Collect pearls of wisdom from this animated discussion on the care and evaluation of febrile infants, who may appear well even with a dangerous issue brewing. Our experienced pediatric emergency specialists provide advice for febrile babies based on age, presentation, and examine the grey areas of clinical practice. This webinar also shares BCH clinical pathways that can help providers determine when sepsis is a concern, which tests to order, and when antibiotics are appropriate. Bonus: pro-tips on performing lumbar puncture and placing urinary catheters in infants.
Hello everyone. Welcome to our first episode of our limited series on Children's emergencies called Send or Men. The title comes from a conference our department hosted last fall and refers to the question of how you decide to send a child to the emergency room or try to amend the medical emergency yourself. I'm dr Sunny Tat and a pediatric emergency doctor. I work at the Children's Emergency department at UCSF in SAn Francisco and at SAn Francisco General Hospital. My co host is Inter Narula. Hi I'm Inder, I'm a pediatric emergency outreach nurse educator. I also work at both Benioff Children's Hospital in SAn Francisco and also at SAN Francisco General Hospital. This webinar series is meant to be a practical and interdisciplinary approach to emergency medical care for Children. Instead of lectures, we're going to invite regional national experts in the field to have a conversation focusing on the challenges related to the gray areas of medicine. So linda, I was flipping through channels recently and noticed that every station now seems to have a show based on emergency rooms and first responders. I noticed though, none accurately portray the excitement of our lives in the pediatric emergency room though. Maybe they can base an episode on what we talked about today. Well, I certainly hope not. If they do, we could give them a flavor of these types of cases that we see. I think while there's a pretty wide range of sick and injured Children, we see there are some common themes, right? Yeah, I think so. Anyone who takes care of Children know that fever is one of the most common chief complaints that we tend to see in the er with fevers, kids just aren't themselves, which is understandably worrisome for both the families and the caregivers. We've come a long way in our approach for caring for kids with fever. Now the approach tends to be that most well appearing kids with a reassuring history. Don't necessarily need extensive testing or antibiotics, just hydration and return precautions. I definitely agree. But I do think that there is one group of kids who don't necessarily fall under that less is more framework specifically the federal child less than three months old really need a lot more attention and evaluation. You're right under these group of federal kids really stand out because of the approach to the evaluation can be pretty complicated and not always easily addressed over the phone or even in many outpatient clinics. Even as a nurse, my ears generally perk up when I see a young infant arriving or being triage in the E. D. Because I know I have to be extra vigilant for infections and injury. By protocol I typically triaged these federal neonatal as an S. I. Level too because even if they look completely well, they are so resource heavy and they have the ability to spiral downhill relatively quickly. Well, the approach to fever and a young infant has evolved over time with more evidence and new recommendations. So today we've invited a colleague and friend of ours who developed the infant fever management guidelines for the UCSF pediatric e. R. In SAn Francisco to talk to us about what we do and what we do not know about fever. Dr Dina Wallen is a pediatric emergency medicine trained doctor who works at UCSF Mission Bay and SAN Francisco General. She did an emergency medicine residency at UCSF and Pediatric Emergency Medicine Fellowship at Dell Children's in Austin. She is also the director of didactic for emergency medicine at UCSF and has been an invited speaker on pediatric emergency medicine both regionally and nationally. Hi sonny and and er it's a pleasure to be here. China, Could you tell us a little bit about the young infant fever guidelines and how they were created and how they shifted as time went on? Probably so evaluating infants under three months actually used to be fairly algorithmic because all of these infants would have their urine, blood and CSF tested and would receive empirical ivy or I am antibiotics. That's because these young Children were at a fairly high risk of serious bacterial infections like bacterial mia, urinary tract infections and meningitis. The vast majority of these serious bacterial infections back in the day were caused by strep Pneumo and H flu and these babies were dying or surviving with permanent disability like blindness or deafness. But then the Prevnar and Hib vaccines came along and rates of serious bacterial infection and young Children with fever have gradually declined prior to these vaccines. The rate of Occult Factory MIA and febrile infants was 11.6% mostly strep pneumo and H flu, But now that rate