New AAP Guidelines for Management of Pediatric Fever

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Ian L. -

How many well appearing infants 8-60 days stay well appearing ? How do you measure the 38 C -Tympanic Axillary Rectal -Primary Care and Even Urgent Care mostly do not have the resources for blood tests and reliable urine collection- Bladder Tap -and Quick Catheter . Why the 22-28 days -unnecessarily complex .

ilene c. -

Great questions- I'll answer the best I can!
1) How many well appearing infants 8-60 days stay well appearing ? This paper does not say. However, in the PROS study (also Pantell lead author), there were 63 patients identified with bacteremia or meningitis. 2 were missed initially- one of the 63 appeared well, was sent home, and became ill appearing (was diagnosed with meningitis at the point of becoming ill-appearing). This is out of a total of 3066 febrile patients 0-3 months that were studied. This study included well- and ill-appearing infants, and the VAST majority of bacteremia/ meningitis was diagnosed in ill-appearing infants. They didn't report data on how many patients without IBI looked well initially then appeared ill. This is probably the best data we have to answer the question, as it was a research study done through pediatricians office where the kids had great follow-up.
2) How do you measure the 38 C -Tympanic Axillary Rectal? rectal temp in the last 24 hours
3) Primary Care and Even Urgent Care mostly do not have the resources for blood tests and reliable urine collection- Bladder Tap -and Quick Catheter. True- may still need to send many of these patients to the ED. Though we just ran low on 5F urine catheters, so I will be bladder taping all day and catheterizing only the positive provoked UAs!
4) Why the 22-28 days -unnecessarily complex? Agree adds complexity, but the BSI rate in 22-28 days is lower than <22 days thus meriting the change

SD -

Hi, great summary.
Are there any recc for the unvaccinated children? It doesn't seem to be in this paper.

ilene c. -

Thanks! I know- we need some recs on that topics badly! This article only covered through 60 days, so no mention of unvaccinated. No great guidelines or literature on the 2 or 3 to 24 mo group with insuffiencent or no vaccines. There is an article in September 2020 Pediatric Emergency Care (Fever Without Source in Unvaccinated Children Aged 3 to 24 Months: What Workup Is Recommended? Finkel, Leah MD*; Ospina-Jimenez, Camila MD; Byers, Michael MD; Eilbert, Wesley MD) which offers and algorithm for unvaccinated children 3-24 months with Temp >39 and well-appearing (less conservative <39). They suggest UA and urine culture if fever >2d, hx UTI, females <12m, uncircumcised males <12m, circumcised males <6m, viral detection panel, CBC and procalcitonin. If WBC >15K, ANC >10K, ABC (bands) >1500K, procal >0.5, get a bld cx and give ceftriaxone, dc with 24h recheck. If WBC >20K or sx, get CXR. I feel like we have so much herd immunity, I'm not this conservative, but I likely would be if we had a low vaccination rate at my shop. Hope that helps!

SD -

thanks! I'll check that article out- it seems like what I have been looking for.

tom f. -

thank you Jessie and Ilene. it does seem a little complicated, but babies aren't simple. and a reasonable decision making algorithm /decision tree even if it involves breaking it down to days 22-28, and considerations of inflammatory markers, and ANC's , to help decide who to LP, and more, is good. it just adds an additional set of tools in our armamentarium. we can carry them, or not. I think this is giving us a statistically studied "out" to not tap (LP) or Cath, and admit, some babies that we might have before.

excellent , thanks to you both

tom fiero, merced, ca

ilene c. -

More options, yes! I guess sometimes more options make things easier, sometimes more to remember!

Mike M. -

You mention that an infection in mother is an exclusion criteria for this guideline. Would that include GBS prophylaxis? Thanks for the summary.

ilene c. -

I know! The inclusion/ exclusion criteria are half a page long (very small font, single spaced, multiple columns!) and I was trying to walk that line between being complete and boring everyone to tears. I knew I would gloss by something important! You bring up an important question and thank you. The way it reads specifically is "Infants < 2 weeks of age whose perinatal courses were complicated by maternal fever, infection, and/or antimicrobial use." It sounds to me like they are more going for a mom who has a true clinical infection, but technically, they do not address the group you discussed. Inherently, I believe the group whose moms are identified as asymptomatic GBS positive and get good prenatal care and appropraite prophylaxis should not be at much elevated risk. However, given the wording and lack of addressing the issue elsewhere in the paper, the child of a a woman getting intrapartum antimicrobials would fall into this excluded category. That said, they only exclude them for the first 2 weeks. The first week of life isn't even included in this guideline and the second week of life is the group that is still getting the robust work-up anyway! So it is a bit of a strange exclusion criteria. I feel like they kind of said- we're excluding this group from getting standard of care so you can give them standard of care??????

Brandon E. -

Hi Ilene, thank you for reviewing these!
Confused about the combination of IMs the AAP is recommending.

Best scenario = use all 4 IMs together if available at your shop (ProCal, CRP, ANC, rectal temp) but if you don't have ProCal then CRP + ANC + rectal temp is an okay alternative? Or are they suggesting use only 3 at a time (ProCal, CRP ANC if available; if ProCal not available can substitute w/ rectal temp)? I've seen a few FOAMed sources interpret this in varying ways...looking for clarification - thanks!

ilene c. -

I am so sorry for the delay. Great point, and I thought I had responded, but it appears I only responded in my own head! The official report is a little wishy-washy on the IM, stating that no IM in isolation is reliable and they expect some shift on the recommendations as different combinations are studied. So the confusion, in part, is that there is alot of noise, but no clear right answer.

There is a sugestion upfront to consider temp >38.5 citing an OR of 1.8 for SBI for each degree C over 38C

Regarding the procal, you are 100% correct. I am transcribing their language here: "The committee recommends procalcitonin in all age groups. Procalcitonin testing testing is not yet routinely available in many institutions in the United States. If procalcitonin is unavailable or results are not reported in a timely fashion, the committee recommends using a fever >38.5 in combination with the other IMs for purposes of risk stratification."

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EM:RAP August 14th Breaking News: AAP Guidelines for Management of Peds Fever Full episode audio for MD edition 33:34 min - 39 MB - M4A