of 23 - 90% depending on the operator and use of ultrasound to determine location and the presence of at least 20ml of urine. It should be only generally considered in infants <6 months or if there is phimosis or labial adhesion.

Urethral catheterisation has a sensitivity of 95% and specificity of 99% compared to SPA. It is also invasive but success rates may be higher than with SPA. It should be used first line in children >6 months who are not toilet-trained or if SPA fails.

Clean catch specimen may be used for children who are unable to void on request, are not toxic, and in whom a delay in obtaining the sample is not detrimental. The child’s perineum should be washed prior to collection and the inside of the clean/sterile container used for collection should not contaminated by touching the collector’s or the child’s skin.

Midstream urine is recommended once the child is toilet trained.

Bag specimens although uncomfortable for the child (especially on removal) are often more acceptable to parents and staff because they are less invasive. Unfortunately, up to 85 - 90% samples are contaminated and thus cannot be used for a culture. A bag sample negative on dipstick urinalysis in a young child (<2 years) is not sufficient to rule out a UTI. A negative dipstick urinalysis on a sample obtained from a bag on a non-toxic febrile child >2 years is sufficient to rule out an infection. The high contamination rates plus potential delays in obtaining samples mean that bag samples should generally be discouraged.





Chest X-ray (CXR)

There is limited value in performing a CXR in a febrile child without cough. The likelihood of detecting pneumonia is increased with longer duration of cough and fever or the presence of leucocytosis.17 Most pneumonia in infants and young children is viral in origin and a CXR cannot reliably distinguish viral from bacterial pneumonia. Even when the CXR suggests a bacterial aetiology, a virus is more often isolated than a bacterial pathogen.47

A CXR is recommended in febrile children with:48

increased work of breathing (chest recession, tracheal tug, use of accessory muscles)

cough, tachypnoea and low oxygen saturation (≤ 93% in room air)

a temperature >39°C and WBC >20 x 109 (as a screen for occult pneumonia).49,50

Blood Culture

Although blood cultures are the gold standard for diagnosing a bacteraemia, there are limitations with this investigation. Now that the incidence of occult bacteraemia is very low, the contamination rate is often higher than the true positive rate. Negative blood culture may also have a poor NPV51 due in part to inadequate sampling (minimum blood sample required usually ≥1 ml but confirm with local laboratory). Young infants have higher rates of bacteraemia, and may become bacteraemic with other invasive SBI's, and it is recommended to collect a blood culture in this group.

Full Blood Count

A recent systematic review found that WCC has no value in ruling out SBI and is less valuable than CRP for ruling in SBI.32 Meningococcal, salmonella & staphylococcal bacteraemias often do not elevate the WCC. When used, the threshold most often used to indicate increased bacteraemia risk is WCC>15 x 109/L, which has only moderate sensitivity and specificity. One large study including the post-PC vaccine era reported 74.0% sensitivity, 54.5% specificity, 1.5% positive predictive value and a 99.5% negative predictive value.52 Some investigators also include WCC<5 x 109/L, absolute neutrophils count (ANC)>10 x 109/L or <1 x 109/L, or the presence of bands as risk factors.

With the current low risk of bacteraemia and using more appropriate tests for the other occult SBI, there appears little value in the test, except in very young infants or the unimmunised.

C reactive protein (CRP)

CRP is an acute phase reactant and concentrations start to rise at four to six (4 - 6) hours after onset of inflammation and peak around 36 - 50 hours. CRP shows promise and is better than the FBC for detecting SBI, especially if used after 12 hours of fever.53 A recent systematic review showed that different cut-off values can be used to identify high risk and low risk children.32 Young children with fever >39.5°C may be divided into three (3) groups according to CRP:

5% risk of SBI if CRP <20 mg/L

15% risk of SBI if CRP 20-80 mg/L

72% risk of SBI if CRP >80mg/L

(Note: likelihood ratios were only moderate and the populations included had intermediate or high prevalence of SBI.)

