1. Dr. Saptharishi L G
Junior Resident

2. LEARNING OBJECTIVES

 Approach to a < 36 month old child with acute
fever (fever< 5 days)
 Concept of ‘Fever Without Source’ and the
related practical issues
 Clinical practice protocols for Fever Without
Source (FWS) in <3 year olds

3. INDEX CASE

 B/o S
 4 month old
 male infant
 Resident of Sec 38, Chandigarh
 Brought with complaints of
 Fever  3 days

4. History Of Presenting illness

 FEVER :
 Moderate to high grade, intermittent
 Documented up to a max of 102 F (by a local doctor)
 h/o excessive crying a/w poor feeding – with fever spike
 At other times, infant is playful, active and feeding well.
 No h/o rigors, No diurnal variation
 No h/o rapid breathing/ retractions/ nasal flaring
 No h/o neck retractions/ bulging fontanelle/ vomiting
 No h/o loose stools/ altered bowel habits

5. Other aspects of History

 PAST HISTORY:
 Born by FTNVD at PGI; Birth weight – 3.1 Kg
 Uneventful antenatal and perinatal period
 No h/s/o birth asphyxia/ NNJ
 FAMILY HISTORY:
 First born; No significant family history
 Exclusively Breastfed since birth
 Immunized appropriately for age (including Hib)

6. Examination

 Anthropometry:
 Weight – 6.1 kg (3rd to 15th percentile – WHO charts)
 Length – 64 cm (50th centile – WHO charts)
 OFC – 42 cm ( 0 to 1 Z score – WHO charts)
 Vitals:
 Temp - 39° C
 HR – 122/min
 RR – 42/min
 BP – 78/50 mm Hg
 CFT – 2 s
 SpO2 – 98%

7. Examination

 No pallor/icterus/ cyanosis/ clubbing/ LAP/ edema
 General impression
 Active, alert but crying
 ‘NOT- TOXIC/ SICK ‘ looking
 Head to toe examination
 No obvious focus of sepsis (cellulitis/ abscess/ furuncle)
 AF – at level, soft; Perianal region – WNL
 Ear – No e/o ASOM, Nose & Throat – mild congestion
 Systemic examination
 CVS/ RS – NAD
 P/A – Liver: palpable 2 cm under RCM, soft, non-tender
 CNS – Irritable but No e/o FND; Normal examination

8. So what would you like
to do for this child??

Child with “just fever”, Sounds familiar?
Because
Almost all of us have „BURNT‟ our fingers !!!

9. FEVER
Identified
FWS / FWF
focus
Serious
Benign
Bacterial
causes
Infections

10. NORMAL TEMPERATURE RANGES
Definition of fever
Axillary  34.7° to 37.3° C (94.5 to 99.1 F)
Oral  35.5° to 37.5° C (95.9 to 99.5 F)
Rectal  36.6° to 37.9° C (97.9 to 100.2 F)

 Core body temperature > 38° C or 100.4 F
 Accurate temperature measurement – a must.
 Fever reported by parent, but now afebrile… Then ?
 Fever documented by axillary/ tympanic membrane
 Fever documented by rectal thermometry

11. Should doctors be worried as well?

 Risk of bacteremia in children with FWS
 Up to 10 % (old US data)
 7% (BMJ 2010)
 Complications of Occult Bacteremia
 Delayed onset meningitis
 Pneumonia
 Septic arthritis
 Osteomyelitis
 Mortality

12. FEVER
Can I somehow
PICK-UP this
group at
Identified presentation??
FWS / FWF
focus
Serious
Benign
Bacterial
causes
Infections
Occult Occult
UTI
Bacteremia Pneumonia

13. Height of fever

 No direct correlation with etiology
 Neonates
 Afebrile/hypothermic response despite SBI
 Older infants & children < 3 years old
 EXAGGERATED febrile response
 Temp > 40° C  38% risk of SBI
 High grade fever – unusual in older
children/adolescents – SERIOUS
 Increasing prevalence of pneumococcal
bacteremia with increasing temperatures

14. Pattern Of Fever

 DOES NOT reliably distinguish between etiologies
 Response to Anti-pyretic – Bacterial Vs. Viral

15. Observational Assessment

 Clinical appearance has good predictive value
 All children with toxic appearance must be
hospitalized, evaluated and started on IV antibiotics

16. What constitutes ‘TOXIC’ look?

 Alertness – child looking at the observer, looking around
the room, with eyes that are shiny & bright, etc.
 Normal motor ability – sitting without support, moving
arms & legs on table or lap, etc.
 Playfulness – vocalizing spontaneously, playing with
objects, reaching for objects, smiling & crying with
noxious stimuli, etc.
 Irritability- consolability of cry
Infant’s smile has a very high negative
predictive value for meningitis

17. Interpretation
Score – 10  2.7% SBI
Yale Observation Score
Score 11-15  26% SBI
Score > 16  92.3% SBI

1 3 5
Quality of cry Strong or No cry Whimper or sob Weak cry / moan/
high pitched cry
Reaction to Brief cry / content Cries off and on Persistent cry
Parents
State variation Awakens quickly Difficult to awaken No arousal/ falls
asleep
Color Pink Acrocyanotic Pale/ cyanotic
/mottled
Hydration Eyes, skin and Mouth slightly dry Mucosa , eyes –
mucosa – moist dry/ sunken eyes
Social Response Alert or smiles Alert/ brief smile No smile/
anxious/ dull

18. 

