Evaluation of the Child With Fever 'f Triage Sepsis Screen Recent Travel Screen Infectious Disease Exposure Screen Isolation & Infection Control Considerations Sepsis Screen Positive Host Compromise Considerations History and Physical Determine Signs Symptoms of Suspected/Recognizable Bacterial or Viral Infection No Obvious Source or Possible Nonspecific Viral Infection ' > Age >56 days -24 months Evaluate UTI risk factors Consider occult pneumonia Immunizations Status Suspected/Recognizable Bacterial or Viral Infection Bedside team huddle with rapid evaluation and treatment, including support, and provision of broad- spectrum antibiotics Febrile Young Infants Oncology Patient > Sickle Cell Disease Central Line Presence Ventriculoperitoneal Shunt Presence Other Host Compromise Signs of Severe Infection Other Considerations Immunization Status Unusual Exposures Fever of Unknown Origin International Traveler Kawasaki disease Nonlnfectious Etiologies Age >24 months History and physical-directed evaluation ' Treatment Supportive care for most viral illnesses Consider Influenza Season/Treatment Indications Antibiotics for Focal Bacterial Infections - Consider Local Antibiotic Resistance Patterns Disposition Discharge Admission Assure adequate hydration and appropriate vital signs Specific discharge instructions by illness Fever supportive care Follow- up recommendations and return precautions FIGURE 31.1 Algorithm for the evaluation and treatment of the febrile child (Adapted from pathway by authors K Cohn, MD, MPH; F Balamuth, MD, PhD; R Marchese, MD; F Henretig, MD; J Gerber, MD, PhD.) Some febrile exanthems are characteristic enough to be diagnostic (see Chapter 70 Rash: Papulosquamous Eruptions and Viral Exanthems ) Varicella, rubeola, scarlet fever, and coxsackievirus can all be identified by their pathognomonic rashes However, if a child with chickenpox presents several days into the illness with a new fever, the possibility of group A β-hemolytic streptococcal or Staphylococcus aureus superinfection should be considered Children with fever and petechiae may have invasive meningococcal disease, disseminated streptococcal infection, or Rocky Mountain spotted fever; however, they may simply have a less serious viral infection or streptococcal pharyngitis Differentiation of these entities is crucial and is based on clinical appearance of the patient and laboratory evaluation A child with only a few petechiae (especially if only above the nipple line), normal white blood cell (WBC) count, normal platelet count, and well appearance is less likely to have invasive disease However, any child who appears ill, has distinctly abnormal laboratory results, or has a rapidly progressive petechial rash needs a more complete evaluation for sepsis or meningitis and should receive empiric antibiotics A patient with fever and diffuse erythroderma should be evaluated carefully for hemodynamic instability or other signs and symptoms of toxic shock syndrome Fever associated in a young child with severe skin blistering and exfoliation may be toxin-mediated staphylococcal-scalded skin syndrome On physical examination, acute otitis media is identified by the acute onset of otalgia or fever with changes in the tympanic membranes, such as redness, bulging, decreased mobility, loss of landmarks and light reflex, air–fluid level behind the tympanic membrane, or purulent drainage from a perforation Careful examination of the head and neck may reveal rhinorrhea and signs of inflammation, suggesting a viral upper respiratory infection (URI) The oropharynx may reveal pharyngitis or stomatitis (see Chapters 52 Oral Lesions and 74 Sore Throat ) Children with a history of a recent respiratory infection may have reactive, tender, swollen cervical lymph nodes; asymmetric enlargement of nodes, especially with tenderness and overlying erythema, might indicate bacterial lymphadenitis Croup is readily identified by a barky cough with or without stridor in young children, whereas a distinctive “hot potato voice” with unilateral tonsillar swelling in adolescents indicates a peritonsillar abscess Wheezing, tachypnea, and fever in infants younger than years of age usually mark bronchiolitis Pneumonia often presents with cough, fever, tachypnea, auscultatory findings, and hypoxemia Wheezing/rales, tachypnea, disproportionate tachycardia, poor perfusion, and hepatomegaly, with or without chest pain, may indicate myocarditis Mild abdominal pain or tenderness, vomiting, and/or diarrhea most often suggest viral gastroenteritis but early hepatitis, appendicitis, or pancreatitis should also be considered More severe findings, particularly the occurrence of peritoneal signs, may indicate appendicitis, intra-abdominal abscess, or peritonitis from other causes (see Chapters 53 Pain: Abdomen , 91 Gastrointestinal Emergencies , and 92 Gynecology Emergencies ) However, in children, fever with abdominal pain may also represent lower lobe pneumonia, streptococcal pharyngitis, urinary tract infection (UTI), gastroenteritis, or mesenteric adenitis Additional findings in UTI may include suprapubic or costovertebral angle tenderness Adolescent girls with pelvic or abdominal pain and fever should be evaluated for pyelonephritis and pelvic inflammatory disease (see Chapter 92 Gynecology Emergencies ) A careful skin examination may reveal an abscess or cellulitis associated with community-acquired methicillin-resistant