Lumbar Puncture (LP)

There is limited evidence regarding which children should have an LP performed as part of the septic workup, especially as the incidence of bacterial meningitis has decreased dramatically since the introduction of the HIB and PC vaccines. Although there is good evidence for several useful clinical features which influence the likelihood of meningitis in a child, no one clinical feature is diagnostic 54 and in the very young infant meningitis often presents with non-specific features like poor feeding, lethargy or irritability. The height of the fever and WCC are unhelpful as they do not reflect the risk of bacterial meningitis. In general, as long as the child is well





enough to tolerate the procedure and there are no contraindications the procedure, an LP should be considered in children with signs or symptoms of meningitis, or in the young febrile infant with non-specific features such as vomiting, lethargy / drowsiness, irritability or poor feeding. [Refer to acute management of meningitis in children clinical procedure – to be hyperlinked]

Other tests

Procalcitonin (a prohormone rises with physiological stress) has restricted availability currently, but has shown utility in differentiating bacterial from viral illness.55 It has been reported to have better specificity and possibly sensitivity than CRP for bacterial meningitis or sepsis especially in first six to eight (6 - 8) hours of fever.56-58

Viral diagnostic studies – limited usefulness in ruling out SBI as noted above.

Stool microscopy and culture – may be indicated in very young infant or if mucoid, bloody or prolonged diarrhoea.

9. Management

The recommended emergency management of febrile children is summarised on the Flowchart and comprises:

Supportive

The child should have excess layers of clothing removed. Over-enthusiastic physical cooling can be counterproductive by stimulating shivering and other heat-retaining reflexes. Oral fluids if tolerated should be encouraged to maintain hydration.

Antipyretics

Antipyretics may be prescribed for an awake child to provide relief from discomfort caused by the fever or the underlying cause of the fever. Parents should be advised that fever is one of the body’s immune system responses to infection and that antipyretics do not treat or shorten the illness, will not prevent febrile convulsions,59 and if the dosing is excessive can cause adverse events.60

Aspirin should be avoided in children as the uncommon possibility of Reye's syndrome increases with varicella or influenza-like illnesses.61

Appropriate choices for symptomatic relief one of:

Paracetamol 15mg/kg up to four (4) hourly with a maximum of four (4) doses per day, or

Ibuprofen 10mg/kg up to six (6) hourly with a maximum of four (4) doses per day (avoid in children <6 months, if significantly dehydrated 60 or history of hypersensitivity. Ibuprofen appears to be safe in asthmatics.62

There is some evidence that ibuprofen reduces fever and discomfort more quickly than paracetamol.63 The popular dual therapy dosing regimes advocated by some reduce the time with fever, however there is no significant difference in resolution of discomfort versus monotherapy.64 Safety concerns have been raised over recommending two drugs with different dosing regimes for little gain.

Risk Stratification

The risk of SBI may be stratified by age, the presence of a focus for infection, and toxicity. See the Flowcharts in Appendix 1 & Appendix 2 for details.

Antibiotics

Antibiotics may be indicated depending upon the perceived risk of SBI or the specific infection found. Antibiotics are usually administered via the intravenous route initially for admitted patients





For choices and doses see Children’s Health Queensland Antibiocard

See flowcharts Appendix 1 - Emergency Management of Fever in Children (< 4 months) and

Appendix 2 - Emergency Management of Fever in Children (≥ 4 months).

Disposition

As indicated by the Flowchart. All toxic children should be reviewed early by a senior medical officer.

Febrile children fit for discharge should be discussed with a senior doctor and arrangements made for a follow up visit at his / her local General Practitioner to check progress and outstanding test results.

See flowchart Appendix 3 - Admission / discharge criteria for children presenting with fever.

