Fever and Febrile Seizures -Garner

Describe the general diagnosis and treatment for newborns < 28 days old with a fever without a "source"

-hospitalize -full evaluation (CSF/blood/urine cultures, CBC/diff, UA, HSV PCR) -empiric IV antibiotics: ampicillin + cefotaxime or gentamicin + acyclovir while labs are pending -change to specific therapy or stop antibiotics based on results/clinical status

Describe the general diagnosis and treatment for 28-90 days old with a fever without a "source" who are *not low risk*

-hospitalize -full evaluation (CSF/blood/urine cultures, etc.) -empiric IV antibiotic(s) -change to specific therapy or stop antibiotics based on results/clinical status

List 4 general management principles for fever

-hydration -remove excessive clothes and blankets -room temperature should be lowered -discourage vigorous activities

What is the goal of therapy for treating fever?

-improve the child's overall comfort (febrile children often have altered activity, sleep, and behavior and decreased oral intake) -achieving a normal body temp is NOT a realistic goal

List the criteria for when a caregiver should call the child's PCP (that wasn't included in the criteria for "right away")

-infant 3-36 months: temp >/= 39 C (102.2 F) -child: temp > 39.4 C (103 F) -child still "acts sick" once the temperature is brought down -child seems to be getting worse -fever persists for > 24 hours in a child < 2 years -fever persists > 72 hours in a child >/= 2 years

Describe the axillary site of temperature measurement

-less accurate, but safer and easier in infants and small children (<5 y/o) -procedure: close armpit by holding elbow against chest -used for screening and if > 99 F, check with rectal or oral temp

Describe the clinical presentation/classification of complex febrile seizures

-less common but more serious -focal seizures -last > 15 minutes -occurs more than once during a 24 hour period

Describe the clinical presentation/classification of simple febrile seizures

-more common -primarily generalized -last < 15 minutes -do not recur within 24 hours

Describe the risk for epilepsy in patients who have had a febrile seizure

-only a slightly greater risk by the age of 7 years than the general population (0.9% vs. 0.5%) -higher risk (2.4%) in those with multiple simple febrile seizures, <12 months of age at onset, or family history of epilepsy

Describe the general diagnosis and treatment for 28-90 days old with a fever without a "source" who are *low risk*

-previously healthy, term birht without complications, nontoxic clinical appearance based on caregiver history and physical exam -normal WBC count (5-15,000 mm3), UA (<10 WBCs), CSF cell counts (WBC, differential, glucose, protein), AND reliable caregiver with phone -could manage as outpatient (draw CSF/blood/urine cultures and follow up closely; give IM ceftriaxone x 1 dose-lasts 24 hours while waiting for results)

Describe skin temperature strips

-quick and gentle -NOT accurate and NOT recommended

Describe the general diagnosis and treatment for children 3-36 months old with a fever >/= 39 C (102.2 F) without a "source" and are immunization *complete* (>/= 2 doses each of Hib and Strep pneumoniae vaccines)

-urinalysis and urine culture for boys </=6 months of age (</= 12 months if uncircumcised) and girls </= 2 years of age -antibiotic (ex: ceftriaxone) if abnormal urinalysis (> 10 WBCs) while waiting for urine culture results

Describe dosing of acetaminophen

10-15 mg/kg/dose q4-6 hours (do not exceed 5 doses/day or 75 mg/kg/day) 10-15 mg/kg/dose q6-8 hours in neonates (max 30 mg/kg/day) concern of hepatotoxicity with overdoses, serious skin reactions (SJS, TEN)

Do not use pharmacotherapy for > _______________ days without consulting PCP

3

Do not use pharmacotherapy in infants < ________________________ without consulting PCP

3 months old

After the first simple febrile seizure in a child > 12 months of age of onset, there is a ______________ % probability of having a recurrent febrile seizure

30%

What is the mean normal axillary body temperature?

36.5 C (97.7 F)

What is the mean normal oral body temperature?

37 C (98.6 F)

What is the mean normal rectal body temperature?

