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PHYSICAL ASSESSMENT 0031-3955/98 $8.00 + .OO

THE HISTORY AND PHYSICAL ASSESSMENTS OF THE

FEBRILE INFANT William A. Bonadio, MD

Fever is a common problem in pediatrics. The evaluation of the febrile child is multifaceted and includes a thorough gathering of infor- mation by history and physical examination. This information is instru- mental in augmenting an accurate prediction of infectious outcome and determining management decisions.

There have been many studies published that correlate the clinical characteristics and infectious outcomes of febrile infants. This article reviews these studies and characterizes aspects of this medical problem. Most issues are specified separately according to ages younger and older than 8 weeks.

HISTORY

A thorough and accurate gathering of historical data from the caretaker of a febrile child is important in distinguishing infectious etiology. Some important historical variables are as follows:

Recent infectious contacts Prior or recent infectious illnesses Current medications (especially antibiotics) Underlying medical problems Immunization status

From the Department of Pediatrics, The University of Minnesota Medical School; and the Department of Pediatric Emergency Medicine, Children's Health Care, St. Paul, Minnesota

PEDIATRIC CLINICS OF NORTH AMERICA _____ _____ ~

VOLUME 45 * NUMBER 1 * FEBRUARY 1998 65

66 BONADIO

Birth history Signs and symptoms

General Irritability Decreased activity or lethargy Vomiting Diarrhea Ocular discharge Cough Respiratory difficulty or apnea Seizure activity Decreased feeding or urine output Rash

Method of measuring temperature Onset or duration Character or height Response to antipyretics

Specific (fever)

Their assessment can help determine risk for serious infection. Most pertinent information involves a relatively short duration of time, usu- ally encompassing less than 3 to 4 days prior to admission.

Specifically, it is important to query caretakers as to their technique used for temperature measurement; prior studies have shown a high correlation (92%) between caretaker and medical personnel documenta- tion of fever when measured by rectal therm~metry.~, It is also im- portant that caretakers clarify the specific height of fever measured, because it is not uncommon for them to mistake a nonfebrile tempera- ture (<100.4"F) as indicating fever.

PHYSICAL EXAMINATION

The importance of integrating historical data with physical findings to distinguish infectious etiology is discussed next. The physical exami- nation can be subdivided into assessment of physical findings and patient clinical appearance.

Physical Findings

Assessment of physical findings is an important component in dis- tinguishing the infectious etiology of febrile children. Vital signs, includ- ing a rectal temperature, should be accurately measured. Rectal ther- mometry is the gold standard method for defining body temperature in infants; axillary and tympanic membrane temperature measurements lack sensitivity and are only accurate in defining the presence of fever

THE HISTORY AND PHYSICAL ASSESSMENTS OF THE FEBRILE INFANT 67

when they record a febrile body temperature (an afebrile temperature by these methods does not eliminate the presence of f e ~ e r ) . ~

Prompt recognition of compromise in general physical characteris- tics indicating severe underlying infection is essential to maximizing patient outcome. Signs like tachypnea with grunting respirations, mot- tled skin or poor peripheral perfusion, decreased muscle tone, lethargy, and irritability can indicate risk for underlying systemic infection (sepsis syndrome). When these signs are present and persistent in a febrile young infant, a sepsis evaluation should be performed with hospitaliza- tion for empiric parenteral antibiotic or supportive therapies and close clinical monitoring.

Focal bacterial infections (otitis media, cellulitis, adenitis, conjunc- tivitis, pharyngitis, pneumonia) should be identified and their potential for associated invasive bacterial infection determined. Likewise, signs of viral infection (wheezing with bronchiolitis, hand-foot-mouth disease with enteroviral infection) can help distinguish the etiology of fever. Due to the potential for deficiencies in host defenses, very young infants with focal bacterial infection (pneumonia, cellulitis, omphalitis, adenitis, otitis media) should be presumed at high risk for invasive bacterial infection and may require a sepsis evaluation and empiric parenteral antibiotic therapy pending culture results. In older children many of these infections can be managed on an outpatient basis, often with oral antibiotics.

Patient Clinical Appearance

Assessment of patient clinical appearance involves determining whether a child appears to be well or ill, which is based on grading degree of compromise in a variety of age-specific behavioral and activity parameters. This assessment is often instrumental in determining subse- quent management decisions; for example, the decision to perform lum- bar puncture for possible bacterial meningitis often rests solely on the degree of compromise exhibited in clinical appearance. Accurate assess- ment of clinical appearance involves a thorough knowledge of normal, age-specific behavioral and activity parameters. Deficits associated with serious infections in very young infants can be subtle, and their recogni- tion often requires considerable pediatric expertise.

