Episode 48 – Pediatric Fever Without A Source

Have you ever seen a child in your emergency department with a fever - he asks sarcastically? At the ginormous community hospital where I work, we see about 25,000 kids each year in our ED and about half of them present with fever. Yes, there still exists fever phobia in our society, which brings hoards of worried parents into the ED with their febrile kids. For most of these kids it's relatively straight forward: Most kids with fever have clinical evidence of an identifiable source of infection – a viral respiratory infection, acute otitis media, gastro, or a viral exanthem. However, about 20% have Fever Without a Source despite your thorough history and physical exam.

A small but significant number of this 20% without an identifiable source of fever will have an occult bacterial infection - UTI, bacteremia, pneumonia, or even the dreaded early bacterial meningitis. These are all defined as Serious Bacterial Infections (SBI), with occult UTI being the most common SBI especially in children under the age of 2 years.

In the old days we used to do a full septic work-up including LP for all infants under the age of 3 months, but thankfully, times have changed in the post-Hib and pneumoccocal vaccine age, and we aren’t quite so aggressive any more with our work-ups. Nonetheless, it's still controversial as to which kids need a full septic workup, which kids need a partial septic workup, which kids need just a urine dip and which kids need little except to reassure the parents.

In this episode, with the help of Dr. Sarah Reid and Dr. Gina Neto from the Children's Hospital of Eastern Ontario, we will elucidate how to deal with fever phobia, when a rectal temp is necessary, how to pick out the kids with fever that we need to worry about, how to work up kids with fever depending on their age, risk factors and clinical picture, who needs a urinalysis, who needs a CXR, who needs blood cultures and who needs an LP, and much more....

Sarah Reid's Best Case Ever is here.



Written Summary & Blog-post prepared by Claire Heslop, edited by Anton Helman, July 2014

Cite this podcast as: Helman, A, Reid, S, Neto, G. Pediatric Fever Without A Source. Emergency Medicine Cases. July, 2014. https://stg-emergencymedicinecases-emcstaging.kinsta.cloud/episode-48-pediatric-fever-without-source/. Accessed [date].

PEDIATRIC FEVER

Fever in a child is a common emergency department presentation. About 20% will have fever without an identifiable source, and a small but significant number of these children will have an occult, serious bacterial infection (SBI) (1).

UTIs are the most common occult SBI (2), especially in children

By definition, fever is an oral temperature >38°C, or rectal temperature >38°C. Take a rectal temperature in toddlers, infants and neonates; axillary and tympanic temperatures are less accurate for core temperature.

Is Fever Dangerous & Do We Need to Treat it?

Fever itself is the natural body’s response to fighting infection, and does not in itself cause harm. However, fever causes dehydration; treat kids to help them feel better and stay hydrated.

The precise height of the fever is not as important as it's duration in predicting bacteremia. Children with infection as a cause for their fever almost never mount a fever high enough to be dangerous (>41.