Febrile kids 30 to 60 days. What's your practice?

[winkleweizen]

are you lping all these kids or just the ill appearing ones?

Are you admitting all of them?




Just curious how people in the community are approaching these ones.

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[shoal007]

If look ill lp, look well talk to pediatrician and discuss close :-follow-up. If they want rocephin, then I give it. After 8 weeks normal term delivery and look well I may not do the above.

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[shookwell]

My approach is similar. Sick kid without a source gets full workup and antibiotics. If not vaccinated then gets full workup and antibiotics even if not that sick.

If there's a source then specific antibiotics if indicated, admission if sick/kinda sick or no good follow up.

If it's a well appearing kid who has good follow up and the family seems reliable, I will discharge with close PMD appointment. If it's a weekend or the PMD isn't available, sometimes I'll have them come back to the ED the next day.

Sometimes if I'm on the fence whether they can go home I'll bring them in for observation without doing any work up except blood cultures.

I do ceftriaxone and discharge for older kids with sickle cell who are not very sick, I don't do it very often for 1-2 month olds.

 

[Zebra Hunter]

A febrile neonate at less than 60 days sounds like an easy admit regardless of their appearance, at least where I'm at for residency. Do y'all get push back from peds out in the community for well appearing kids? Maybe I'm just not comfortable with neonates, but I just wouldn't sleep well sending a febrile neonate home.

 

[deleted109597]

Do it all. LP BCx UCx. ABx (some cephalosporin is good enough, 3rd or 4th)
Admit high risk (Rochester Philly Boston).
24hr followup if not admitting.

 

[emergentmd]

Ped EM where I work

Full work up except LP only if pt looks great
If any concerns or elevated WBC, LP and admit.

 

[em1234]

My approach is similar. Sick kid without a source gets full workup and antibiotics. If not vaccinated then gets full workup and antibiotics even if not that sick.

If there's a source then specific antibiotics if indicated, admission if sick/kinda sick or no good follow up.

If it's a well appearing kid who has good follow up and the family seems reliable, I will discharge with close PMD appointment. If it's a weekend or the PMD isn't available, sometimes I'll have them come back to the ED the next day.

Sometimes if I'm on the fence whether they can go home I'll bring them in for observation without doing any work up except blood cultures.

I do ceftriaxone and discharge for older kids with sickle cell who are not very sick, I don't do it very often for 1-2 month olds.

Do you really use an 8 week or even 10 week old's vaccination status as useful information?
They wouldn't have had enough time to make any useful passive immunity from the vaccinations if they'd even gotten them. If an 8 week old was "unvaccinated" all it would have missed, other than the bevy of 2mo shots, was the hep B at birth...can't say any of that would change my management.
Not trying to be a Dbag...just wondering

 

[shookwell]

Do you really use an 8 week or even 10 week old's vaccination status as useful information?
They wouldn't have had enough time to make any useful passive immunity from the vaccinations if they'd even gotten them. If an 8 week old was "unvaccinated" all it would have missed, other than the bevy of 2mo shots, was the hep B at birth...can't say any of that would change my management.
Not trying to be a Dbag...just wondering

No, you're right, that's more for slightly older kids where I'll work them up/give antibiotics if unvaccinated where I would otherwise just discharge.

 

[winkleweizen]

A febrile neonate at less than 60 days sounds like an easy admit regardless of their appearance, at least where I'm at for residency. Do y'all get push back from peds out in the community for well appearing kids? Maybe I'm just not comfortable with neonates, but I just wouldn't sleep well sending a febrile neonate home.

At my residency it was an easy admit. I recently had this in a small community shops where I'm moonlighting and got a lot of pushback from the transfer doc.

 

[gman33]

Here's a great resource from CHOP in Philly.
Gives you an idea of how the Peds hospital would approach the case.

http://www.chop.edu/pathways/emergency#.Vo51KTZlnVo

Up to 6 weeks I do everything, including LP and OBS.
6-8 weeks depends on possible source and appearance.

This is how I look at it in my mind.
These are very high risk patients. Both for disease and medico-legally.
I don't see a ton of kids at that age, so I'm not as comfortable saying a certain one isn't sick.

 

[BigRedBeta]

PICU Attending here...

Not an easy situation to be sure. I'll have to find it but there is a good study (with really large sample size for a pediatric study) with 29-60 day olds with confirmed bacterial UTI from a couple years ago. #1 predictor of severe disease (I believe defined as bacteremia/meningitis) was clinical judgement of the provider if they looked sick/not sick. Complications in well appearing kids were extremely rare (less than 1% if I remember correctly). Again, these were babies with confirmed bacterial infection.