in all comers is just 0.25%. Furthermore, we're finally starting to find some serum screening tests that are approaching sufficient sensitivity to detect these bacterial infections. Given all of this. We've started to rethink a little bit if we need to invasively test all these Children. That is understandably led to more variability and management of young Children with fever. Well, fantastic. We invited you to date, not only because you're one of our favorite people to work with, but also because we know you review the literature on fever and young Children to develop management pathways for RgDS. You know, we both thought that you could talk about your work and talk to us today about how the approach has changed or remains the same. Sure, sonny, yes, you're totally right along with team members from nursing. We wrote these pathways to try and assist providers and nurses with their evaluation and management. When these febrile infants arrive, they're so small and so vulnerable that people get scared and forget what to do. A pathway can help streamline their approach. So basically the main purpose of these pathways and zooming out of our evaluation and management of federal young infants in general is to detect and treat serious bacterial infections before they cause permanent damage. In infants 0 to 28 days old. We search for urinary tract infections, battery MIA and meningitis and in infants 29 to 90 days old we focus mostly on detecting U. T. S. Now, while of course these infants might have viral infections and we'll test for those viral infections often threaten less morbidity and mortality and also don't have time sensitive specific treatments the way that bacterial infections do. So the focus of our pathways and of our discussion today is serious bacterial infections. So just to clarify it seems like the work up for federal neonatal up to 28 days. This hasn't really changed yet, right. Yes. Those tiny little neonatal are far too vulnerable to take the risk of not performing the full evaluation. This is for multiple reasons. First of all their immune systems are immature and can't yet mount a full response secondly, newborns don't do very much, they just eat sleep, pee and poop and it's difficult to assess if they're well based on history and physical alone, the data supports how high risk they are compared to older infants. Rates of serious bacterial infections in febrile infants decline from 22% in the first week of life, two, after one month following up on that, You know, there are few who are saying that there are markers like CRP and pro calcitonin that can stratify patients risk for serious bacterial infection. I noticed that these pathways that you've created don't use those markers. Are you saying that that approach isn't quite ready for prime time? Well, first of all, let me give you the caveat that my center is currently don't offer pro calcitonin with a meaningful turnaround time. So it's just not available to me and that's why it's not in our specific pathways. But you do make a great point. Although many authors have looked at serum screening tests including the good old CBc with differential the I two T ratio, which is looking at immature to mature neutrophils, C reactive protein, CRP, and pro calcitonin. But to blow the punchline, none of these tests yet are adequately sensitive enough in isolation to screen infants out. For example, the white blood cell count is 58% sensitive, barely better than flipping a coin. The crp is a bit better at 74% and pro calcitonin is the most sensitive at 83% but that's still an unacceptable mystery. So also all of these tests also take a moment to become abnormal. So newly febrile babies are at a much higher risk. The newest test that's out on the horizon now is RNA bio signatures to try and detect bacterial microorganisms really in vivo and that's super cutting edge. Researchers have also tried to look at combining labs to increase sensitivity. So one of the most popular ones these days is the step by step method. Well, I'm on board with that Dina. I mean I generally like being on the cutting edge of things, but for kids with under 60 days with fever, I'm pretty fine with being a few steps back from that edge until evidence is more solid. And besides that just gives us an excuse to invite you back for the sequel later this year. Looking at the pathway, there is a section that says a positive result on the diagnostic work up. Does not eliminate the need for the above work up. Can you clarify that? So we know that having an active viral infection doesn't mean that the child can't have a concomitant serious bacterial infection. Even in kids with symptomatic PcR confirmed RSV infection, there's a 5 to 7% rate of concomitant. Ut and what's worse? These PcR studies can stay positive for weeks after a viral infection. So, a positive test you have in front of, you might not even explain the current fever because of this. And the tiniest babies. We can't trust a positive viral pcR enough to not do the full work up. You're saying just because the neonatal as bronchiolitis or otitis media they don't get to bypass this evaluation. Is that right? Exactly. Sunny. I myself did that