19. BUT, Remember…. No combination of clinical
history-taking & examination is good-enough


20. Age-based Clinical
Practice Protocols

< 28 days old
1-3 months old
3 – 36 months old

21. Neonates with FWS

 Highest risk group – 12% SBI – UTI/ Occult bacteremia
 Strep B, E coli, Listeria  Highest sequelae
Signs of viral illness – does not negate need for full diagnostic evaluation
RSV infected neonates – same risk of SBI as RSV negative neonates
All neonates with FWS should undergo
• Blood c/s, Urinalysis, Urine c/s, CSF study, WBC count
• CXR if respiratory symptoms/ Stool testing for WBC
count if diarrhea present
• IV antibiotics initiated as early as possible
• Hospitalization and follow up

22. 1 – 3 month old with FWS

ROCHESTER Criteria – LOW RISK group
Appearing well
Previously healthy
No e/o skin/ soft tissue/ bone/ joint/ ear infections
WBC count – 5000 to 15000/mm3
ANC < 1500/mm3
Urine WBC < 10 WBCs/HPF of centrifuged sample
Fecal leucocyte count < 5/ HPF in children with diarrhea
 Boston criteria
 included routine CSF also (<10 WBC/HPF)
 Philadelphia criteria
 Criteria by Baker et al

23. 1 -3 month old with FWS

 Must Dos
 WBC counts / Urine dipstick / Urine & Blood c/s
 CSF  Optional (depending on local protocol)
LOW RISK Not LOW RISK
F/u in 24 hrs Hospitalize
No antibiotics IV antibiotics
Collect cultures Collect cultures

24. 3 – 36 month old with FWS

 Fever definition stays…
 But for evaluation purpose,
 Temperature > 39° C  CUT-OFF for further work-up
 Rationale:
 Risk of bacteremia – 0.8 % till 39° C
 Jumps to 8% beyond 39° C
 No significant further rise beyond 40 or 41° C

25. OCCULT OCCULT
OCCULT UTI Pneumonia
Bacteremia
• IV Antibiotics
• Hospitalize
• CSF ( if not
done already)
• Blood c/s
• Urine c/s
• Urinalysis

26. American Family Physician 2007

27. 

28. Rules of the Game

 Never do Lumbar Puncture in a child with FWS with
suspected bacteremia, if you are not planning to give
at least one dose of IV Antibiotic…
 Never start IV antibiotics to a <3 year-old child with
FWS without CSF analysis*…

29. Emerging trends

 Effect of Pneumococcal and Hib vaccines
 Decrease in bacteremia in 3 – 36 months age group
 NEWER Recommendations  Urinalysis more useful
than CBC in this group
Lee GM et al. Management of febrile children in the age of the conjugate
pneumococcal vaccine: a cost-effectiveness analysis. Pediatrics 2001; 108: 835-44
Improving pneumococcal vaccine coverage
Bacteremia rates < 0.5%
STOP empirical testing and treatment

30. Caveats / Pitfalls

 Emphasis on detection of bacterial diseases…
 Useful for large tertiary care centers…
 Exclusion of certain sub-groups of children…
 Artificial chronological age distinctions…
 Majority assumed to be infectious…
 Useless unless based on local epidemiological data…

31. Role of newer markers

 C-Reactive protein
 Lacour et al  sensitivity – 89%, specificity – 75%
 Andreola et al  sensitivity – 88%, specificity – 61%
 Procalcitonin
 Lacour et al  sensitivity – 93%, specificity – 78%
 Lopez et al  CRP Vs. Pc – similar ROC AUC values

32. ‘TAKE- HOME’ MESSAGES

 Significant subset of febrile, 0 to 36 month old children 
‘AT-RISK’ for Serious Bacterial Infections
 MORE So in Indian setting/ developing countries
 Higher bacteremia/ occult bacterial infections
 Even ‘ADEQUATE’ history & physical examination falls
short…Misses SBI & over-treats benign illnesses
 Development of an INDIGENOUS data-based protocol –
a necessity for every major tertiary care centre

33. ‘TAKE- HOME’ Practice points

 Febrile Neonate (0 to 28 days old)
 CBC, Blood c/s, urinalysis & urine c/s, CSF analysis,
CXR*/Stool*  Empiric IV antibiotic  Hospitalize
 Febrile Young Infant (1-3 months)
 CBC, Blood c/s, Urinalysis and c/s, CXR*/Stool*
 Optional CSF# + IV/IM Ceftriaxone  Hospitalize
 Follow-up as detailed
 OPD Vs. Admission

34. ‘TAKE- HOME’ Practice points

 Febrile child 3 – 36 months:
 Temp cut-off > 39° C
 Evaluate for occult infections
(UTI/Bacteremia/Pneumonia)
 CBC with differential  in children with fever > 39° C
 Indications for Urine c/s  Boys Vs. girls
 CXR indications  clinical / WBC > 20,000/mm3
 Decision reg antibiotics & hospitalization

35. Primary Reference


36. Pediatrics 2011


37. THANK YOU !
Would be pleased to respond to queries… If any