37.5 C (99.5 F)

Pharmacotherapy is indicated if temperature is > _______________ AND the child is _______________

38.9 C (102 F); uncomfortable

Fevers accompanying common infections are seldom > ____________

41.1 C (106 F)

Temperature must generally exceed ____________________ before there is serious risk for brain damage

41.7 C (107 F)

Describe dosing for ibuprofen

5-10 mg/kg/dose q6-8 hours (max 40 mg/kg/day); OTC labeling states 7.5 mg/kg/dose q6-8 hours, max 30 mg/kg/day concern of nephrotoxicity, gastritis, and ulcers

After the first simple febrile seizure in an infant < 12 months of age at onset, there is a ______________ % probability of having a recurrent febrile seizure

50%

After the second simple febrile seizure, there is a ____________% probability of at least 1 additional recurrence

50%

Ibuprofen should NOT be used in infants < ______________

6 months

Which drug can be administered per rectal route: ASA, APAP, or ibuprofen?

APAP only (but erratic absorption)

If fever is greater than 41.1 C (106 F), there is an increased risk of what complications?

CNS infections, brain tumors, or an impaired capacity to dissipate heat

Is continuous or intermittent drug therapy for children with 1 or more simple febrile seizure recommended?

NO

What is the definition of febrile seizures?

a seizure that occurs in febrile children b/t the ages of 6 and 60 months of age who do not have an intracranial infection, metabolic disturbance, or history of afebrile seizures

List intermittent therapy options that are NOT effective for simple febrile seizures

antipyretics (APAP and ibuprofen)

List contraindications for ASA

avoid in children and teenagers (< 18 y/o) due to Reye's syndrome (especially during viral illnesses)

List contraindications for ibuprofen

avoid in patients with bleeding disorders, ulcer disease; hypersensitivity to ibuprofen, NSAIDs or ASA; or dehydration

List contraindications for APAP

avoid in patients with hypersensitivity

List 2 continuous pharmacotherapy options that are NOT effective for simple febrile seizures

carbamazepine and phenytoin

If a fever without an identified "source" in a well-appearing patient is found, ________________ and ______________________ depends on age

diagnostic work-up and treatment

List one intermittent (given at the start of fever) therapy option for simple febrile seizures

diazepam

Take temperature before each _________________ to avoid unnecessary medication administration

dose

What is fever?

elevated "set point" to which physiologic processes are altered to elevate body temperature (natural defense vs. infections with some benefits; fever is a symptom)

There is no evidence that treatment for simple febrile seizures prevents the development of what?

epilepsy

Which is a more common complication of high fever: febrile delirium or febrile seizures?

febrile seizures

What is FOC?

fever of concern; threshold for contacting PCP but may differ in at-risk populations

After identifying that a fever is present, how should we further classify?

fever with a "source" or fever without a "source"

Describe glass thermometers

filled w/ mercury (silver line), alcohol (red or blue line), or galinstan (silver line); AAP recommends against glass thermometers filled with mercury b/c the glass can break and mercury is poisonous; take several minutes

List 2 temperature measurement tools

glass thermometers or electronic digital thermometers

Describe electronic digital thermometers

most commonly used and recommended and can measure oral, rectal, or axillary temperatures within seconds

Bottom line: if the patient is </= 90 days (3 months) old and they have a fever, what should be done?

need to be seen by PCP

Is alternating or combining ibuprofen and APAP recommended?

no

Should you wake a child to take their temperature or administer antipyretics?

no

What is hyperthermia?

normal "set point" but abnormal physiologic processes elevate body temperature (normal homeostasis fails)

What is the definition of a FOC in children?

oral temp > 39.4 C (103 F)

What is the definition of a fever in children?

oral temp >/= 37.8-39.4 C (100-103 F)

List 2 continuous pharmacotherapy options for simple febrile seizures

phenobarbital and valproic acid

What is the definition of a fever and Fever of Concern (FOC) in neonates and infants 1-3 months?

rectal temp >/= 38 C (100.4 F)

What is the definition of a fever in infants 3-36 months?

rectal temp >/= 38-39 C (100.4-102.2 F); axillary temp >/= 37.2 C (99 F)

What is the definition of a FOC in infants 3-36 months?

rectal temp >/= 39 C (102.2 F)

There is no evidence that simple febrile seizures cause what?

