Peds - Fever (3)

8/7/2019 Peds - Fever (3)

1/20

Fever in Neonates and Young

Infants

(0-3 months)

K R Mahmood MDFAAP

8/7/2019 Peds - Fever (3)

2/20

Definition:

Fever = 1-2C increase overnormal body temperature

Axillary and Tympanictemperatures are unreliable in

young children Bundling has minimal effect on

rectal temperature

Comparative Fever Definitions:

Children 3-36 months c fevermanagement changes if well or illappearing and immunization status

TRECTAL > 39C in children 3-36months require evaluation

Caregiver Report of Fever

92% pts with reported fever athome (rectal temp) had fever atpresentation-48hrs hospitalization

46% pts with reported fever athome (tactile) had fever atpresentation-48hrs hospitalization

5 of 19 infants with SBI wereafebrile at presentation

TRECTAL > 38.0 C

8/7/2019 Peds - Fever (3)

3/20

Immunology:Cell-Mediated Immunity

No maternal transfer of T-Cells cytotoxic CD8+ T cell response to CMV is

similar in neonates and adults, although theCD4+ T cell response is reduced

Humoral Immunity

Transfer of maternal IgG across theplacenta during the 3rd trimester;

(most of newborns serum Ig) Maternal Ig then gradually cleared

while antibodies produced by infant o

Only maternal IgG is transferred

Innate-Immunity

q neutrophil & monocyte fxn:

Limited ability to accelerate neutrophilproduction response to infection/sepsis.

Variability in classic & alternativepathway activity & components

Complement levels o after birth;reach adult levels at 6 - 18 months

Clinical Effects

osusceptibility toHIV, CMV, and VSV; Normal responseto other viruses & graft rejection

Strong antibody responses to proteinantigens/vaccinesSeverely blunted response topolysaccharide antigens until ~ 18 to

24 months of age

Breast Feeding

Transfer of immunoglobulins (IgG, IgA),promotion of normal GI flora, transfer ofWBC, anti-microbials

q incidence of gastroenteritis, Respinfections, Otitis media, UTIs, andSepsis

Save ~$1000 per year

8/7/2019 Peds - Fever (3)

4/20

Etiology:Viral Illness

Herpes simplex

Varicella

Enteroviruses

Influenza virus

Some adenoviruses

Respiratory syncytial virus

Serious Bacterial Infection GBS

Bacterial meningitis

Bacterial pneumonia

Cellulitis

Osteomyelitis

Bacterial gastroenteritis Urinary tract infection

Herpes Simplex

Gen: -among etiologies of TORCH

Eti: -generally transmitted from maternal genitaltrack at birth

Sx: -temperature instability, respiratory distress,poor feeding, and lethargy

-hypotension, jaundice, DIC, apnea, shock

-Vesicular skin lesions may or may not bepresent and develop late in some patients

Dx: -cultures of skin lesions, mouth/nasopharynx,eyes, urine, blood, stool or rectum, and CSF.-Serologic tests generally are not helpful.

Tx: -parenteral high-dose Acyclovir(60/mg/kg per day) for 21 days

-supportive care

8/7/2019 Peds - Fever (3)

5/20


Herpes simplex

Varicella

Enteroviruses

Influenza virus

Some adenoviruses




Bacterial pneumonia

Cellulitis

Osteomyelitis


Congenital Varicella

Gen: -among etiologies of TORCH

Neonatal Varicella

Pres: -Fever followed by a vesicular eruption.-Mild cases: lesions heal within 7-10 days-Disseminated disease: varicella pneumonia,hepatitis, and meningoencephalitis

Dx: -clinically, upon characteristic appearance of

skin lesions.-VZV may be cultured from vesicular fluid,but the virus takes several weeks to grow

Post-exposure Prophylaxis:

-Varicella-zoster immuneglobulin

prepared from donors with high levels of

VZV antibody- VariZIG

purified human immune globulinpreparation; alternative to VZ-Ig

Tx: -Acyclovir (30 mg/kg per day, 3 divided dosesIV) for 10 days

-Breast Feeding

8/7/2019 Peds - Fever (3)

