Baby K is usually full of smiles and never fusses (a model child), but over the past day she has been more temperamental AND developed a temp.
Mom (who is significantly more reliable than Dad) reports a temperature of 102.4 rectal. Age/wt appropriate doses of tylenol seemed to help briefly yesterday. Today, nothing seems to relieve her fever or fussiness. She is not taking bottle as often or as much. She has had one moderately wet diaper in the past 8 hours. No URI symptoms, ear tugging, cough, vomiting, diarrhea, or rashes. Her brother is in daycare but has not had any recent illnesses.
Her past medical history is unremarkable: normal term delivery without complications. Immunizations are up to date.
VS: Temp 102.1 (rectal) HR 130 BP 75/45 RR 24 Sat 100% ra
Physical exam:
General: recurrently fussy, intermittently consoled by mom.
HEENT: anterior posterior fontanelles are soft, conjunctiva clear, tearing present. TMs normal. (You can't talk yourself into the notion that maybe one looks "a little red." On the contrary, they are the most perfect ear drums you have ever seen.) Oropharynx is a little dry. Neck is supple. No lymphadenopathy.
Chest, Abdomen, GU, Skin: all normal for age.
Neuro: alert, intermittently fussy but able to be consoled by mom.
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Alright "test-o-philes" and "test-o-phobes" HAVE AT IT.
What labs?
What imaging?
What if you give her motrin and the fever goes down? or goes away? (Does your management change?)
Has anyone actually seen this movie?
It was produced in Canada in 1982.
Susan Anton was one of the "Stars." Can you name the TV series in which she made regular appearances AND which provided an opportunity for her to wear a bikini regularly?
(Hint: it ALL somehow connects to David Hasselhoff.)
GERMANY: WE LOVE YOU!!!
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Pediatric fever is a challenging problem, particularly in the 3-36 month age range. There are many recommendations and numerous studies.
ACEP published a clinical
policy in 2003 (almost 10 years ago): http://www.annemergmed.com/article/S0196-0644(03)00628-0/fulltext
AAFP published a more recent article
in 2007: http://www.aafp.org/afp/2007/0615/p1805.html
A very interesting paper
published in Pediatrics, December 2011, concluded that for fever in the 3-36
month range physicians obtained fewer studies than were recommended: http://pediatrics.aappublications.org/content/128/6/e1368.full
Pediatric fever in the 3-36
month range can be fraught with grey area and subjectivity. In order to simplify
this challenging clinical presentation, I referred to the lecture/algorithm
provided by one of our local Minneapolis Children’s Docs. (The algorithm is published in the PAGES
section on this blog.) I would be happy to email it to you...it is literally a life saver.)
So let’s get to our case:
First, does this child have a fever?
Yes!
(Fever is defined as >38 c
(for those of you like me that simply cannot convert to F…that is 100.4)
Second, you have to decide if this child appears TOXIC
or NONTOXIC?
In our case, I would describe the patient as NONTOXIC.
NONTOXIC is defined as: vigorous/purposeful activity, calm
interactions with parents/environment, normal perfusion, normal respiratory
effort, pink, euvolemic.
TOXIC is defined as: lethargy, inconsolable irritability,
poor perfusion, hypo/hyperventilation, cyanosis, dehydration.
Third, you have to decide if this is a fever that we
are going to be worried about for the age range 3–36 months; > or = 39 c (102.2 F):
Yes although this child has a temp of >102.1 F she has a reported temp
of 102.4
(My understanding is that you
must also consider reported fever >39 ie. If mom says the fever was
102.4…it was 102.4)
Fourth…If you agree with me that this child is
NONTOXIC and has a temp of >102, then we must try to find a focus of
infection.
In this case I do not find an obvious focus of infection.
(Foci of fever may include: pneumonia, stomatitis, pharyngitis,
otitis media, gastroenteritis, URI, croup, chicken pox, bronchitis, influenza.)
Fifth, we must determine whether or not this child’s
immunizations are COMPLETE, not just “up to date.”
Immunizations NOT complete!!!
(She’s 5 months old and has
not yet received her 6 month immunizations. That means she has incomplete
coverage for H. Influenza and S. pneumonia.)
Sixth…with incomplete immunization she is at increased risk for H flu. and S pnuemo. So we need to get busy, which means we need to obtain a CBC/blood culture and since she is a female less than 24 months old, a cath sample UA/UC.
-If
the WBC > 15k then empirically give ceftriaxone 50-100 mg/kg and consider
admission.
-If
the WBC > 20k then get a CXR and treat pneumonia as recommended and consider
admission.
-If WBC is < 15k but UA is positive then treat
with antibiotics as recommended and consider inpatient vs outpatient
management.
-If
WBC is < 15k and (if indicated) UA is negative; then you can discharge to
home with review of cultures in 1 day.
These kids should have repeat evaluation in 48 hours if they remain
febrile or have any new or worsening symptoms. (Personally if I were to
send this child home, I would want repeat evaluation in <24 hours…but that’s
me.)The key to this entire case rests in following the algorithm. I am opposed to algorithms for many areas of medicine, but honestly, I believe this is one area where the algorithm REALLY helps. After you work through a couple scenarios, it becomes pretty easy and makes sense. WE'LL DO SOME MORE FEVER CASES AS THE YEAR EVOLVES.
STAY TUNED.
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And the answer to this week's totally non-medical trivia question that some how links this web site to Germany: Susan Anton made appearances in Baywatch. That's her in the upper lefthand corner (I think) and David Hasselhoff is of course right smack in the middle.
Keep up the great work ECC life-guards...you may not be pretty...but you're plenty HOT!!!
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