S1E6: The Febrile Child and Covid-19 - PEM
Welcome back to another episode of TheCase.Report! Our very special first paediatric episode in fact!
As usual, we’re kicking things off with a case. Anna, Tadgh and Mohammed chat through a case of a sick bub - A very sick bub in fact!
But not to worry, as our Adult-in-the-Room Dr. Michael Barrett is on hand to check our work.
Anna also sat down with Dr. Dani Hall for an update on head injuries.
And Mohammed was joined by Dr. Yvonne MacAuley, who had some great tips on managing dental trauma.
We’ll leave links to the different papers and resources mentioned in the show notes at TheCase.Report.
Right, let’s get to it!
KOVID in Kids
Back talking about COVID-19… it never really left us though.
In terms of numbers among children, our numbers in Ireland are broken down into 5 year age bands, so we’ve got 0-4, 5-14 and 15-24, and excluding that last grouping probably gives us the best idea of our numbers here.
As of latest figures at time of recording, we’ve had 855 cases in kids aged under 15, representing just under 3% of all our cases. About 1.3% of those needed hospitalisation, and 2 required ICU admission.
That’s comparable to the European average rates
Is this representative of true rates? We don’t test kids as much as we test adults (because we test more unwell people), and just cause we don’t test for it, doesn’t mean it aint there.
But even in countries that tested more widely across their populations, kids and especially younger kids, still didn’t account for that many cases.
“Super-Spreaders”??
CDC:“Recent evidence suggests that children likely have the same or higher viral loads in their nasopharynx compared with adults and that children can spread the virus effectively in households and camp settings.”
However… China/WHO joint commission couldn’t find any episodes of child to adult transmission, and in family clusters kids were unlikely to be the index case
Pre-print article on transmission mentioned by our AITR Dr. Barrett:
https://www.medrxiv.org/content/10.1101/2020.05.20.20108126v2
The author gave a talk at a national meeting held in UCD just days ago. Definitely worth a watch!
https://www.youtube.com/watch?v=yC4219LOVwM
Presentation
Many develop no symptoms
Tend to have milder illness
Cough and fever in over half, with other symptoms of URTIs common
May have solely GI symptoms
“COVID-toes”?
So not wildly different to adults in terms of presentation… but also not really different from other childhood viral infections…
Here’s another pre-print article Dr. Barrett mentioned on the biphasic presentations in children:
https://pediatrics.aappublications.org/content/early/2020/09/08/peds.2020-014902
Investigations
Here’s where things differ a bit from adults...
May have normal/raised lymphocytes
CXR are often normal - some multifocal pneumonia are found though
CTs are often normal, with less severe abnormalities when they’re there.
May appreciate CT findings before symptoms develop
Outcomes
Generally speaking illness is not very severe and vast majority will have an uncomplicated recovery
Kids who have a high background risk of complications from viral illness anyway, i.e. those with significant co-morbidites (cardiac/neurodisability), still by and large only have mild symptoms, but are more likely to need hospitalisation and subsequently ICU admission.
Some develop a hyperinflammatory syndrome now referred to as PIMS TS …
PIMS TS is not quite the summer cocktail that we were hoping for in 2020.
PIMS-TS
PIMS TS is not quite the summer cocktail that we were hoping for in 2020.
PIMS TS stands for Paediatric inflammatory multisystem syndrome temporarily associated with SARS-CoV-2.
Since mid-April 2020, clusters of paediatric cases of severe systemic hyperinflammation and shock epidemiologically linked with COVID-19 have been reported. PIMS TS is what appears to be a new, unusual syndrome of fever and inflammation.
It is important to note that evidence is still scarce but rapidly emerging in the literature.
Is it common? Thankfully, no the literature still agrees that this remains uncommon. As we have already discussed, COVID 19 initially appeared to affect children less often and less severely.