precise thing when I was an intern working up an incredibly well appearing 14 day old in the E. D. He was smiling and drooling and incredibly snotty as were the three siblings in the room. And it was clear that he had a viral upper respiratory infection. So my attending and I barely did any work up at all. And we sent the little bugger home and then we woke up to a slew of concerned emails from our pediatrics team. The baby was called back, got a full sepsis work up was admitted and ultimately did fine. Nothing came back positive but I never forgot that case. It really helped me to realize that the smallest of babies will do their very best to trick you at U. T. I. In one of these little ones can jump into the bloodstream and into the meninges in a matter of hours leading to sepsis, permanent disability and even death. I think it's also really tough for less experienced Pete's nurses to know what a well appearing unit looks like ideally if you are the initial nurse that identifies this child you should advocate for that full work up. And even if you're not fully comfortable doing all the tasks, find someone who is and have them coach you through it so that you can learn for the next time. Oh man and I do not envy the nurses having to get an I. V. And a cat in those young babies. I have to say the pediatric nurses I work with do make it look really easy. Go Dina. I guess NLP is in a walk in the park either right since fever guidelines have loosened and we do a lot fewer lps than we did just a few years ago. There are trainees and recent graduates have done only a small handful of lps in their time. Or even none at all. Do you have any pearls for the new or less experienced providers who feel a little rusty performing at neonatal LP. Honestly sunny neonatal lps are so much easier than performing lPS and fluffy er adult patients who often have arthritis in their back and might be actively psychotic. So I would first say to the listeners you've got this. Although the idea of shoving a needle into a baby's back is really intimidating. The actual process is not too bad. Not unlike every procedure you do set up is absolutely key. Optimise your chances for success by applying lidocaine cream such as L. A. Max or Emma depending on what you have at your shop to the infants back right away. This is actually part of our nursing guideline and can start prior to physician evaluation. Yes I try to remind providers about the L. M. X. Or ella early before it's too late to make that difference. Dina. What other tips or tricks do you have? Well make sure your kit is organized the way you like it with tubes open and ready to go grab some oral sucrose such as sweeties and a pacifier and designate a person in the room to periodically dip the pacifier in sucrose and give it to the baby. Yeah, sweeties. And the young infant is a low risk nonsedating pain control option. That's really way under used. I think Sucrose is key. The person giving it could be a parent, a nurse attack or any other member of the care team. Next is your positioning and holding as a person who trained primarily on adults. First. I was always doubtful about the seated LP because few adults can actually curl up well enough while they're seated. But sitting up is the way to go with neonatal lPS. Your holder will curl the infant up into a really tight C shape and the infant's neck will automatically flex to assist china. Tell us more about this mysterious holder you talk about. Yes, the holder is the most important person in the room. One person must be dedicated to holding the infant in position. You want the most experienced holder you can find. I also recommend raising the lead up to a level that's the most comfortable for the holder and they're back. Then you as the procedural list. Can adjust your stool hide or even stand to perform. The LP. Also make sure you have chuck's under the baby. The stress around the LP often makes for a massive code brown in the E. D. I. Often dust off the infant warmer that we keep around for precipitous deliveries and do the LP on there. I think the warmer lets you do an LP in a standing position and I think it's also more appropriately sized for an infant than the squishy patient bed lets you turn on the warmer since babies get really cold if you leave them unwrapped for awhile. Finally, unrelated to this patient, it's a great excuse to practice using a rarely used but important piece of equipment in the That's an awesome idea, sonny. I honestly have never said that and I'm going to try that on my next LP. Remember you've got this confidence is key. Since we're talking about LPS, I noticed that the pathway mentioned sending off HSV PCR from the cerebral spinal fluid. When there is a concern for herpes meningitis, when should we be concerned? It's great question, injured. You're totally right. Typically infants younger than six weeks and especially those younger than two weeks are at greatest risk, since this is likely vertically transmitted during delivery. Are there specific areas on the neonatal that we should look for these HSG lesions? Well, if the infant had a scalp probe during labor, then the scalp is a common sight. Otherwise, anywhere