When a decision is made to transfer a child to a Level 6 facility, referral must be made through RSQ.65

Activation of the QLD emergency medical system coordination centre (QCC)

Further information on the preparation of a infant prior to transport can be obtained through RSQ Clinical Guidelines paediatric section (page 31-35).65

Statewide RSQ clinical guidelines - Paediatrics

Abbreviations

Term Definition

AAP American Academy of Pediatrics

ANC Absolute neutrophil count

BSL Blood sugar level

Children 0-14 years of age

CHS Children’s Health Services

CRP C-reactive protein

CXR Chest x-ray

E.Coli Escherichia coli

FBC Full blood count

HIB Haemophilus influenzae type B

HIV Human immunodeficiency virus

HSP Henoch-schonlein purpura

IV Intravenous

LP Lumbar puncture

MCS Microscopy, culture and sensitivity pathology test

NICE National Institute for Health and Clinical Excellence

NPV Negative predictive value

OB Occult bacteraemia

PC Pneumococcal

PUO Pyrexia of unknown origin

RSQ Retrieval Services Queensland

SBI Serious bacterial infection

SPA Supra-pubic bladder aspiration

SVC Superior vena cava

UTI Urinary tract infection

UEC Urea, electrolytes and creatinine

http://qheps.health.qld.gov.au/rch/docs/pharmacy/Antibiocard.pdf

http://qheps.health.qld.gov.au/rts/docs/rsq_activation.pdf

http://qheps.health.qld.gov.au/rts/docs/clin_guide_pt2.pdf





WCC White cell count

YOS Yale observation score

4. Supporting Documents

Appendix 1. Emergency management of children presenting with fever – less than 4 months

Appendix 2: Emergency Management of children with Fever (>4 months)

Appendix 3: Admission / Discharge Criteria for Children with Fever

Fever in children fact sheet

Children’s Health Queensland Antibiocard

5. References and Suggested Reading

1. Alpern, E.R, Henretig, F.M. (2010), ‘Chapter 27 - Fever’, in Textbook of Pediatric Emergency Medicine, 6th edn, Lippincott Williams and Wilkins: Philadelphia.

2 Herzog, L.W, Coyne, L.J. (1993), ‘What is fever? Normal temperatures in infants less than three months old’, Clin Pediatr, Vol. 32: pp. 142-6

3 Lefrant, J.Y., Muller, L. et al. (2003), ‘Temperature measurement in intensive care patients: comparison of urinary bladder, oesophageal, rectal, axillary, and inguinal methods versus pulmonary artery core method’, Intensive Care Medicine, Vol. 29(3): pp.414-8.

4. Erickson, R.S., Kirklin, S.K. (2003), ‘Comparison of ear-based, bladder, oral and axillary methods for core temperature measurement’, Critical Care Medicine, Vol. 21(10): pp. 1528-1534.

5. El-Radhi, A., Barry, W. (2006), ‘Thermometry in paediatric practice’, Arch Dis Child , Vol. 91: pp. 351-6.

6 Teng, C.L., Ng, C.J., Nik-Sherina, H., Zailinawati, A.H., Tong, S.F. (2008), ‘The accuracy of mother's touch to detect fever in children: a systematic review’, J Trop Pediatr , Vol. 54 (1): pp. 70-73.

7. Corneli, H.M. (2000), ‘Beyond the fear of fever’, Clin Ped Emerg Med, Vol.1: pp.94-101

8. Crocetti, M., Moghbeli, N., Serwint. J. (2001), ‘Fever phobia revisited: Have parental misconceptions about fever changed in 20 years?’, Pediatrics, Vol.107: pp.1241–1246.

9. Powell, K,R. (2007), ‘Chapter 174: Fever’, in Nelson Textbook of Pediatrics, 18th edn, Wayne State University: Detroit, USA.

10. Browne, G., Currow, K., Rainbow, J. (2001), ‘Practical approach to the febrile child in the emergency department’, Emerg Med, Vol. 13: pp. 426-35.

11. Queensland Health. (2011), EDIS Data from Mater Children’s Hospital, Royal Children’s Hospital: Brisbane. [Retrieved 2011].

12. Waddle, E., Jhaver1, R. (2009), ‘Outcomes of febrile children without localising signs after pneumococcal conjugate vaccine’, Arch Dis Child, Vol. 94: pp. 144-7.

13. Craig, J.C., Williams, G.J., Jones, M., Codarini, M., Macaskil,l P., Hayen, A., Irwig, L., Fitzgerald, D., Isaacs, D., McCaskill, M. (2010), ‘The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15 781 febrile illnesses’, BMJ , Vol. 340:pp. c1594.