The European Journal of Paediatrics August 2020 edition describes this well-
PIMS TS has a wide spectrum of presenting signs and symptoms and indeed disease severity. These range from persistent fever and inflammation all the way to myocardial injury, shock and the dreaded development of coronary artery aneurysms.
How do you spot it?
Patients have presented with persistent fever, gastrointestinal symptoms, polymorphic rash, conjunctivitis, and mucosal changes.
Sounds serious?
Well it can be.
The Lancet Journal of Child and Adolescent Health September 2020 edition outlines a multicentre observational study of ICU admissions with PIMS TS in the UK of children under 18 years of age.
They found 78 cases which fit the definition of PIMS TS as per Royal College of Paed and Child Health’s definition. Historical data for similar inflammatory conditions showed an average of 14 admissions per week for PIMS TS and 32 admissions per week during their study period.
Interestingly the rate of PICU admissions for PIMS TS was at least 11 fold higher than historical trends for similar inflammatory conditions. The clinical presentations and treatments varied but the coronary artery aneurysms appear to be an important complication.
Is there any good news here? Yes, though we are dealing with a new, as of yet, poorly understood paediatric syndrome, immediate survival is high. What remains to be seen are the long term outcomes of children with PIMS TS.
The Febrile Child
This is not an uncommon presentation. Assessment of the febrile child is something we need to be very familiar with.
Up to 40% of kids have a febrile illness each year.
14% of all ED attendances in England are for a kid with a fever. Not PED, ALL ED attendances. Numbers are likely similar here I’d suspect.
Can have serious consequences in infants and young children, so that’s where our focus will lie today.
So how do we sort the real sickies from the ones that’ll just need some TLC at home?
Let’s take it step by step.
So we’ll be talking about:
What it is
How we measure it
Common causes
Standard approach to assessment and management
Variations according to age
Occult infections
The unvaccinated child
First up, what is classified as “fever” and how are we measuring it? Is feeling hot to touch a good enough metric?
QUESTION: How are measuring temperature and do we ‘trust’ Mums hand here in detecting fever?
The available data would suggest mothers touch to be correct up to 90% of the time in detecting presence of fever if the child is under two, but this drops to just over 50% in those over two years of age. NICE specifically advises taking parental perception of fever as valid. In this high risk age range we are definitely taking mum’s perception of fever as fact.
How are we measuring? NICE :< 4weeks electronic thermometer in axilla
4 weeks to 5 years electronic thermometer in axilla, chemical dot thermometer in axilla, or infra-red tympanic thermometer.
What’s making these kids hot?
Their little hypothalamuses’ in response to pyrogens, but that’s not what we want to talk about.
Where are those pyrogens coming from?
Most of the time, the answer is a virus.Most of these will be mild and self limiting respiratory/GI viruses
It’s probably no surprise that kids get a lot of viral illnesses, in the first couple of years of life, they can expect between 8-12 per year, sometimes coming in quick succession, so some parents may feel their kid is “always sick”
It’s important to note that while most of these will be mild illnesses, kids can be very sick with viral illnesses too, so don’t get complacent.
So that’s the most common thing (or broad group of things) that’ll give a kid a fever, but not the only thing, not by a long shot.
Teething (COMMON MISCONCEPTION- NO Literature to support this, meta analyses agree that tooth eruption can raise body temperature but not to pyrexic level)
Then there are the things we’re particularly concerned about: the serious bacterial infection.
Serious. It’s in the name.
Why? Well bacteremia is never good, but the small % that subsequently develop meningitis makes it even worse.
Vaccinations have helped in some regards here, but we’ll get back to that…
Many parents worry that the height of the fever correlates with the seriousness of their child’s illness-
Height of fever does not necessarily mean the source is more likely to be bacterial. Assessment will continue regardless of how high or low the temperature recorded was. NICE specifically recommends against using temperature alone in those aged over 6 months to identify those with serious illness. While bacteremia is more frequent in children with a temperature > 39, having a temperature > 39 does not necessarily increase your risk of having a bacteremia.