structural damage or an adverse effect on intelligence

Observation of _____________ and _________________ is more important than the actual temperature

symptoms and signs

What is "set point" temperature?

the body temperature set by the normal neuronal regulatory mechanisms within the hypothalamus; the summation of heat production and heat dissipation

Should pharmacotherpay be used for simple febrile seizures?

the risks outweigh the benefits most often

Describe the pathophysiology of a fever

trigger-leukocytes-endogenous pyrogen (IL-1, IL-6, TNF)-hypothalamus-increase PG synthesis-increase cAMP-increases thermoregulatory set point-increase heat conservation (vasoconstriction) and increase heat production (shivering)-FEVER

Describe the general diagnosis and treatment for children 3-36 months old with a fever >/= 39 C (102.2 F) without a "source" and are immunization *incomplete* (< 2 doses each of Hib and Strep pneumoniae vaccines)

-CBC with differential -blood culture -urinalysis and urine culture for boys </= 6 months of age (</= 12 months if uncircumcised) and girls </= 2 years of age -antibiotic (ex: ceftriaxone) if abnormal urinalysis (> 10 WBCs) while waiting for urine culture results

Describe the temporal artery site of temperature measurement

-a probe detecting infrared heat flow from the temporal artery (across the forehead toward the hairline) -measure body temp within seconds, painless, good comparison to rectal (maybe better than tympanic) -inaccurate readings if pt. is sweating -used for *screening*

Describe the tympanic membrane site of temperature measurement

-a probe detecting infrared heat flow from the tympanic membrane, converts to rectal temp -measures body temp within seconds, painless, good comparison to rectal -technically difficult in infants < 3 months old -take 3 readings, use the highest of the 3 -used for *screening*

Describe the oral site of temperature measurement

-accurate -preferred for cooperative patients (>/= 3-4 years old) who do not have respiratory illnesses (need to be able to breath through nose) -no recent cold or hot beverages (should wait > 10 minutes) -procedure: place thermometer tip beside the tongue or inside the cheek, hold thermometer in place with child's lips sealed

List the criteria for when a caregiver should call the child's PCP *right away* if they also have a fever

-age < 3 months -fever is repeatedly > 40 C (104 F) for a child of any age -looks very ill, is unusually drowsy, or is very fussy -has other symptoms (stiff neck, severe headache, severe sore throat, severe ear pain, unexplained rash, or repeated vomiting or diarrhea) -has had a seizure -has signs of dehydration (dry mouth, sunken fontanelle, and significantly fewer diapers and is unable to take in fluids) -has underlying immune system illness (ex: sickle cell disease, cancer) or is taking steroids -has been in a hot location (ex: overheated car)

Describe palpating the forehead

-better at predicting absence of fever, high fevers -NOT a substitute for other routes

List 3 general diagnostic methods for febrile seizures

-complete history -physical and neurologic exam -EEG, lab, or neuroimaging studies (lumbar puncture)

Describe the general diagnosis and treatment for children 3-36 months old with a fever < 39 C (102.2 F) without a "source"

-do NOT need lab work and antibiotics -instruct to return if fever persists for 2 days of if child worsens

List predisposing factors for febrile seizures

-genetics (increased risk w/ family hx) -infectious illnesses -higher temps (every 0.6 C increase doubles the likelihood of a febrile seizure) -childhood immunizations (related to DPT and MMR due to pertussis and measles components) -history of developmental delay -neonatal hospitalization > 28 days -prenatal smoke exposure

Describe the rectal site of temperature measurement

-gold standard b/c accurate and consistent but scary and uncomfortable -preferred for infants and young children -procedure: lie child stomach down on your lap, lubricate end of thermometer and the child's anal opening with petrolatum jelly, carefully insert the thermometer about 1 inch, but never force it, hold child still, pressing the buttocks together

List 6 factors affecting body temperature

-"bundling" (increases skin, but not core temp) -vigorous exercise -hot bath -time of day (late afternoon or early evening peak up to 100.4 F; early AM b/t 3 and 5 AM nadir down to 97 F; independent of sleep habits, eating or working patterns) -hot or cold beverages -mouth-breathing (may decrease temp measured orally by 0.5 C)