on the skin or mucosa. This is one reason why neonatal always need to get fully unbundled and get a full skin exam. That's a great point about the scalp. Dina. Don't forget to remove that cozy knit beanie and look at that scalp switching gears to antimicrobials. At what point would you add acyclovir or bank mason? Well, you're going to add in a cycle of here if there's any concern for HST. So what we think about is vaginal delivery by a mom with the history of herpes. Whether or not she had an active outbreak at the time of delivery, although primary infection during pregnancy or delivery is the highest risk scenario, babies with seizures, skin or mucosal lesions, focal neurologic findings on exam, elevated LFTs or thrombosis, Wikipedia on their labs and or CSF pleo psychosis without a bacterial profiles or more viral appearing. Profile providers can consider vinca mason. If the infant has any evidence of a skin and soft tissue infection, like cellulitis on Phil itis or mastitis Or if the baby is really ill appearing. We've been talking a lot about the under one month patients, but one of my patients the other day was a six week old with a fever to 38 to she was well appearing and otherwise normal exam. I feel like this is pretty typical for ERs and clinics and I think that these are the patients that live in the gray area of evaluation of work up. Yes. Sunny, you are so right, that infant is the mayor of the gray zone. The ill appearing infant, the 10 to 28 days and the one older than three months. These are all no brainers, but the well appearing six week old is tough. So as we discussed earlier rates of serious bacterial infection, especially Occult factory Mia and meningitis due to strep pneumo and H flu are essentially zero post Prevnar and hib. The real culprit is E. Coli. So almost all reported cases of serious bacterial infection in infants older than 28 days are from E. Coli and start in the urine. This is why in the february 29 2 90 day old we focus on the urine. So looking at the pathway, we see that our first question, our first branch point is, is the infant younger than 60 days old. And if so, urine is recommended, The 29-60 day olds are still a bit more vulnerable and most haven't received their first round of vaccines yet. They're also not quite as active as 2-3 month olds. So are more difficult to assess clinically. And this is why we recommend testing with urine as a screen. If the urine is negative and the baby is well appearing, they can go home without further work up. Especially also without antibiotics. No antibiotics without a source and without cultures of blood, urine and CSF. Although a dose of antibiotics might make us feel better as the provider in the care team. This really muddies the picture. Should the infant decompensate down the line. Return federal, get full cultures and they're all negative because then we don't know. Is this a partially treated bacterial infection or is this just bad viral sepsis? We literally will never know. And we need to act as if this is a partially treated bacterial infection which buys the kid a picc line in weeks of antibiotics. If the 29-60 day old has evidence of a U. T. I. Then the provider again has some flexibility if you look at the pathway because as we just discussed, invasive bacterial infections tend to come from the urine via the blood. If the infant has a U. T. I. It's recommended to get at minimum of blood culture. Some providers might also choose to get a CBc at the same time and some might even go on to perform an L. P. I. Personally would not do either a cbc or an L. P. If a 29 to 60 day old had a U. T. I. And was well appearing I would get a blood culture only then give a single dose of oral antibiotics in the emergency department and likely discharge home by way of antibiotics and disposition. Many providers would administer I. V. C. F. Try Axinn and admit the child and they wouldn't be incorrect conservative but not incorrect oral antibiotics Most commonly Sefa lexan are also appropriate in the well appearing child who is not vomiting when the caregiver feels comfortable providing care at home and when the patient has good follow up in place. If all of these criteria aren't met though you're just better admitting the great info. I mean I think in the recent past 1 to 2 month olds with confirmed U. T. I. Often had a lumbar puncture zor were admitted even if they looked really well. So I think the biggest revelation is that meningitis and bacteria from a U. T. I. And a well appearing child at this age. It's just not that common. So the data does support you if you choose not to do an LP or admit all of these Children if you're not quite ready to make that leap yet you can also admit them for I. V. Antibiotics without an L. P. Yep. Now if you're over 60 days you're bigger and your immune system has developed more. You might have even received your two month vaccines. Plus your parents have gotten to know you and you do a little bit more activity throughout the day. So providers have a lot of leeway here. We recommend on the pathway that they consider you A and that's it. I mean they might perform viral studies in the right season and of course