14. Petersdorf, R.T., Beeson, P.B. (1961), ‘Fever of unexplained origin: Report on 100 cases’, Medicine Vol. 40: pp.1-30.

http://qheps.health.qld.gov.au/ed/docs/child_fever.pdf

http://qheps.health.qld.gov.au/rch/docs/pharmacy/Antibiocard.pdf





15. Baraff, L.J,, Oslundm S,A., Schrigerm D,L,, Stephenm M,L. (1992), ‘Probability of bacterial infections in febrile infants less than three months of age: a meta-analysis’, Pediatr Infect Dis J, Vol. 11:pp. 257-64.

16. Ishimine, P. (2007), ‘The evolving approach to the young child who has fever and no obvious source’, Emerg Med Clin N Am, Vol. 25: pp. 1087-1115.

17 . Murphy, C.G., van de Pol, A.C., Harper, M.B., et al. (2007), ‘Clinical predictors of occult pneumonia in the febrile child’, Acad Emerg Med, Vol. 14(3): pp. 243–9.

18. Wilkinson, M., Bulloch, B., Smith, M. (2009), ‘Prevalence of occult bacteremia in children 3-36 months presenting to emergency department with fever in post pneumococcal conjugate vaccine era’, Acad Emerg Med, Vol. 16(3): pp. 220-5.

19. Baskin, M.N., O’Rourke, E.J., Fleisher, G.R. (1992), ‘Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone’, J Pediatr, Vol. 120(1): pp. 22–7.

20. Baker, M.D., Bell, L.M., Avner, J.R. (1999), ‘The efficacy of routine outpatient management without antibiotics of fever in selected infants’, Pediatrics, Vol. 103(3): pp. 627-31

21. Wang, V.J., Kuppermann, N., Malley, R., Barnett, E., Meissner, H.C., Schmidt, E.V., Fleisher, G. (2001), Meningococcal disease among children who live in a large metropolitan area, 1981–1996’, Clin Infect Dis, Vol. 32(7): pp.1004–9.

22. Levine, D,A., Platt, S.L., Dayan, P.S., et al. (2004), ‘Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections’, Pediatrics, Vol. 113(6): pp. 1728-1734.

23. Baskin, M.N. (1993). ‘The prevalence of serious bacterial infections by age in febrile infants during the first 3 months’, Pediatr Ann, Vol. 22: p.462.

24. Jhaveri, R,, Byington, C.L., Klein, J.O., Shapiro, E.D. (2011), ‘Management of the non-toxic-appearing acutely febrile child: a 21st century approach’, J Paediatrics, Vol. 159(2): pp.181-185.

25. NSW Health. (2007), ‘Infants and children: Acute management of fever’, 2nd edn, NSW Health: NSW.

26. Yarden-Bilavsky, H., Ashkenazi-Hoffnung, L. Livni, G., Amir J, Bilavsky, E. (2011), ‘Month-by-month age analysis of the risk for serious bacterial infections in febrile infants with bronchiolitis’, Clinical Pediatrics, Vol. 50(11): pp.1052-6

27. Ralston, S., Hill, V., Waters, A. (2011), ‘Occult serious bacterial infection in infants younger than 60 to 90 days with bronchiolitis younger than 60 to 90 days with bronchiolitis’, Arch Pedriatr Adolesc Med, Vol. 165: pp. 951-6

28. Greenes, D.S., Harper, M.B. (1999), ‘Low risk of bacteremia in febrile children with recognizable viral syndromes’, Pediatr Infect Dis J, Vol. 18(3): pp. 258-261.

29. Rothrock, S.G., Harper, M.B., Green SM, et al. (1997), ‘Do oral antibiotics prevent meningitis and serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia?’, A meta-analysis. Pediatrics, Vol. 99: pp. 438–44.

30. Baraff, L.J. (2008), ‘Management of infants and young children with fever without source’, Pedatr Ann, Vol. 37(10): pp. 673-9.