6/20


Herpes simplex

Varicella

Enteroviruses

Influenza virus

Some adenoviruses




Bacterial pneumonia

Cellulitis

Osteomyelitis


Enteroviruses

Micr:-Poliovirus, echovirus,coxsackievirus, enterovirus

Early sx

-may be mild and nonspecific:listlessness, anorexia, and transientrespiratory distress. -Approximately 1/3 of

cases have a biphasic illness

Generalized non-polio enterovirus disease inthe newborn most often occurs in one of twocharacteristic clinical syndromes:1. Neonatal myocarditis,

2. Fulminant hepatitis-hypotension, profuse bleeding,jaundice, and multiple organ failure.

Tx: -supportive-judicious fluid management inmyocarditis

-IVIG in severe cases

8/7/2019 Peds - Fever (3)

7/20


Herpes simplex

Varicella

Enteroviruses

Influenza virus

Some adenoviruses




Bacterial pneumonia

Cellulitis

Osteomyelitis


Influenza

Complications:

-Otitis Media (most common)

-Laryngotracheitis

-Pneumonia

(2 bacterial)-Neuro: aseptic meningitis, transverse

myelitis, Guillain-Barr syndrome, acutenecrotizing and postinfectiousencephalitis, encephalopathy, febrileseizures, acute mental status changes,and Reye syndrome with use of aspirin

-Myositis & Rhabdomyositis

Dx: -Rapid test, culture, serology

Tx: -Supportive-Oseltamivir/Zanamivir (A&B)-Amantidine/Rimantidine (A)

8/7/2019 Peds - Fever (3)

8/20


Herpes simplex

Varicella

Enteroviruses

Influenza virus

Some adenoviruses




Bacterial pneumonia

Cellulitis

Osteomyelitis


Adenovirus: clinical manifestations Rsp: -Pharyngitis

-Coryza-Otitis Media-Pneumonia (causes 10% in children)

Eye -Pharyngoconjuctival fever

GI: -Diarrhea-Gastroenteritis

GU -acute hemorrhagic cystitis CNS -occasional encephalitis, menningitis

8/7/2019 Peds - Fever (3)

9/20


Herpes simplex

Varicella

Enteroviruses

Influenza virus

Some adenoviruses




Bacterial pneumonia

Cellulitis

Osteomyelitis


Respiratory Syncytial Virus

Gen: -November-April (peak Jan, Feb)

-strains shift yearly p reinfection possible Epi: -MCC LRTI in children < 1yoa

-viral shedding = ~3-8 days-transmission: direct contact, aerosol droplets contact and aerosol precautions

Prs: -Apnea (20% in hospitalized pts)

-Bronchiolitis, bronchospasm,pneumonia, wheezing and acuterespiratory failure

Cmp: -associaed with later development of reactiveairway disease

Dx: -clinical-rapid assay of nasal secretions

DDX:Influenza, parainfluenza, adenovirus

8/7/2019 Peds - Fever (3)

10/20


Herpes simplex

Varicella

Enteroviruses

Influenza virus

Some adenoviruses




Bacterial pneumonia

Cellulitis

Osteomyelitis


Group-B Streptococcus

Gen: -acquired in utero during vaginal passage

Risk: -maternal GU GBS colonization

Sepsis-irritability, lethargy, tachypnea, grunting,temperature instability, poor perfusion, andhypotension.-Most infants < 24hrs old will not have fever

Pneumonia-tachhypnea, grunting, cyanosis, pulmonaryeffusion, and increased work of breathing

Menningitis-Specific CNS Si

Septic-arthritis & Osteomyelitis

Eval: -CBC c diff, blood culture, CXR, and lumbar

puncture (cell count, protein &glucose concentration, Gram stain & culture)-Urine culture if over 6 days of age

Tx: -Initial emperic tx (cover streptococci, gram-neg enterics, staph, and Listeria)-PCN G (once GBS isolated)

Prevention: Screen pregnant women for GBScolonization, tx with antibiotics

8/7/2019 Peds - Fever (3)

11/20


Herpes simplex

Varicella

Enteroviruses

Influenza virus

Some adenoviruses




Bacterial pneumonia

Cellulitis

Osteomyelitis


Bacterial Meningitis

Eti: Group B Streptococcus 50 %

E. coli 25 %Other gram-negative rods 8 %Listeria monocytogenes 6 %Streptococcus pneumoniae 5 %Group A Streptococcus 4 %Haemophilus influenzae 3 %N. Mennigitidis, S. Aureus, enterococcus