The failure of fever to ‘come down’ after medication. Most parents are worried this will either cause a febrile seizure or means that their child is more unwell. Neither is true. Firstly we should remind ourselves and parents that we should not be giving anti pyretic for the sole purpose of reducing the temperature. If the child is running around having fun outside with a temperature of 38 – leave him off! However having a fever is likely to leave you miserable - so m0re often than not that same child with the fever will be cranky, and miserable – therefore we are giving the anti-pyretic to reduce the distress around the fever.
Anti pyretics will not prevent a febrile seizure. Some recent evidence from japan has slightly challenged this in that treatment of a fever in those who had a febrile seizure was shown to slightly reduce the risk of recurrence for the same febrile illness. However we still don’t have evidence of prevention of febrile seizures during further infective periods. The largest RCT of 230 children showed no difference between placebo/paracetamol or ibuprofen in the prevention of febrile seizures. Message should remain unchanged – treat the fever with anti pyretics if the child is distressed, and don’t worry if the fever doesn’t come down.
Do rigors increase the risk of SBI? Probably not…some weak evidence to suggest their presence increases the likelihood of SBI (note they also occur with influenza so bear this in mind during flu season!)
The flip side remember the absence of fever or the presence of a low grade fever does not preclude the possibility of a serious infection
Standard Approach
Critically unwell? - Resuscitate as per APLS.Brief history to help understand aetiology done in tandem.
Otherwise, we start with history.
Important points to note here:
Symptoms (duh)
Duration of this illnessSick contacts
Recent travel
Birth and medical history - note high risk groups e.g. prematurity, immunosuppression, chronic lung disease, congenital heart disease.
Vaccination history
Examine your patient! Take note of:
Activity/lethargy
Respiratory function
Circulation incl. Colour and hydration
Neurological
Your “E”s - ENT, skin, joints, gait
Your impression:
This will guide how you proceed with the febrile child. This isn’t all down to the numbers, a patient can look good on their triage vitals sheet, but when you see and assess them you know they’re sick.
The important thing to know here is that you should be asking for help if you have any doubts. You’ll get better at discriminating between sick/not sick with the more experience you have, but until then, play it safe and ask for help.
So,
Does this kid look sick? - If yes, we’re investigating and treating. That’s it. No discussion.
Does this kid seem well? - Then in most* cases, we’ll be careful to exclude anything we might be worried about, but we can delay starting treatment as they may not need it.
*The one caveat here is the very littlest of them all, the <28 day olds. This is where the important variations come in.
Variations according to age
≤ 28 days: the WORKS
Assessment and early senior review/discussion
Investigations incl. Bloods, cultures, urine, LP, NPA
Consider CXR
Empiric antibiotics
1-3 months: where’s the line?
2 months apparently… for decades now the global paeds community has been grappling with where to draw the line for the “full” workup as above. Rochester, Philadelphia, modified Philadelphia criteria, Step-by-Step - these will all miss some SBI… so what’s an acceptable miss rate?
1% of those classified as “low risk” by Rochester will have SBI, and 0.7% of those classified as “low risk” by Step-by-Step.
So there’s understandably some discord
AAP:“We recommend that febrile infants 29 to 60 days of age undergo a full sepsis evaluation”
NICE:“all infants aged 1–3 months who appear unwell… infants aged 1–3 months with a white blood cell count (WBC) less than 5 × 10^9/litre or greater than 15 × 10^9/litre.”
RCH Melbourne:
They have a snazzy algorithm, but essentially they save “the works” incl. LP for the unwell child with no obvious clinical focus.
What’s the local policy where you’ve worked?
PECARN rule (Kupperman et al) for predicting low risk infants (looked prospectively at multiple sites at infants less than 60days. Used Urinalyis, Absolute neutrophil count and Procalcitonin. Between 2007 and 2018. Excluded infants with a focus, or critically ill or prematurity/ significant PMHx.