31. McCarthy, P.L., Sharpe, M.R., Spiesel, S.Z. et al. (1982), ‘Observation scales to identify serious illness in febrile children’, Pediatrics, Vol.70(5): pp. 802–9.

32. Van den Bruel. (2011), ‘Diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review’, BMJ, Vol. 342: pp. d3082.

33. Dagan, R., Powell, K.R., Hall, C.B., Menegus, M.A. (1985), ‘Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis’, J Pediatr, Vol.107(6): pp.855–60.

34. Jaskiewicz, J.A., McCarthy, C.A., Richardson, A.C., White, K.C., Fisher, D.J., Dagan, R. Powell, K.R. (1994), ‘Febrile infants at low risk for serious bacterial infection - an appraisal of the rochester criteria and implications for management’, Pediatrics, Vol. 94(3): pp.390-6





35. National Institute for Health and Clinical Excellence. (2007), ‘Feverish illness in children. Assessment and initial management in children younger than 5 years’, [online] Available at: http://publications.nice.org.uk/feverish-illness-in-children-cg47 [cited May 2007]

36. Hewson, P., Poulakis, Z., Jarman, F., Kerr, J., McMaster, D., Goodge, J., Silk, G. (2000), ‘Clinical markers of serious illness in young infants: a multicentre follow-up study’, Journal of Paediatrics & Child Health, Vol. 36(3): pp. 221-5.

37. Brogan, P.A., Raffles, A. (2000), ‘The management of fever and petechiae: making sense of rash decisions’, Arch Dis Child, Vol. 83: pp. 506-7.

38. Klinkhammer, M.D., Colletti, J.E. (2008), ‘Pediatric myth: fever and petechiae’, CJEM, Vol. 10(5): pp. 479-82.

39. The Royal Children’s Hospital Melbourne. (2011), Clinical Practice Guidelines: Fever and Petechiae, [online] Available at: http://www.rch.org.au/clinicalguide/guideline_index/Fever_and_Petechiae_Purpura/ [Cited November 2011]

40. Trautner, B.W.,Caviness, A.C., Gerlacher, G.R. et al. (2006), ‘Prospective evaluation of the risk of serious bacterial infection in children who present to the emergency department with hyperpyrexia (temperature of 106°F or higher)’, Pediatrics, Vol. 118(1): pp. 34–40.

41. Kuppermann, N., Fleisher, G., Jaffe, D. (1998), ‘Predictor of occult pneumococcal bacteraemia in young febrile children’, Ann Emerg Med, Vol. 31(6): pp. 679-87.

42. Teach, S.J., Fleisher, G.R. (1997), ‘Duration of fever and its relationship to bacteremia in febrile outpatients 3 to 36 months old: the occult bacteremia study group’, Pediatr Emerg Care,Vol. 13(5): pp.317–9.

43. American Academy Paediatrics (AAP). (2011), ‘Urinary Tract Infection: Clinical Practice Guideline for the diagnosis and management of the initial UTI in febrile infants and children 2-24 months’, Pediatrics, Vol.128(3): pp. 595-610.

44. Williams, G.J., Macaskill, P., Chan, S.F., Turner, R.M., Hodson, E., Craig, J.C. (2010), ‘Absolute and relative accuracy of rapid urine tests for urinary tract infection in children: a meta-analysis’, Lancet Infect Dis, Vol. 10: pp. 240–50

45. Doley, A., Nelligan, M. (2003), ‘Is a negative dipstick urinalysis good enough to exclude urinary tract infection in Paediatric Emergency Department patients?’, Emergency Medicine, Vol. 15: pp. 77-80.

6. Consultation

Key stakeholders (position and business area) who reviewed this version are:

Director of Paediatric Emergency Medicine, Children’s Health Queensland Clinicians (medical, nursing, allied health) working within Level 4, Level 5 and Level 6 Children’s Health

and Metro Children's Health Queensland in emergency, inpatient and ambulatory services Children’s Health Queensland Hospital and Health Service clinical leaders - medical, nursing and allied

health District Chief Executive Officers — Children’s Health Queensland, Metro South, Metro North and West-

Moreton Health Service Districts Queensland Ambulance Services — Manager Clinical Standards.

