Fever: Fear and Tradition

“Doc, he’s burnin’ up!”  Fever is probably the commonest presenting complaint we manage in Paediatric Emergency Departments.  The cause is usually an infection… but not always.  The infection is usually a benign, self-limiting viral illness… but not always.

Join us for this podcast as we tease out the facts from the fiction, the myths and the mystery.

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Fever Basics (Fear and Tradition)

CP/all: welcome, disclaimer, hello, intro

Background:

CP: Physiology / theoretical survival advantage of fever

SF: Methods of measuring: core (rectal), tympanic (not under 6 months), oral, axillary, ‘forehead strips’, ‘feels hot to parents’
KB: Definition of a fever, significant ‘cutoff’ values eg depending on age (neonate, 1-3months, 3-24 or 36 months)

Causes of fever:

KB: infections (viral, bacterial, rickettsia, malaria, others ) central theme = benign viral vs serious bacterial
SF: haematological/ oncological (lymphoma, leukaemia, Wilms, Neuroblastoma, others)
CP: auto-immune/ chronic inflammation (JIA, SLE, etc)

Periodic fevers:

See:  Periodic Fever Syndrome
and Causes of Cyclical Fever in Children

KB: Familial Mediterranean Fever
SF: Cyclical Neutropaenia
CP: Hyper-IgD syndrome
KB: TNF-Receptor Associated Periodic Syndrome (TRAPS)
SF: PFAPA syndrome

CP: drug-induced fevers
KB: factitious / induced illness
SF: don’t forget Kawasaki Disease
CP: idiopathic fever?

CP: FWS vs PUO (2 weeks)

Risk Stratifying FWS (SBI vs benign viral illness)

CP: past strategies – risk minimisers vs test minimisers, use of WCC
Changing landscape post-Pneumococcal Conjugate Vaccine (following the US experience)
“Needle in a haystack” problem and the Ian Everitt corollary…

SF: factors to consider in risk-stratifying:

• age
• height of fever (or not)?
• clinical findings / source (incl “soft”/ co-existent signs like slightly red throat, pink TMs from fever itself)
• urine sampling in those without clear clinical focus

KB: “well” vs “unwell” – hard to define, hard to teach!

Can we forget about “Occult Bacteraemia” now?

Treatment of febrile illness

SF: treat underlying infection:

• clear source/focus: treat appropriately based on diagnosis and severity
• no focus but unwell: screen (LP, CXR, Urine, BC) admit, IV AB’s pending negative cultures
• well but FWS: follow-up strategy 12-24 hrs GP/ED, (+/- IM antibiotics, Blood cultures)- evolving

CP: supportive care: hydration, nutrition, observation, comfort

Antipyretics for comfort?

KB: arguments FOR antipyretics (feel better, look better, drink better, easier to assess clinically, placebo effect?)
SF: arguments AGAINST antipyretics (not natural – defence mechanism, medication side-effects – Reye Syndrome historically, ?wheeze from NSAIDs,  may prolong illness)

CP: physical cooling: methods (undressing, fan, tepid sponging, cool bath, “hydrotherapy”) benefits & risks

Fever Myths

CP: “Fever is Dangerous” (boiled brain)
SF: “Antipyretics prevent Febrile Convulsions”
KB: “Favourable Response to Antipyretics excludes Serious Bacterial Illness”
CP: “Social smile excludes Serious Illness”

Bass JW, Wittler RR, Weisse ME. Social smile and occult bacteremia. Pediatr Infect Dis J. 1996;15(6):541.
PubMed PMID: 8783353.

Advice to Parents on Discharge

CP: fever in perspective, supportive care, follow-up if necessary
All: specific reasons to return

CP/All: Summary

Goodbye for now Folks!
Next time, we will discuss: NICE Guideline CG47 – Feverish Illness in Children.
As always, we welcome your intelligent and insightful comments!