Si: -Temp. Instability (>38, 1000 WBC/microL)

-oCSF protein concentration(>150 mg/dL preterm, >100 mg/dL term)

-qCSF glucose concentration

(

8/7/2019 Peds - Fever (3)

12/20


Herpes simplex

Varicella

Enteroviruses

Influenza virus

Some adenoviruses




Bacterial pneumonia

Cellulitis

Osteomyelitis


Bacterial Meningitis

Tx: -Supportive

-1-7d: Ampicillin+Gentamycin+Cefoxaxime-7+d: -Non-hospitalized

Ampicillin+Gentamycin+Cefoxaxime-7+d: -Hospitalized

Vancomycin+Gentamycin+Cefoxaxime+Ampicillin

-Selective tx once bacteria isolated

F/U: -Repeat lumbar puncture in 24-48hrs

-Ultrasound

-Perform CT or MRI c contrast

-F/u of hearing, visual acuity, developmentalstatus

8/7/2019 Peds - Fever (3)

13/20


Herpes simplex

Varicella

Enteroviruses

Influenza virus

Some adenoviruses




Bacterial pneumonia

Cellulitis

Osteomyelitis


Bacterial Pneumonia-any infant with respiratory distress

or illness should be evaluated forpneumonia/sepsis

EARLY ONSET

Respiratory distress soon after birth

LATE ONSET

Changes in condition: respiratory distress,tachypnea, apnea, poor feeding, juandice, emesis

Labs: -Blood, CSF, pleural fluid-CXR

8/7/2019 Peds - Fever (3)

14/20


Herpes simplex

Varicella

Enteroviruses

Influenza virus

Some adenoviruses




Bacterial pneumonia

Cellulitis

Osteomyelitis


Cellulitis

Dx: -Clinical, Cx usually unhelpful

Eti: -beta-hemolytic strep, S. Aureus

Osteomyelitis

Sx often non-specific in infants

Warmth, inflammation, tenderness

Plain films, MRI Staph Aureus, Gram(-) Bacilli, GBS

3rd-gen Cephalosporin (Cefotaxime)+ anti-staph (nafcillin or vacomycin ifICUexposure)

Bacterial Gastroenteritis MCC = Salmonella

(esp. bloody diarrhea)

8/7/2019 Peds - Fever (3)

15/20


Herpes simplex

Varicella

Enteroviruses

Influenza virus

Some adenoviruses


SeriousB

acterialInfection

GBS


Bacterial pneumonia

Cellulitis

Osteomyelitis


Urinary Tract Infection

Sx:Often fever only manifestation-Fever (20 to 40 %)-Failure to thrive (15 to 43 %)-Jaundice (3 to 41 %)-Vomiting (9 to 41 %)-Loose stools (3 to 5 %)-Poor feeding (3 to 5 %)

Epi:16% of pt 39C had UT

I

-1/3 of infants with UTI have bacteremia

-MCC = E-Coli

-Higher incidence in girls and uncircumcised males

Dx: Urine collection by catheter, suprapubic aspiration

-UA and Urine Cx

-renal US & voiding cystourethrogram(evaluate presence of GU abnormalities)

Tx: -Ampicillin + Gentamycin

8/7/2019 Peds - Fever (3)

16/20

Evaluation/Management:Neonates (0 to 28 days)

blood, urine, and CSF cultures performed regardless of clinical appearance. chest radiograph be obtained in those with any sign or symptom of pulmonary disease.

admision to the hospital (Grade 1B).

presumptive treatment with antibiotics (Ampicillin and gentamicin or ampicillin andcefotaxime provide adequate empiric therapy for the pathogens that are common in thisage group.)

Infants 0 to 28 days who are ill-appearing and lethargic and have mucocutaneous vesicles,have had seizures, a CSF pleocytosis with a negative CSF Gram stain, or elevated livertransaminases may have a CNS or disseminated herpes simplex virus (HSV) infection. Inthis select population of infants, we suggest initiating presumptive treatment with acyclovir(60 mg/kg per day divided three times daily), particularly if the bacterial cultures remainnegative at 48 to 72 hours and the patient has not improved clinically (Grade 2B).Laboratory studies to confirm the diagnosis ofHSV should be sent prior to the initiation of

acyclovir.

