Fever Clinical Practice Guideline Update-What’s new in managing fever in children under age 2?

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by Becky Burger, beckyburger@emory.edu

The Children’s Healthcare of Atlanta Clinical Practice Guideline (CPG) on fever in infants and young children was updated in November 2018. The updated guidelines are available on Careforce:  https://choa.careforceconnection.org/docs/DOC-19464

Here are the changes based on age:

For children 0-28 days:

  • The recommended empiric antibiotics are Ampicillin and Gentamicin IV (If there is no IV access, ok to give first dose of both IM)
  • If there is concern for meningitis, give Ampicillin and Ceftazidime (this is for CHOA Emergency Departments only, Urgent Cares do not have Ceftazidime in their pharmacies)
  • If there is suspicion for HSV, it is recommended that HSV PCR be sent from blood, CSF and any suspicious skin lesion. Also nee d to swab eyes, nose & rectum for HSV
  • If patient has diarrhea, send GI PCR panel (GI PCR panel replaces stool culture)

For children 29-60 days:

  • If CRP is obtained, there was consensus on CRP>2 mg/dl as the new cut off for abnormal
  • Urine WBC cut off for abnormal is >9 WBC hpf or Nitrite positive or LES ³2+
  • Preferred antibiotic is still Ceftriaxone, but if there is suspicion for bacterial meningitis add Vancomycin (this is for CHOA Emergency Departments only, Urgent Cares do not have Vancomycin in their pharmacies)

For children 2-6 months:

  • Urine WBC cut off for abnormal is >9 WBC hpf or nitrite positive or LES ³2+; if any one of these abnormal values are present, urinalysis will reflex to urine culture automatically
  • The recommended empiric antibiotic for UTI is Cephalexin 25mg/kg/dose TID x10 days (alternative regimen if concern for compliance with TID dosing is Cefprozil 15mg/kg/dose BID)
  • If there is suspicion for UTI and plan to treat for UTI, ensure that urine culture is ordered (if urinalysis has not already reflexed to culture). As always, urine culture should be from an acceptable specimen (bag specimens not adequate for urine culture)

For children 6-24 months:

  • Same updates as 2-6 months as listed above

If there are any further questions about the Fever CPG 2018 updates, feel free to contact Dr. Becky Burger (beckyburger@emory.edu) or Shabnam Jain (sjain@emory.edu).

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Non-Accidental Trauma Tips

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By Erin Wade
erin.wade @choa.org

 

 

 

 

 

 

Child physical abuse is a serious health problem that affects many children in Georgia and the United States. Along with the potentially devastating trauma of physical abuse, we now know that adverse childhood experiences can cause other issues that can affect a child’s health and well being throughout their lives. Appropriate identification of non-accidental trauma is of paramount importance for all pediatric healthcare providers. Thus, as April is National Child Abuse Prevention month this article gives you a few tips to utilize.

Research has shown that a large number of infants who present with severe injuries secondary to abuse had recently been evaluated by a healthcare provider and had demonstrated subtle injuries during those initial evaluations[i]. These subtle injuries, or sentinel injuries, when detected, give healthcare providers an opportunity to intervene and prevent more serious harm from befalling the child, and should warrant a trip to the Emergency Room for further evaluation.

The Ten-4 rule is a great guide when evaluating small children for possible non accidental trauma[ii].

  • Any bruising to the Torso, Ears, or Neck is highly concerning for abuse and requires further evaluation
  • Bruising anywhere on a child 4-months of age or younger is highly concerning for abuse and requires further evaluation. This is true of any child that is not yet cruising, regardless of their age.

In addition to the TEN-4 rule, other highly concerning physical exam findings include[iii]:

  • Fractures with a high specificity for abuse[iv]
    • Classic metaphyseal lesions (bucket handle fractures, corner fractures)
    • Rib fractures, especially posterior
    • Scapula fractures
    • Spinous process fractures
    • Sternal fractures
  • Multiple fractures at various stages of healing
  • Patterned injuries (burns, bruises, healed skin injuries, etc.)
  • Loop marks
  • Bite marks
  • Immersion burns
  • Significant injury without a plausible reported history to account for the injury

The identification of sentinel injuries in children of any age requires further evaluation for non-accidental trauma. A thorough history, physical exam, and photographic documentation, along with appropriate radiographic and laboratory analysis are of utmost importance. If a provider is unable to complete such a work up, the child should be evaluated in the Emergency Room as soon as possible in order to complete the necessary non-accidental trauma work-up.

For further non-emergent questions contact us at 404-785-3820; for emergent questions call the Children’s Transfer center at 404-785-7778

[i]Sheets, L. K., et al. “Sentinel Injuries in Infants Evaluated for Child Physical Abuse.” Pediatrics, vol. 131, no. 4, 2013, pp. 701–707., doi:10.1542/peds.2012-2780.

[ii]Pierce, M. C., et al. “Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma.” Pediatrics, vol. 125, no. 1, 2009, pp. 67–74., doi:10.1542/peds.2008-3632.

[iii]Christian, C. W. “The Evaluation of Suspected Child Physical Abuse.” Pediatrics, vol. 135, no. 5, 2015, doi:10.1542/peds.2015-0356.

[iv]Kleinman PK ed. Diagnostic imaging of child abuse 2nd ed Mosby 1998

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