Factors Affecting Clinical Appearance

ance of a febrile child are as follows: The extrinsic and intrinsic factors that can affect the clinical appear-

EXTRINSIC Type of underlying infection Hunger Physical discomfort Stranger or separation anxiety

68 BONADIO

Hyperpyrexia Dehydration Experience of evaluator

INTRINSIC Patient level of neurologic maturity

An important extrinsic factor is the type of underlying infection present. Although exceptions exist, it is generally more common for significant compromise in clinical appearance to accompany serious infectious processes (e.g., bacterial meningitis) than a trivial, self-limited viral infecti0n.2~ Other extrinsic factors that can affect clinical appearance are the presence of hunger, discomfort, stranger or separation anxiety, hyperpyrexia, and dehydration.

An important intrinsic factor affecting behavior and activity is the child’s level of neurologic maturity, which is largely an age-dependent phenomenon. The range of normal activity in a 2-week-old infant in- cludes the basic functions of feeding, sleeping, and crying; these infants exhibit a relative paucity of purposeful behavioral parameters. The rela- tive lack of integrated neurologic function in very young infants can render unreliable the assessment of clinical appearance in distinguishing the severity of an underlying illness. By contrast, a 2-year-old child is capable of exhibiting a relatively wider range of more complex behav- iors, such as playful interaction, purposeful vocalization, purposeful eye contact, and social smile.

Assessing Patient Clinical Appearance

Most of this assessment should take place prior to other components of the physical examination that may induce alterations in behavior, either from stranger or separation anxiety or discomfort (e.g., otoscopy, venipuncture). Patient comfort should be maximized prior to assess- ment. Young infants should be placed in a warm, undisturbed supine position on an examining table; older children should be held by a parent, undisturbed, with the physician positioned at a distance to eliminate stranger anxiety. Much relevant information can be obtained by a rapid cursory inspection of the patient; variables such as level of alertness and activity, respiratory effort, peripheral perfusion, muscle tone, and eye contact do not require physician intervention, physical contact, or close proximity. Parents can offer the child a toy to allow assessment of playfulness and a bottle to assess ability and eagerness to feed. Consolability can be assessed when the entire physical examination is completed and the child is returned to the parent. Clinical appearance should be reassessed serially whenever abnormal findings are noted to determine if they are transient (e.g., irritability due to hunger) or persis- tent (e.g., irritability due to meningeal irritation). From a medicolegal perspective, it is important to document improvement thoroughly in any significant deficit in clinical appearance with an interim progress note when a febrile child is not hospitalized.

THE HISTORY AND PHYSICAL ASSESSMENTS OF THE FEBRILE INFANT 69

lnfants Younger Than 8 Weeks of Age

It is convenient to consider infants younger than 8 weeks of age as a homogeneous group because they share the common feature of neuro- logic immaturity. Due to a limited range of often stereotypic neurologic responses to noxious stimuli, abnormalities in behavior and activity exhibited by these infants are often subtle or nonspecific, and the magni- tude of a given deficiency may not be commensurate with the severity of an underlying illness.

Many studies that performed sepsis evaluation on febrile infants younger than 8 weeks of age have correlated clinical appearance with infectious outcome. The main outcome assessed was the presence of a serious bacterial infection ([SBI], including bacterial meningitis, bacter- emia, urinary tract infection [UTI], osteomyelitis or septic arthritis, and Salmonella enteritis) versus non-SBI febrile illnesses (NSBI-FI). These studies are discussed next.

Retrospective Studies

A major shortcoming in most retrospective studies is that clinical appearance was graded by unsupervised resident housestaff not utiliz- ing a standardized objective scoring system. Mixed results have been reported from these studies in correlating clinical appearance with infec- tious outcome,8’ 11-147 17, 27, 28 and are summarized in Table 1. The overall trend shows that most febrile children with invasive bacterial infections (i.e., bacterial meningitis and bacteremia) appeared to be ill, whereas only a minority with UTI appeared to be ill.