Based on that, I typically recommend that anyone under 4 weeks gets everything: LP, Amp/cefotax, admit, etc.

4-6 weeks, if ill appearing gets everything. If clinically looks fantastic, will do blood/urine/amp/cefotax and admit, but no LP. However if they so much as look at me crossways, they get a needle in the back. Obviously, ideally you want LP before abx, but we can deal with it if not. There is still pleocytosis to note and while we threaten 21 days of abx when parents refuse the LP, it's more often than not about clinical course for abx duration.
I would be more cautious than CHOP, mostly because it's impossible to guarantee the degree of follow up that they can.

After 6 weeks, if well appearing AND have reliable parents, blood/urine, no abx, close follow up. If parents are unreliable or there's any question, admit, no abx and watchful waiting.

It's worth noting that ceftriaxone does cause calcium issues in newborns, so it's best to avoid that until after 2 months, hence the cefotaxime

 

[TooMuchResearch]

Great to get picu thoughts on this. Thanks.

 

[GeneralVeers]

There is very different practice depending on who I'm admitting to. The less experience community pediatricians who are admitting for the day tend to want everything including LP, blood cultures. I find that the more experienced pediatric hospitalists and PICU attendings rely less on labs and LP. I've often consulted the PICU attending to see if they wanted an LP on a kid who looks great, and they just tell me to hold off, admit the kid and they will observe.

I really think a less-is-more strategy is going to become more prevalent on these kids who look good and have otherwise normal vital signs. We've already seen that in general with routine pediatric EM. The peds-EM trained folks I've worked with rarely order labs on kids.

 

[gro2001]

I think this is a very difficult patient population to make a reasonable clinical judgement on who looks sick. How many sick (septic, or dying from any other cause) <8 week babies have you seen in your career? Enough to say you have a mental heuristic of what a sick 6 week old baby looks like?

Your clinical gestalt is like any other test: to know how good it is you need a bunch of true positives (thought a patient was sick and they were), true negatives (thought they were fine and they were), false positives (thought they were sick but they weren't) and false negatives (thought they were fine and then they crumped). Most EPs don't have enough false negatives and might not have enough true positives in their experience in order to really know how good their gestalt is in regards to really really young kids.

In the absence of that, febrile 4-8 week olds that look well I do a full sepsis workup and admit if any high risk criteria. Shot of ceftriaxone if any doubt. Must follow up in 24 hours. If they look at all not well, full sepsis workup and admit.

 

[The White Coat Investor]

I see little downside to doing the whole shebang until they get their 2 month immunizations. It's not like LPs are particularly dangerous or that you're not being paid to do them or something. Sure, it scares parents a little, but not as much as meningitis does. And it doesn't seem to make the kids cry any more than the CXR, cath, or IV.

 

[BigRedBeta]

I think this is a very difficult patient population to make a reasonable clinical judgement on who looks sick. How many sick (septic, or dying from any other cause) <8 week babies have you seen in your career? Enough to say you have a mental heuristic of what a sick 6 week old baby looks like?

Your clinical gestalt is like any other test: to know how good it is you need a bunch of true positives (thought a patient was sick and they were), true negatives (thought they were fine and they were), false positives (thought they were sick but they weren't) and false negatives (thought they were fine and then they crumped). Most EPs don't have enough false negatives and might not have enough true positives in their experience in order to really know how good their gestalt is in regards to really really young kids.

In the absence of that, febrile 4-8 week olds that look well I do a full sepsis workup and admit if any high risk criteria. Shot of ceftriaxone if any doubt. Must follow up in 24 hours. If they look at all not well, full sepsis workup and admit.

That's absolutely a fair assessment and knowing one's limitations is the hallmark of a great clinician. If there's any doubt, do it all and be safe. Frame the admission decision as one of safety and most parents will bend over backwards to meet you.

And when you're on the phone arranging transfer, frame it as a precautionary move to PICU fellow or Chief Resident or whoever. Really the only time I got frustrated on transfer calls is when the ED Provider was breathless telling me how sick a kid was with VS that didn't match (and subsequent assessment by my transport nurses), as if they were trying to sell me on the transfer.

 

[GeneralVeers]

An LP isn't saving any lives. If they are < 8 weeks then they get broad spectrum antibiotics and admission, assuming a source isn't apparent.

 

[winkleweizen]

Thanks for the responses