peds - fever (3)
TRANSCRIPT
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8/7/2019 Peds - Fever (3)
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Fever in Neonates and Young
Infants
(0-3 months)
K R Mahmood MDFAAP
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8/7/2019 Peds - Fever (3)
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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
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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
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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
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8/7/2019 Peds - Fever (3)
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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
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
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8/7/2019 Peds - Fever (3)
6/20
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
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
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8/7/2019 Peds - Fever (3)
7/20
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
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)
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8/7/2019 Peds - Fever (3)
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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
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
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8/7/2019 Peds - Fever (3)
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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
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
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8/7/2019 Peds - Fever (3)
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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
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
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8/7/2019 Peds - Fever (3)
11/20
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
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
(
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8/7/2019 Peds - Fever (3)
12/20
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
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
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8/7/2019 Peds - Fever (3)
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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
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
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8/7/2019 Peds - Fever (3)
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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
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)
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Etiology:Viral Illness
Herpes simplex
Varicella
Enteroviruses
Influenza virus
Some adenoviruses
Respiratory syncytial virus
SeriousB
acterialInfection
GBS
Bacterial meningitis
Bacterial pneumonia
Cellulitis
Osteomyelitis
Bacterial gastroenteritis Urinary tract infection
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
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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.
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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.
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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.
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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.
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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