Table 1. RETROSPECTIVE STUDIES CORRELATING INFANT CLINICAL APPEARANCE WITH INFECTIOUS OUTCOME

Patient With 111 Investigator Age Outcome Appearance (%)

Craig and GersheP Roberts and BozayZ7 Bonadio12

Berkowitz and Tully8 King et al l7

Rosenberg et aIz8 Caspe et aIj3

Craig and GershelT4 Bonadio et al l1

<2 wk <8 wk <8 wk

<8 wk <8 wk <8 wk <8 wk

<8 wk 8-12 wk

SBI SBI Bacterial meningitis and bacteremia UTI UTI Bacterial meningitis and bacteremia Bacteremia Bacterial meningitis and bacteremia UTI UTI Bacterial meningitis and bacteremia UTI

37 89 100 44 21 75 83 91 43 15 38 12

70 BONADIO

Prospective Studies

A prior study4 showed that 5.4% of febrile infants aged 28 to 90 days who were not ill appearing (specific criteria for this was not given) had underlying SBI, including nine cases of bacteremia, eight cases of UTI, and 10 cases of bacterial enteritis. In the same study, attending- level physicians made assessment of clinical appearance using the Yale Observation Scale ([YOS], described later) and found that the mean YOS score in those with SBI (8) was not significantly different from those with NSBI-FI (7.3).

Another study' showed limited efficacy of the YOS in distinguishing infectious outcome of febrile infants aged 4 to 8 weeks. Of those who appeared to be well (total YOS score -=lo), 22% had a serious illness; of those who appeared to be ill (total YOS score r16), only 45% had a serious illness. Methodologic flaws in this study, however, may have decreased the sensitivity of the YOS (1) all infants with bronchiolitis were included in the group with serious illness, whereas the original studyz3 assessing the YOS included only the more compromised group of infants with bronchiolitis and hypoxia; (2) infants with aseptic menin- gitis (AM) were included in the group with serious illness, which disre- gards the marked difference in degree of compromised clinical appear- ance in those with SBI versus those with AM; and (3) a blood culture was not performed in all cases, with possible misclassification of some patients with unidentified occult bacteremia into the nonserious illness group. Similar results were obtained in a later study2 assessing febrile infants aged 29 to 56 days, because 66% with SBI appeared to be well (YOS score 510).

Following this, a studylo assessed the utility of the Young Infant Observation Scale (YIOS) in correlating clinical appearance of 233 infants younger than 8 weeks of age and infectious outcome. The three outcome groups compared were those with SBI, AM, and culture-negative with normal cerebrospinal fluid (CSF) (CN-NCSF). The YIOS is given in Table 2; each variable was graded 1, 3, or 5 (total score can range from 3 to 15), with a higher score indicating a greater degree of compromise. There was a significantly greater mean total YIOS score for patients with SBI (9) versus either AM (5) or CN-NCSF (5) groups. Of note was that the mean total YIOS score was identical for AM and CN-NCSF; and that infants with AM often did not manifest abnormalities in behavior and activity (53% were not irritable and 80% had a normal feeding pattern). None of the 19 infants noted to exhibit a smile during the course of the evaluation had SBI. A receiver-operated characteristic curve was generated (Fig. 1) showing that for a total YIOS score equal to or greater than 7 the sensitivity is 76%, specificity 75%, and negative-predictive value 96% for outcome of SBI.

Although at times disparate, the trend shown by these studies suggests that the majority of febrile young infants with bacterial menin- gitis and bacteremia appear to be ill. In some retrospective series, rela- tively high rates of either possible or minimal compromise in clinical

THE HISTORY AND PHYSICAL ASSESSMENTS OF THE FEBRILE INFANT 71

Table 2. THE YOUNG INFANT OBSERVATION SCALE* ~ ~ ~ ~

1. AFFECT Smiles or not irritable (1) Irritable, consolable (3) Irritable, not consolable (5)

2. RESPl RATORY STATU S/EFFORT No impairment, vigorous (1) Mild-moderate compromise (tachypnea, retractions, grunting) (3) Respiratory distress or inadequate effort (apnea, respiratory failure) (5)

3. PERIPHERAL PERFUSION Pink, warm extremities (1) Mottled, cool extremities (3) Pale, shock (5)

*Total score ranges from 3 to 15

appearance was found in those with SBI, indicating that deviations from normal can be subtle. By contrast, young infants with UTI and AM frequently exhibit minimal or no compromise in clinical appearance. Potential for inconsistent exhibition of compromised clinical appearance with serious underlying infection makes performance of a sepsis evalua- tion a necessary diagnostic adjunct when evaluating fever in very young infants.

Infants and Children Older Than 8 Weeks of Age These children have an extended range of normal behavior and

activity relative to very young infants. Parameters such as purposeful

100

80

20

/ 5

1 3

loo -

20 - 13

I 1 . 1 . I i 0 20 40 60 80 100

1 - Specificity

O f I 1 . 1 . I i 0 20 40 60 80 100

1 - Specificity

Figure 1. Receiver-operated characteristic curve for the Young Infant Observation Scale (YIOS). The numeric values of the YlOS are given on the curve and correlate with their respective predictive values for SBI.