Velasco attempted to externally validate the prediction rule but showed a miss rate for SBI/IBI of 10% dropping the sens from 97.7% to 89.8% and spec from 60 to 55.5%. However Kupperman responded to this by pointing out the latest study was a retrospective analysis of a registry at one Spanish hospital whereas the pecarn study was a prospective study in 20 centres. The rate of SBI was much higher in Velasco study @ 20% - ? different population ? different enrolment criteria ? enrolment bias
> 3 months: Now leaving controversy country … *phew*
Stepwise approach here
Focus your investigations to the likely clinical focus
Don’t forget the urinalysis though!!
QUESTION: What investigations are needed for this febrile neonate?
< 1 month – book thrown at them. This is because clinical exam and available biomarkers are not currently sensitive enough to rule out SBI or meningitis. Even though the prevalence of SBI and meningitis is low – acceptable miss rate needs to be zero. Under three months the incidence of bacterial disease is 10% and bacteremia 2-3%. In the neonate bacterial infections tend by be more insidious. Main danger is UTI and meningitis. In those under 30 days established practice for the most part is:
Full septic screen; FBC, Blood culture, Urine culture, LP. CXR if respiratory signs are present, stool culture if diarrohea present
Hospitalisation and empirical treatment
QUESTION IF this child was 2 months would this alter practice?
In the case presented with abnormal vitals and exam….probably not. But…uncertainty exists in treating those 1-3 months who present with fever. Rochester criteria, PECARN rule for low risk febrile infant
What does NICE say?
Younger than three months:
FBC, blood culture, CRP, Urine culture CXR if resp signs present, stool culture if diarrohea present.
1-3 months if unwell appearing, WCC < 5 or > 15 (X 10/L)
Advocates parenteral Abx in 1-3 months if
Unwell appearing, WCC < 5 or > 15 (X 10/L)
Antibiotic – 3rd generation cephalosporin (cefotaxime/ceftriaxone) plus anti-listeria agent (amoxicillin)
Occult infections
A good structured approach should mitigate the risk of missing something important, but that said, we’re only human and some things will slip by us unless we’re specifically looking for them
UTIs and RTIs are a given, we should have them at the very front of our minds, but what else is there?
Retropharyngeal abscess
Fever, cervical adenopathy, irritable, muffled voice
Lateral neck XR
Abx + ENT
Osteomyelitis
Haematogenous origin
Limping child
Septic arthritis
Haematogenous origin
Fever, systemically unwell
Kocher’s criteria
NWB
Temp >38.5
ESR >40
WCC >12
The unvaccinated child
All the above assumes we’re dealing with a vaccinated kid. The unvaccinated child poses 2 separate challenges for us:
Excluding/diagnosing and managing a vaccine preventable illness
Incl. increased risk of occult bacteraemia, approx. 10-fold
Having the chat with mum and dad
This WHO doc gives some good pointers in terms of your strategy when approaching this. https://www.euro.who.int/__data/assets/pdf_file/0006/160755/Talking-with-parents_EN_WHO_WEB.pdf?ua=1
Critical Care Videos
Brilliant set of videos recommended by Dr. Barrett. I’ll be poring over these over the next few days.
https://www.paediatricemergencies.com/conference/waiting-for-the-retrieval-team-2019/
Head Injuries
The 3 big decision rules discussed were:
PECARN (Lead author’s name sound familiar to anyone?)
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61558-0/fulltext
CATCH
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2831681/
CHALICE
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2082967/
With a new contender on the scene:
PREDICT - “Coming Soon”
https://www.predict.org.au/head-injury-guidelines/
We await with bated breath…
Dental Trauma
https://dentaltraumaguide.org/
https://www.ucc.ie/en/media/academic/dentalschool/documents/savethattooth_new_30072014.pdf