Acknowledgements:

Children’s Health Queensland would like to acknowledge the contribution made by:

Dr Jason Acworth - Director of Paediatric Emergency Medicine, Children's Health Queensland Donna Franklin - Project Manager SEQ PP, Children's Health Queensland Dr John Gavranich - Director of Paediatrics, Ipswich Hospital Dr Adrian Bonsall - Fellow, Emergency Services, Mater Children's Hospital Shahn Horrocks - Nurse Practitioner, Emergency Services, Gold Coast and Logan Hospitals Andrea Hetherington - Clinical Nurse Consultant (Paediatrics) Emergency Services, Logan Hospital Sharon Bluett - Nurse Educator, Emergency Services, Mater Children’s Hospital

http://publications.nice.org.uk/feverish-illness-in-children-cg47

http://www.rch.org.au/clinicalguide/guideline_index/Fever_and_Petechiae_Purpura/





Rachel Browne - Project Officer / Clinical Nurse Consultant, Ipswich Hospital Ange McMillan - Clinical Nurse Facilitator, Emergency Service, Ipswich Hospital Suzanne Williams - Nurse Practitioner, Emergency Services, Mater Children’s Hospital Dr David Wood - Paediatric Emergency Fellow, Emergency Services, Royal Children’s Hospital Petrina Hetherington - Acting Clinical Nurse, Emergency Services, Royal Children’s Hospital.

7. Procedure Revision and Approval History

Version No Modified by Amendments authorised by Approved by

1.0 Director, Paediatric Emergency Medicine

Chief Executive, Children’s Health Queensland

General Manager Operations

8. Audit / Evaluation Strategy

Level of risk High

Audit strategy 1. Staff survey to evaluate awareness of procedure and emergency management practices

2. Observe practice

3. Review documentation, i.e. chart audit, to evaluate compliance with procedure

Audit tool attached Nil

Audit date Annual snapshot review (August)

Audit responsibility Individual Greater Brisbane Metropolitan hospitals, i.e. Ipswich, Logan, Redland, MCH, RCH, TPCH, Redcliffe, Caboolture

Key Elements / Indicators / Outcomes

KPI 1 — greater than 80% staff awareness of procedure

KPI 2 — greater than 80% compliance with procedure

9. Appendices Appendix 1: Emergency Management of Children with Fever (<4 months) Appendix 2: Emergency Management of children with Fever (>4 months) Appendix 3: Admission / Discharge Criteria for Children with Fever


Appendix 1 – Emergency Management of Children with Fever (< 4 months)




As

ses

sm

ent

Inve

sti

ga

tio

n &

Tre

atm

ent

Rev

iew

Child presents to emergency service with a fever

Emergency management of children with FEVER (< 4 MONTHS)

Age ≤ 2 months

Age 2-4 months

A. Toxic· Marked lethargy/decrease in activity· Altered mental status· Inconsolable irritability· Tachypnoea, increase work of breathing, grunting· Cyanosis· Poor perfusion (mottled skin, pallor)· Marked/persistent tachycardia· Moderate to severe dehydration· Infant feeding <50% normal· < 4 wet nappies in 24 hours· Seizures· Petechial rash· Parental concern

Assess SeverityConsider pre-hospital management given

· Treat discomfort with antipyretic· Remove excess layers of clothing· Consider offering oral fluids

No toxic features Toxic features A

B. CXR indications· Increased work of breathing· Cough· Tachypnoea· SaO2 ≤ 93% in room air· T > 39°C & WCC > 20 x 109/L

Typical respiratory illnesssee bronchiolitis guideline

Not a typical respiratory illness

Investigations· Urine MCS· +/- CXR B +/- NPA

Investigations· Urine MCS· FBC· CRP/PCT· Blood culture· +/- CXR B

· +/- LP C

Any high risk features? D

Meets discharge criteria?