8/7/2019 Peds - Fever (3)

17/20

Evaluation/Management:Young infants (29 to 60 days)

I

ll-appearing infants all infants who are ill-appearing, have abnormal cry, or temperatures 38.5C undergo a completehx and physical exam, and full laboratory evaluation including CBC, blood culture, UA and culture,and CSF for cell count and culture.

Stool culture is suggested if diarrhea is present.

CXR if at least one clinical sign of pulmonary disease (respiratory rate >50 breaths/minute, rales,rhonchi, retractions, wheezing, coryza, grunting, stridor, nasal flaring, or cough).

Admission regardless of the initial laboratory results and treated empirically with cefotaxime or

ceftriaxone

Well-appearing Infants complete history and physical examination with appropriate laboratory evaluation including CBC,

blood culture, urinalysis and culture, and CSF for cell count and culture.

Although lumbar puncture may not be necessary in some well-appearing infants, lumbar puncturebe should performed if empiric antibiotics are prescribed, including in infants who have anabnormal UA.

Stool culture is suggested if diarrhea is present.

CXR be obtained only in infants with at least one clinical sign of pulmonary disease (respiratoryrate >50 breaths/minute, rales, rhonchi, retractions, wheezing, coryza, grunting, stridor, nasalflaring, or cough).

Infants who have a CSF pleocytosis or an abnormal chest radiograph be admitted to the hospitaland treated with presumptive antibiotic therapy

Infants with an abnormal urinalysis also be admitted and treated with antibiotics

well-appearing infants c normal laboratory evaluation and CXR, can be sent home as long asreliable follow-up within 24 hours can be arranged ; tx with ceftriaxone (50 mg/kg in a single dose) ;CSF be obtained if antibiotics are given empirically.

8/7/2019 Peds - Fever (3)

18/20

Evaluation/Management:Young infants (61 to 90 days)

Ill-appearing full laboratory evaluation including blood, urine, and CSF.

Signs of pulmonary disease should also receive CXR

Admission for empiric antibiotic therapy (with cefotaxime or ceftriaxone), regardless ofthe initial laboratory results

Infants with CSF pleocytosis should be treated with doses of antibiotics adequate to

treat meningitis. Well-appearing

CBC, urinalysis, and cultures of blood and urine

Si of pulmonary disease should receive a chest radiograph

CSF be obtained when empiric antibiotics are prescribed. (See "Lumbar puncture"above).

Infants with an abnormal urinalysis consistent with a urinary tract infection may beadmitted to the hospital and treated with empiric antibiotics. However, outpatienttherapy possible for the well-appearing infant for whom follow-up can be assured.

8/7/2019 Peds - Fever (3)

19/20

Summary: Fever in neonates and infants less than three months of age is defined as a rectal

temperature 38C (100.4F)

A reliable caretaker report of fever should be carefully evaluated, even if the infant isafebrile at presentation.

Presence of fever should be evaluated with complete H&P, laboratory evaluation--generally including CBC, blood culture, UA and culture, and CSF evaluation forculture for cell count, UA and culture; CXR and stool Cx if indicated--and, in most

cases, admission.

8/7/2019 Peds - Fever (3)

20/20

References:Up To Date:

Definition and etiology of fever in neonates and infants (less than 3 months of age)

Strategies for the evaluation of fever in neonates and infants (less than 3 months of ag

Overview of TORCH infections

Varicella-zoster infection in the newborn

Clinical manifestations and diagnosis of enterovirus infections

Clinical features and diagnosis of influenza in children Epidemiology and clinical manifestations of adenovirus infection

Clinical features and diagnosis of respiratory syncytial virus infection

Groub B streptococcal infection in neonates and young infants

Clinical features and diagnosis of bacterial meningitis in the neonate

Treatment and outcome of bacterial meningitis in the neonate

Clinical features and diagnosis of urinary tract infections in children

Acute management, imaging, and prognosis of urinary tract infections in children

Peds - Fever (3)

Documents

Transcript of Peds - Fever (3)