now a covid test but in the well appearing 2 to 3 month old urine is optional after only a day or two a fever. So if you do get a you and it's suggestive of a U. T. I. Then the discharge criteria are exactly the same admit on cefTRIAXone if ill appearing or doubtful follow up and discharge on Steph election if they meet all discharge criteria. Thanks Dana. And I think that um follow up question is a really important one. I think ensuring follow up. It's important for all infants with fevers but especially for patients who do not get a you and urine culture. I usually call the primary care office to discuss the plan and they're often great about squeezing them in for the next day. Follow up. Okay. I have a question. Having worked at both A pete specific E. R. And a general er I have noticed in a peat specific er we almost always cath for you a while in the general er It tends to be variable where sometimes we have sometimes we use a urine bag. Why are bag you is frowned upon in this work up? Uh Yes the perennial. Do I really need to cap this kid question. So let me start by stating that very young infants have difficulty concentrating their urine releasing a few drops at a time. So it is very possible that the urine wouldn't have rested in the bladder long enough to accumulate sufficient white blood cells to make the U. A. Positive. Although the culture will show evidence of an infection furthermore in all infants. Although equally it is the most common pathogen by far. Other organisms can cause A U. T. I. And we might need to change antibiotics, especially if the kid isn't improving. So we very much need a culture. As I mentioned earlier, giving antibiotics without a culture at all is the real disservice in this instance when the kid doesn't improve or decompensate in the future. So the urine culture is an absolutely critical test here. Even more important than the U. S. You cannot culture bad urine. This will grow skin and enteric flora and will yield no useful information because the culture is critical to management and you can't culture a bad specimen we need to calf so a bag urine might not be helpful. A few times that I've still seen, providers give the option of the bag away and it's negative. And then they say that the patients all clear. How about that as an option? I know some providers do that. The trouble again here is that the youngest infants do not concentrate their urine. So in those babies a negative you A. Does not mean that they don't have a U. T. I. They need a culture for older infants. The A. Is more accurate but from a practical perspective Think about the time required for the bag. 1st Catholic needed approach evaluate means that the family needs to wait until the infant peas enough into the bag that we get a sample that could be ours in the E. D. Waiting. Especially if this febrile baby hasn't been drinking well. So then if the bag sample suggests a. U. T. I. You still need to get a catheter rise sample for a culture and you can't culture a bag urine. Don't know if I mentioned that before. Since the baby now likely has an empty bladder after peeing into the bag. The family has to wait even longer for the baby to fill their bladder again to cath for the culture specimen. So rather than doing a cath which takes less than five minutes you've now added literal hours to length of stay. Okay. Okay got it got it. So you can't culture a bag you a got it. But practically besides parental hesitation I imagine another reason places are hesitant to do Kathy ways is the staff might not be comfortable doing it. I mean it's challenging and stressful procedure. If you don't do it frequently. I've actually had nurses actively praying that a baby with the chief complaint of fever triage wouldn't need any work up because they weren't comfortable with doing the procedures. Can you give us a few pearls from the nursing standpoint for how to perform a catchy way on a young infant? Sure, sonny. I have to say. I don't think praying is part of the protocol, but if it helps the nurse go into the room with more confidence, do whatever you need to do. I do have to say it's nerve racking. Performing any schools up for the first time. But if you've ever done a urine calf on an adult, it's a very similar process for neonatal. The first step is generally to prepare yourself and anticipate the unexpected kind of what Dina was saying before about LPS. You need to set yourself up for success. So I would recommend gathering all equipment ahead of time. I would suggest to urine cath collections just in case. Extra sterile gloves, cleaning wipes, fresh diaper and an extra urine cup. Whenever you try to clean a Urethra with data dine some babies just naturally need a P. And that having that extra urine cup just to catch anything is going to be helpful. Another pediatric parole is to make sure to prepare the family ahead of time. So explaining the procedure, giving them the option to either stay in the room or if they need to take a break and want to grab some coffee support whatever decision they need. If they decide to stay in the room, I suggest positioning the caregiver closer to the head of the bed so they can be face to face with the