Jul 13, 2012
What age should we use for the
febrile ex-premie? At what temperature does a fever become
dangerous? How should we approach the unvaccinated febrile infant?
How many blood cultures should we get in febrile
..these questions and many more will
be answered on this episode of ERcast
Interviewer: Dr. Rob
Dr. Justin Arambasick
Does the height of the fever affect your work up
in a fully vaccinated child between 3 and 12 months – example very
high fever though looks great after antipyretics? Also, does
a higher fever correlate to a higher liklihood of bacteremia?
Evaluate appearance using the TICLS mnemonic
“Tickles” (TICLS) mnemonic – Criteria to
evaluate the well appearing “sick” kid
Disposition based on initial assessment (if fever but meet TICLS
criteria, probably ok to go home)
|Is he/she moving around or resisting
examination vigorously and spontaneously? Is there good muscle
How alert is he/she? How readily does a person, object, or
sound distract or draw attention? Will they reach out,
grasp and play with a toy or new object, like a penlight or tongue
Can he/she be consoled or comforted by the caregiver or by the
Can he/she fix her gaze on the clinician’s or caregiver’s face
or is there a “nobody home,” glassy-eyed stare?
Is their speech/cry strong and spontaneous? Or weak, muffled,
Does height of fever influence management?
Once there’s a fever…there’s a fever.
How high it goes isn’t too important.
Bring fever down for to make child feel better
Feeling better helps the patient stay hydrated
Dehydration is a main reasons they will bounce back to the ER.
Recent evidence suggests that with the advent of prevnar, there is
little correlation with bactermia and height of fever
The exception to
this is hyperpyrexia
106.7 F/41.5 C-brain proteins start to
PARENTS SHOULD BRING BACK ANY CHILD WITH A TEMP OF 106.7 F or 41.5
What are acceptable sources of fever?
Hand, foot and mouth **
Viral exanthem **
Otitis media in a child >2months **
NOTE: Some sources add these
What are the 5 Main sources of fever?
Work through the LUCAS mnemonic when you
cannot find a source. Never heard of the LUCAS mnemonic? That’s
because we just made it up…an ERcast original.
What is the likelihood of serious bacterial infection based on
1/100 at 1 month
1/1000 at 3 months with a set of vaccines
What are the concerns in an unvaccinated child up to 6 months
with fever without a source?
There is no magic answer and there are many opinions on this
topic. As is often the case, the more opinions, the less evidence
there is to support a definitive pathway. One theory is to work up
fevers like we used to before Prevnar and H Flu vaccination.
Another is to approach this cohort as you would any other febrile
infant. Below are your options.
IF child looks good, may apply TICLS Mnemonic and check a
urine and be done
May do middle of the road and get urine with blood work
OR Conservative with full work-up including
What is the correct dosing of ceftriaxone?
If meningitis 100mg/kg
Most providers use cefotaxime for <1 month due to biliirubin
displacement from ceftriaxone
When should steroids be used in meningitis?
Do not give at less than 6 months
DO use after 2 years
Difference of opinion between 6moths -2years- most often given in
this range only if severely ill or concern for
Steroids are ok to give before during or after antibiotic
administration-prefer to give before or during
Hydrocortisone is the steroid used most often in
25, 50, 100mg/kg/m squared(BSA) –calculate the BSA
In kids, BSA is generally 0.8-1 approx 1
Steroid dosing rough estimates
Small kids 25mg- i.e. newborn
Medium 50mg—i.e. 1 year old
Large 100mg- >1 year
0.6mg/kg or max of 10mg
Some centers use 0.15, 0.30, or 0.5 mg/kg
Who is the best person to hold the child during the lumbar
puncture and what position?
NOT THE PARENT
Person with most experience holding the child (who can hold them
One hand on upper back/neck, one on hamstring/hips
OK to flex neck intermittently-(Not constantly-can make hypoxic).
An example of this is to flex the patient to identify landmarks and
place local angelsia-then relax the position and flex them
Sedation recommended for kids > 6-months old due to muscle
Should we order a CRP or Procalcitonin in the workup of a
Sloas says no. The best data shows wide sensititivity of
How do we actually calculate ‘AGE’
And now for the big question, the one that gives us
headaches and no small degree of consternation…..
When evaluating the febrile child who is an ex-premie,
do we calculate their age from the time they were born or their
relationship to 40 weeks (e.g. a child was born at 35 weeks and
presents with a fever 8 weeks after birth, for the purposes of
fever, are they considered 8 weeks old or 4 weeks
4 types of age
how many weeks actually inside the uterus
menstrual-age from date actually
age- THE ONLY THING YOU CARE ABOUT FROM IMMUNE
STATUS STANDPOINT – the time since birth to the time seen in ED.
Another way to think about this is the patient’s “time in the
age- Used by paediatricians for
growth, feeding and milestones. Corrected age = Chronological age
**33-34 weeks is when most babies will develop normal reflexes
(i.e. suck, respiratory)
What is Andy Sloas’ final word on what age to use
for an ex-premie?
CHRONOLOGICAL AGE- time in the atmosphere