S aureus or Streptococcus pyogenes Differentiation of these diverse diagnoses depends on a thorough history, physical examination, and at times, well-directed laboratory evaluation Continued advancements in immunizations have changed the frequency and risk of certain febrile illnesses in children The Centers for Disease Control and Prevention reported that the Haemophilus influenzae type B (Hib) vaccine has drastically changed the risk and causative agents for meningitis in children with a 94% reduction in the incidence of H influenzae meningitis and a shift in the median age of those affected from 15 months to 25 years of age The current rarity of epiglottitis in children is also due to this decline in H influenzae infections In addition, the conjugate pneumococcal vaccine (PCV) has significantly decreased the overall risk of invasive pneumococcal diseases in children However, after the initial heptavalent PCV vaccine introduction, there was noted a small, but not inconsequential increase in invasive bacterial infections in children due to nonvaccine pneumococcal serotypes The current 13valent vaccine, with expanded serotype coverage, has continued to decrease invasive pneumococcal disease in children, especially those less than years of age, but a small increase in pneumococcal disease due to nonvaccine serotypes continues to be observed Recognition of these epidemiologic changes is crucial in evaluating and treating the febrile child These findings obviously influence the evaluation and treatment of febrile children with signs of meningitis, as well as those young children without an identified source of infection after thorough historical and physical examination Although vaccines have significantly changed the risk and epidemiology of infectious diseases in children, the clinician must be aware of increasing and important outbreaks of vaccine-preventable illnesses in children Although measles was declared eliminated (without year-round endemic transmission) in the United States in 2000, there have been recent significant outbreaks due to worldwide travel from endemic areas and infection in unvaccinated (due to personal choice, missed vaccine opportunities, or in children too young to receive the primary vaccine series) individuals in the United States For example, clinicians must continue to consider measles in suspicious cases with the constellation of fever, rash, cough, coryza, and conjunctivitis, especially in un- or underimmunized patients Given these general considerations, an algorithmic approach to the child with an acute (less than days) febrile illness can be formulated using the following key features: overall degree of toxicity and presence of signs or symptoms of lifethreatening disease, immunocompromised host status, patient’s age, unusual risk factors (immunization status, travel, animal exposures), and presence of localizing features on history and physical examination (see Table 31.3 ) Laboratory studies are indicated only for selected situations as defined by clinical features Most older febrile children not need routine laboratory testing Infants younger than months of age are at increased risk of serious bacterial infections and bacteremia and are more difficult to assess clinically than older children The management of febrile young infants is particularly challenging because of the relatively high prevalence of serious bacterial infections (up to 15%) and the inability to easily distinguish those with serious bacterial disease or herpes simplex virus from those with uncomplicated, common viral illnesses such as respiratory syncytial virus (RSV), parainfluenza, influenza, adenovirus, human metapneumovirus, or enteroviruses Thus, for infants with fevers of 38°C (100.4°F) or higher who are younger than month of age, many authorities recommend a laboratory investigation for serious infection (“sepsis workup”), including some combination of complete blood count (CBC), blood culture, urine analysis, urine culture Lumbar puncture with cerebrospinal fluid (CSF) for cell count, glucose, protein, Gram stain, and culture is generally recommended for all febrile infants less than month of age and in infants to months of age if they are high risk Figure 31.2 shows an algorithm for the evaluation of infants younger than months Clinical examination alone, without further laboratory evaluation, is generally not considered sensitive enough to identify serious illness in these very young infants In addition, the peripheral blood WBC count has been shown to be inadequate as an indicator of young febrile infants at risk for meningitis Herpes simplex virus polymerase chain reaction (PCR) or culture from blood and CSF with presumptive antiviral treatment should be considered in acutely ill neonates less than weeks of age and in those with historical concerns or physical findings of skin, eye, or mouth lesions; respiratory distress; seizures; signs of sepsis; or CSF pleocytosis Stool for leukocytes and culture should be obtained if diarrhea is present Respiratory findings are good predictors of clinically significant positive chest radiographs in children younger than months; therefore, chest radiographs may be obtained only when there are clinically evident respiratory signs During local enteroviral season, CSF enterovirus PCR testing has been shown to decrease length of hospitalization and unnecessary antibiotic use in neonates and young