baby. They can either have the role of providing the sweeties or just talking, singing to their child or holding their hands. Their job isn't really to restrain or to be the holder but to provide comfort and care if they don't want to stay in the room, I would suggest bundling the baby's upper body like a burrito. And that way the babies will gain comfort being held or swaddled even with waddling. The general rule of them is the smaller the patient, the more hands you need to do any task. And Kathleen, a child is not something you can do or should do by yourself. And if you haven't done this procedure with the holder you're working with before I was just having a discussion outside of the room. Pre procedure on what you need from them personally. I generally use a five french on a new and eight. And then secondly, if you're not receiving urine and you're positive the catheter tip is in the urethra, you might not get your in return for one of two reasons the patient could be tried the baby. Like if they're Fabbro, they might be dry and they might eat a fluid bolus or you might need to unscrew the bottle cap while the catheter tip remains in their urethra because it allows air to flow in and release pressure for the urine to drain. Once the procedure is completed, clean the baby up, get all that data Dine off if you can and make sure that the caregivers know that they might see some beta dine stains in the diaper. It'll freak them out if you don't prep them ahead of time for that. Thanks for sharing those. So for the infant age 29-90 days with fever Dina, when do you think about admitting without antibiotics for observation? When would you consider other work up? Well, like we discussed, I mean, admit all infants who don't meet all discharge criteria, it's absolutely appropriate to admit an infant just because you don't like how they look or because the family is overwhelmed and unable to closely observe the infant, that is absolutely fine. But as far as additional diagnostic tests, I very rarely order additional stuff. If a febrile infant had respiratory symptoms and a consistently focal lung exam without clinical evidence of bronchiolitis, I might consider a chest X ray. The trouble is that many pneumonias in this age group are viral and that's indistinguishable on chest X ray from a bacterial infection. So this is why chest X rays actually aren't recommended and bronchiolitis by the way. Because kids who get X rays have way more diagnoses of pneumonia, greater antibiotic usage and exact same outcomes as the kids who didn't get a radiated, really, these adjuncts are always going to be guided by specific concerns in my history and physical, you know, we love clinical pathways in the emergency department because it standardizes care for a specific subset of patients and it gets the whole team, nurses, physicians, text everyone on the same page. Here's a broader question to close. Are there situations where you deviate from these pathways you've made? So these pathways are just a guide, not anything prescriptive. I would say that the most common situation when I deviate from the pathways is when a caregiver declines one or most of the tests. I totally understand this. And look, you got to meet the family where they're at. I make sure the caregiver understands risks for their specific child, what to look out for at home, how to come back, etcetera. And that's it. I mean it's not my favorite thing to do. But that's reality. I would be remiss to if I didn't share that. The data actually suggests that this real life scenario might not be as dangerous as we worry. So in a really, really cool study out of Kaiser permanente system up here in northern California, the authors simply described their populations experience. So in their group in term previously healthy well appearing young febrile infants, 14% has serious bacterial infections, 13.2% with U. T. I. 2.6% with factory mia and 0.3% with meningitis. And that's right along with what we've already talked about. The interesting thing here is not everyone got a full work up. Only 59% of babies 0 to 28 days had blood, urine and CSF sent 59%. But of infants with no cultures, there was only a 1% Miss rate of beauty and no Miss Factory mere meningitis. So maybe deviating from the pathway when it's necessary isn't really the end of the world. Fevers and young Children are one of the more common high risk things we see in young infants in the pediatric Emergency Department evaluation of babies with fevers has changed over time. As the epidemiology and evidence have changed. There's a really wide spectrum of approaches to infants with fever, ranging from doing everything to observing and everything in between, depending on a host of factors. Today we talked to Dr Dina Wall in our pediatric emergency medicine specialist about the infant fever guidelines she developed for U. C. S. F. She walked us through the evidence and where we still have some leeway. Thanks so much for joining us and sharing your expertise for copies of our pathways searched for UCSF's pediatric emergency medicine clinical pathways join us next time as we keep asking the essential question of when dissent and went to.