72 BONADIO

vocalization, meaningful eye contact, playful interaction, and social smile can reliably be assessed with consistency.

Prospective Studies

Nelsonz5 used a clinical scoring system to assess degree of acute illness in a large group of children receiving outpatient evaluation. The five-point assessment scale (Severity Index) consisted of behavior and activity variables. When correlating Severity Index profile with physician assessment of illness severity, a total score of less than or equal to 7 (i.e., very sick) was 84.2% accurate for predicting severe illnesses, whereas a score of more than 10 (i.e., not sick) was 98.7% accurate forpredicting nonsevere illness.

McCarthy et alZo evaluated history and observation variables used by health care professionals that form the basis of instinctive judgments regarding degree of illness of febrile children. Physicians identified playfulness as the individual variable with the strongest correlation in forming an overall impression of patient clinical appearance; most re- ported a greater reliance on information obtained by direct observation versus information obtained by parental history when grading clinical appearance.z0 A related studyI9 correlated physician overall assessment of degree of illness with infectious outcome of febrile children younger than 24 months. The most frequently mentioned observation variables assessed by attending and private physicians, resident housestaff, and nurses were those related to eye function (i.e., the child looking at the observer or looking around the room) and motor activity (moving extremities, playing with objects, sucking on a bottle); other important variables identified were vocalization, crying with noxious stimuli, and smiling. A serious illness was five to seven times more likely when the overall assessment of clinical appearance was judged to be moderately or severely impaired versus completely unimpaired using these variables.

A later studyz3 devised and tested the utility of the YOS in distin- guishing outcomes of febrile children aged younger than 24 months. The outcome of serious illness was assessed (bacterial) meningitis, bac- teremia, UTI, osteomyelitis, septic arthritis, cellulitis, pneumonia, bron- chiolitis with hypoxia, AM, hypernatremia, and metabolic acidosis). The six variables of the YOS were each graded either 1,3, or 5, with a higher score indicative of a greater degree of compromise (Table 3). The YOS had a specificity of 88%, sensitivity of 77%, positive-predictive value of 5670, and negative-predictive value of 97% for outcome of serious illness. When patients appeared to be well (total YOS score less than or equal to 10) the rate of serious illness was only 2.7%, whereas when patients appeared to be ill (total YOS score equal to or more than 16) the rate of serious illness was 92.3%. No child who exhibited a normal social smile had a serious illness.

Two other studies assessed the interrelation of variables identified by history and physical examination in febrile children younger than 24

THE HISTORY AND PHYSICAL ASSESSMENTS O F THE FEBRILE INFANT 73

Table 3. THE YALE OBSERVATION SCALE'

Observation Variable Normal (1) Impairment (3) Impairment (5) Moderate Severe

Quality of cry

Reaction to parent stimulation

State variation

Color

Hydration

Response (talk, smile) to social overtures

Strong with normal tone or content and not crying

Cries briefly then stops or content and not crying

If awake, stays awake or if asleep and stimulated wakes up quickly

Pink

Skin normal, eyes normal and mucous membranes moist

alert Smiles or becomes

Whimpering or sobbing

Cries off and on

Eyes close briefly when awake or awakes with prolonged stimulation

Pale extremities or acrocyanosis

Skin, eyes normal and mouth slightly dry

Brief smile or becomes alert briefly

Weak or moaning or high-pitched

Continual cry or hardly responds

Falls to sleep or cannot be aroused

Pale or cyanotic or mottled or ashen

Skin doughy or tented and dry mucous membranes or sunken eyes

No smile, anxious, dull, expression- less or cannot be alerted

*Total score ranges from 6 to 30

months of age in determining infectious outcome. Onez2 showed that the rate of serious illness in those who appeared to be completely well with no abnormalities identified by history (tachypnea, wheezing, grunting respirations, irritability with movement, or convulsion) or physical examination (nasal flaring, decreased breath sounds, intercostal retractions, full fontanelle, Kernig's sign) was only 4%, whereas the rate of serious illness was 36% in those who appeared to be ill or had abnormalities identified by history or physical examination. Anotherz1 found a significantly greater rate of abnormal physical findings in those who appeared to be ill (total YOS 210, 64%) than those who appeared to be well (total YOS <lo, 15%). A serious illness was documented in 79% of those with abnormal physical findings who appeared to be ill versus 25% of those with abnormal findings who appeared to be well. The authors concluded that the risk for serious illness in patients who appear to be ill increases approximately eightfold when associated with abnormal physical findings versus when there are no abnormal findings.

evaluated YOS efficacy in distinguish- ing risk for occult bacteremia in non-toxic-appearing (this was not de- fined by the authors) febrile children aged 3 to 36 months. The mean rank among those with bacteremia was significantly greater compared with those without bacteremia. The predictive values of the YOS for bacteremic outcome in children were sensitivity 5.2%, specificity 97%,

A recently published

74 BONADIO

positive-predictive value 4.5%, and negative-predictive value 97%. They concluded that the YOS had limited clinical efficacy in distinguishing non-toxic-appearing children with bacteremic from nonbacteremic dis- ease. It is important to note that the study omitted those who were most ill-appearing, thus skewing the analysis toward evaluating YOS efficacy in distinguishing relatively well-appearing children with occult bacter- emia.

