Febrile Child

Last updated 24/12/18

Definition

• Fever in a child <3 years old

Features

• Of clinical concern due to diffculty in finding source
• In children >3 years old source of infection is usually more apparant

Causes

• Viral
• Most common cause
• Bacterial
• Around 1% without an obvious focus
• Higher if not immunised
• Streptococcus pneumoniae: most common bacterial infection causing fever
• Presentations
• Bronchiolitis
• Croup
• Otitis Media (OM)
• Tonsillitis
• Pneumonia
• Impetigo
• Wound infection
• Urinary Tract Infection (UTI)
• Meningitis

Associated Signs & Symptoms

• Fever
• Irritability
• Anorexia
• Vomiting
• Look for accompanying signs and symptoms suggestive of source
• Respriatory
• Cough
• Productive: pneumonia
• Barking: croup
• Stridor: croup
• Rhinitis
• Sore throat
• Increased work of breathing
• Paradoxical breathing
• Intercostal/subcostal recession
• Grunting
• Nasal flaring
• Wheeze: croup, bronchiolitis
• Rash
• Blanching: viral exanthem
• Cellulitis
• Non-blanching: Meningococcal meningitis

Risk Factors

• Immunisations not up to date
• Preterm delivery

Complications

• Dehydration: due to reduced intake
• Febrile convulsions
• Sepsis

Differential Diagnosis

• Heat illness
• Kawasaki disease
• Bilateral conjunctival injection
• Strawberry tongue
• Erythema on palms and soles of feet
• Cervical lymphadenopathy
• Periungual desquamation

Investigations

• Vitals
• HR: tachycardia
• CRT: >2 seconds: dehydration
• RR: tachypnoea
• Sensitive indicator for serious illness
• Respiratory illness: Pneumonia, Bronchiolitis, Croup, etc.
• Consider respiratory compensation for metabolic acidosis
• Pulse oximetry: hypoxia: respiratory illness
• Temp: fever
• Otoscopy: otitis media, viral URTI
• Septic Workup
• FBE
• Blood film
• CRP
• Blood Cultures (BC)
• Urine Dipstick + MCS
• +/- Suprapubic Aspirate (SPA)
• +/- CXR
• Particularly if suspected respiratory source
• +/- LP

Management

• <1 month old or <3.5kg
• If fever >38 perform full septic workup and give empirical antibiotics
• Antibiotics
• Ampicillin 15mg/kg IV 12hourly
• Gentamicin 2.5mg/kg IV STAT then review
• Avoid Ceftriaxone due to risk of jaundice
• 1-3 months old
• If clinically unwell perform full septic workup, admit +/- cover with empirical antibiotics
• Benzylpenicillin 50mg/kg IV 6 hourly
• Gentamicin
• Cover for 48hr whilst awaiting results of septic workup
• 3 months - 3 years
• Clear focus
• Treat as indicated
• If clinically unwell offer admission for overnight observation
• Without clear focus
• If well send urine MCS and consider discahrge with 24hr follow up
• If clinically unwell perform full septic workup, admit and cover with empirical antibiotics
• Benzylpenicillin 50mg/kg IV 6 hourly
• Gentamicin
• Cover for 48hr whilst awaiting results of septic workup

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References