Thursday afternoon – second last patient of the day. The parents bring in a tired looking 5yo M missing two front teeth and carrying a rather moth eaten teddy bear (not prognostic). The parents look worn out and significantly anxious. You shake hands and sit down glancing intermittently at the child who lies his head across his mothers lap who catches glances at you with a look that says “where are you hiding the needles…”
He’s been unwell for 72 hrs with temperatures up to 39 degrees. Been grizzly and upset and not really sleeping. No real localising signs (Resp/GI/GU), just high temperatures. Other friends at school have had recent viral illnesses. Obstetric/Developmental history normal, vaccinations UTD, no signif PMHx, no meds/allergies. No FHx of note. No one else in the house is currently sick. He has had decreased oral intake and seems to go to the bathroom less.
You examine him – OE: Appears mildly pale and lethargic. Moist mucous membranes, warm peripheries (does this help?), HR 110 regular (what is normal?), RR 26 (no increased WOB), cap return <2 secs, skin examination normal, no photophobia/neck stiffness, no rashes, ENT exam reveals minimally red bilateral TMs and pharynx (though febrile?), tongue appeared normal, maybe some LNs up submandibularly, chest clear, HSx2+0 (do I need this?), abdomen soft non tender no rebound/guarding, no HSM, testicles normal, lower limbs normal no P.oedema.
The parents head off to the bathroom with the child to get a urine specimen while you ponder what to do next. Essentially, you have two choices – send to ED or send home. Which do you choose and why?
Lets start with a great entertaining 6 minute video from EMPEM.org on paediatric emergencies in children – Link
What is a fever in a child and how should we measure it? RCH guidelines suggest >38.0 and how it is taken is discussed here – Link
What are the normal vital values for paediatrics? I can never remember and keep my trusty RCH guidelines book on my desk. On the internet however, check out dontforgetthebubbles.com (fabulous website for all paediatric FOAM – check it out if you haven’t already!) – Link
I couldn’t find much research specifically in Australian General Practice on ED vs Home. Here is a massive study (20,000) looking at paediatric fever in PAEDIATRIC primary care and outcomes in Canada (Paediatrics 2000) – Link
Some of these are highlighted in an Italian Journal of Paediatrics study – Link – Some erroneous beliefs included: 85% prescribed antipyretics to prevent febrile seizures, 90% said that febrile convulsions can cause brain damage, 65% stated that fever is harmful to a child, 76% used the height of the fever to differentiate bacterial vs viral causes, and finally 10% still thought aspirin can be used to bring down fever (read: Reye’s Syndrome).
I would like to hope our doctor’s perceptions are different to Italians. But I have no evidence to back this up.
So I now understand how to assess ‘toxicity’ based on the ABCD guidelines which will help my decision planning.
Life in the Fastlane has a great summary of the latest (2013) NICE guidelines for paediatric fever – Link – and here ARE the NICE guidelines for a detailed read on Green/Amber/Red features for decision making (page 16) – Link
Ok so I have some clinical guidelines on green/amber/red flags. What can give me a guide to where the infection may be?
A great chart and discussion of serious causes of fever is again in the NICE guidelines 2013 page 17 – Link
(Bladder) UTI – Here is a great podcast from EmPEM on paediatric UTI 2012 – Link PS. NEVER send a bag specimen for MCS to diagnose UTI – Link – Here is a patient information handout for advice on how to catch a clean specimen – Link
(Bronchus (including ear!)) Pneumonia/URTI/OM – Here is a Q&A quick review of paediatric pneumonia from Life in the Fastlane – Link. Another good resource is the management chart on the RCH website – Link – There is a great summary article on Otitis media on dontforgetthebubbles.com – Link
(Bone) Septic arthritis/Osteomyelitis – American Family Physician 2011 discusses this topic well – Link
(Blood) Septicaemia/Infective Endocarditis – For an update in paediatric sepsis there is a great online lecture here (American though) – Link
(Boil) Skin infection/Cellulitis – The RCH has great pictures and tables about common bacterial skin infections – Link
Leukaemia/Lymphoma – This is discussed in this article in the free online textbook paediatriccareonline.org (under differential diagnosis) – Link Unfortunately I didn’t find a good FOAM on leukaemia in paediatrics yet? Can anyone help me out?
Cat Scratch Disease – Great description from American Family Physician 2011 – Link
Factitious fever – Here is an interesting read and some good anecdotes on factitious fever and Munchhausen – Link
I know there are a bucket load more possibilities but beyond the scope of discussion here.
Question 4 – If I want to do some basic investigations if I am uncertain, what should I order?
AAFP has a good discussion article on levels of testing in fever of unknown origin in paediatrics and when to initiate it – Link
RCPA 2011 has a good list of possible investigations you could consider based upon your suspected list of culprits – Link – Standards – (FBC, Film, CRP, Bilirubin, LFTs, LD + BCultures, urine MCS, faeces MCS)
Question 5 – Can I do anything about the risk of febrile seizures?
Antipyretics DO NOT help prevent febrile seizures – JAMA 2009 – Link
Diazepam has been shown to help prevent seizures in a febrile illness or continous use of phenobarbital or valproic acid have been shown to stop these – benign and self limiting seizures. I wouldn’t be putting my paediatric patients on these medications for this indication and this is supported here (Paediatrics guidelines for management of simple febrile seizures (American)) – Link
Further detail on simple/complicated febrile seizures are beyond the scope of this discussion today.
Question 6 – What else can I tell parents about fever?
A good article by American Academy of Paediatrics (2011) talks about advice for parents about fever and common questions – Link
Question 7 – So what did I do?
Well the urine came back clear. (and subsequent MCS).
So looking at the above guidelines – the child did not look toxic, was well hydrated and tolerating ongoing fluids, was fully immunised, had responsible parents, lived nearby (and thus within 30 minutes of a hospital), and they were happy to bring the child back tomorrow.
I did what any doctor does in these cases – I phoned a friend! (I mean I went down the hall and chatted it through with another doctor to see if he had any other thoughts – “A problem shared….”).
They agreed that we could review the child again tomorrow based upon current symptoms/signs.
I handed the parents a good handout from the RCH – Link – described some red flags to watch for and then told them to return tomorrow.
ADDIT: The end of this story was the child was still having fevers at day 5 so I ended up doing some basic bloods which showed a mild lymphopenia, otherwise normal FBC/Film, CRP 60, ELFTs all normal. BCultures still pending. Child continued to remain well and fever settled a day or so later. Subsequently we have had several children with similar fevers and non-specific symptoms when I discussed it with other doctors in the clinic. Something in the water/kindergarten?