The YOS assesses those bedside variables that experienced pediatri- cians intuitively rely on to distinguish risk for serious infection. Yet these studies have not conclusively proved YOS consistently distin- guishes between those with and without invasive bacterial infections.

Parental Reliability in Grading Illness Severity

24 showed that parental anxiety about their child’s illness confounded their ability accurately to grade degree of compro- mise in clinical appearance; this phenomenon was not affected by prior experience in raising other children.l6 Using an observation scale to grade their child’s clinical appearance, parents frequently overestimated illness severity; their judgment that a child was moderately or severely impaired occurred in 50% of cases, whereas pediatricians simultaneously evaluating the same cohort judged that only 17% exhibited this degree of compromise.” The specificity of parental judgment of moderate or severely impaired clinical appearance for outcome of serious illness was only 52%.

Three studies5,

Antipyretic Effect on Patient Cfinical Appearance

There are mixed findings reported on the effect of antipyretic medi- cation on clinical appearance for different infectious etiologies. In one series, Richardson et alZ6 examined febrile children younger than 24 months who received YOS assessment before and after administration of a therapeutic dose of acetaminophen. On presentation, 62 patients appeared to be ill (total YOS score 210) and 14 (22%) of these had a serious illness. The mean total YOS score was significantly greater in those with serious illness than in those with nonserious illness both before and after administration of acetaminophen.

Another study6 evaluating febrile children younger than 24 months of age who received YOS assessment before and after administration of acetaminophen correlated change in clinical appearance with infectious outcome. There was a significantly greater mean total YOS score in those with SBI versus those with culture-negative disease before administra- tion of acetaminophen. After acetaminophen, there was a significantly greater mean total YOS score in those with bacterial meningitis versus either bacteremia or culture-negative disease, but no significant differ- ence in mean total YOS scores between bacteremic versus culture-nega- tive disease.

Hyperpyrexia can commonly augment compromise in the clinical

THE HISTORY AND PHYSICAL ASSESSMENTS OF THE FEBRILE INFANT 75

fable 4. PREDICTIVE VALUE OF OBSERVATION SCALES FOR ASSESSING PATIENT CLINICAL APPEARANCE

Outcome/ Negative- Patient Cutoff Sensitivity Specificity Predictive

Age Score (%I (%I Value (%)

Young Infant SBI/O-8 wk 27 76 75 96 Observation Scale

Obsetvation illness/ Scale >24 mo

Yale Serious 210 77 88 97

appearance of febrile infants. Improved affect is often exhibited in highly febrile children after antipyretic therapy; this phenomenon can accu- rately guide the selection of adjunct diagnostic laboratory tests (e.g., lumbar puncture after a febrile seizure).

Retrospective Studies

Assessing clinical appearance can be useful in distinguishing the infectious outcome of children with occult bacteremia when re-evaluated at least 24 hours after obtaining the blood culture. One studyI6 found that 80% who appeared to be ill at re-evaluation had an invasive bacte- rial infection (44% had bacterial meningitis and 56% had persistent bacteremia); by comparison, of those who appeared to be well at re- evaluation, none had bacterial meningitis and only 13% had persistent bacteremia.

CONCLUSIONS

Grading patient clinical appearance using the two observation scales described previously can effectively classify about 75% of infants with a serious illness or infection as ill appearing and 95% who appear to be well as having low risk for serious illness or infection (Table 4). Most children with invasive bacterial infections appear to be ill at the time of evaluation, although exceptions to this are not uncommon. Accuracy in distinguishing the etiology of fever in infants is an integrated evaluation including thorough assessment of historical data, clinical appearance, and physical findings.

References

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76 BONADIO

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THE HISTORY AND PHYSICAL ASSESSMENTS OF THE FEBRILE INFANT 77

28. Rosenberg N, Vranesich P, Cohen S: Incidence of serious infection in infants under the age of 2 months with fever. Pediatr Emerg Care 1:54-57, 1985

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