Admit to children’s inpatient service Discharge

Emergency Management(Resuscitate using ABCD)

Call ED ConsultantA Provide highflow oxygenB Support ventilation (BVM) Consider ETT intubation if not respondingC Obtain IV or IO access Give IV fluid boluses 20mL/ kg 0.9%NaCl as requiredD Check BSL & give IV 10% Glucose (2 mL/kg) as needed

C. LP indications· Age < 2 months of age· Bulging fontanelle· Vomiting· Lethargy/drowsiness· Cerebral irritability· Poor feeding· Seizures

D. High risk criteria· WCC < 5 or > 15 x 109 /L· ANC < 1 or > 10 x 109 /L· Bands > 1.5 x 109 /L· CRP > 20 or PCT > 0.5ng/mL· CSF: > 7 WBC· Urine microscopy: >10 WBC or bacteria· CXR: Infiltrate, collapse· Prematurity· Immunodeficiency or significant underlying chronic disease

Low risk criteria· No high risk criteria

Antibiotics

Investigations· Urine MCS· FBC· CRP/PCT· Blood culture· +/- CXR B

· +/- LP CN

N

Y

Dis

po

siti

on

Y


10. Appendix 2 – Emergency Management of Children with Fever (≥ 4 months)


Ass

essm

ent

Inv

esti

gati

on

& T

reatm

ent

Rev

iew

Child presents to emergency service with a fever

Emergency management of children with FEVER (> 4 MONTHS)

A. Toxic· Marked lethargy/decrease in activity· Altered mental status· Inconsolable irritability· Tachypnoea, increase work of

breathing, grunting· Cyanosis· Poor perfusion (mottled skin, pallor)· Marked/persistent tachycardia· Moderate to severe dehydration· Infant feeding < 50% normal· < 4 wet nappies in 24 hours· Seizures· Petechial rash (see text)· Parental concern

Assess SeverityConsider pre-hospital management given

· Treat discomfort with antipyretic· Remove excess layers of clothing· Consider offering oral fluids

No toxic features A Toxic A

ORImmunocompromised

B. CXR indications· Increased work of breathing· Cough· Tachypnoea· SaO2 ≤ 93% in room air· T > 39°C & WCC > 20 x 109 /L

Investigate and treat asindicated by specific

infection found

Focus of infection evident?(including bronchiolitis)

Meets discharge criteria?

Admit to children’s inpatient service

Discharge

Emergency Management(Resuscitate using ABCD)

Call ED Consultant A Provide highflow oxygen B Support ventilation (BVM)

Consider ETT intubation if not responding

C Obtain IV or IO access Give IV fluid boluses 20mL/kg 0.9%NaCl as requiredD Check BSL & give IV 10% Glucose (2 mL/kg) as needed

C. LP indications· Age < 2 months of age· Bulging fontanelle· Vomiting· Lethargy/drowsiness· Cerebral irritability· Poor feeding· Seizures

Investigations· Urine for urinalysis +/- MCS

Investigations· Urine for urinalysis +/- MCS· FBC· Blood culture· +/- CXR B

· +/- LP C

Dis

po

siti

on

Focus of infection evident?

≥ 2 doses of immunisations (Hib +

PCV)?

Investigate and treat as indicated by specific

infection

Investigations· Urine for urinalysis +/- MCS· FBC· CRP/PCT· Blood culture· CXR B

· LP C

Any high risk features? D

Antibiotics if presumed UTI

N

D. High risk criteria· WCC < 5 or > 15 x 10 9 /L· ANC < 1 or > 10 x 10 9 /L· Bands > 1.5 x 10 9 /L· CRP > 20 or PCT > 0.5 ng/mL· CSF: > 7 WBC· Urine microscopy: > 10 WBC or bacteria· CXR: Infiltrate, collapse· Prematurity· Immunodeficiency or significant

underlying chronic disease

AntibioticsY

N

Y N

Y N

Y

Y N

d




11. Appendix 3 – Admission / Discharge Criteria for Children with Fever


d



Febrile Illness - Emergency Management in · PDF fileeasons for paediatric presentations ......

Documents

Transcript of Febrile Illness - Emergency Management in · PDF fileeasons for paediatric presentations ......