Written by: Stephen Dunay, MD; Edited by: Nicholas Thompson, MD
16 day-old male brought to the ED by his parents after his father noted an axillary temperature of 100.7 at home. He was in his usual state of good health until earlier that day, when his parents noted decreased feeding earlier in the day and increased fussiness.
Precipitously delivered at 37+4 weeks following an uncomplicated pregnancy to a 29 y/o G1P1 mother. Prenatal US showed right sided renal cyst. Prenatal labs significant for O+/DAT-, GBS+ without prophylactic abx given prior to delivery. Delivery was otherwise complicated by umbilical cord avulsion that was tied by EMS at the house. The infant was brought to the ED after the delivery and received HepB, VitK, and erythromycin eye ointment upon admission. At pediatrics follow up, he was noted to be gaining weight appropriately. He is bottle fed and usually drinks 2-3 ounces every 2-3 hours. He had been voiding and stooling well without concerning issues. No sick contacts at home or recent travel.
Relevant vitals/PMH/meds/allergies, etc:
Vitals – HR 190-219, RR 52-55, SPO2 100 RA, T 100F
Physical exam –
General – Asleep on bed, arouses easily but sleepy, no acute respiratory distress
HEENT: NC/AT, AFOSF, dry mucus membranes, sclera non icteric
RESP: CTAB, no wheezes, rales, rhonchi, symmetric rise, no signs of increased WOB.
CV: Tachycardic, no appreciable murmur, brisk cap refill, adequate pulses
Abd: soft, non-tender, mildly distended, normal BS
MSK: active ROM
Neuro: Brisk Moro, mild decrease in tone, good suck
Skin: clear, umbilical granuloma
PMH – As per HPI
Meds – None
Allergies – NKDA
Surgeries – None
Work up: ECG, labs, imaging
CBC: 2.9>9.2/28.1<260, N 44.1, L 47.5, M 4.3
CMP: 140/4.1|101/23|5/0.4<114, Ca 9.6, Tpro 5.1, Alb 3.1, ALT 10, AST 22, ALP 148, Tbili 1.1
UA: yellow, hazy, SG 1.011, pH 8.0, all neg
Blood, Urine Cx pending
CSF culture (intermediate report) – no growth
Blood culture (29APR) – Streptococcus Group B
CXR: Distension of small bowel, no focal cardiopulmonary findings.
Ddx: Things to consider
Pediatric Meningitis and Encephalitis
Group B streptococcus septicemia
What you learned from the case:
Keys to performing a successful LP in an infant:
(from CPG of the Royal Children’s Hospital Melbourne http://www.rch.org.au/clinicalguide/guideline_index/Lumbar_Puncture_Guideline/, and ACEP Peds EM Section https://www.acep.org/content.aspx?id=83269)
· Recommend delaying LP for 1-2 days and giving steroids/antibiotics if the following are present: Coma, signs of increased ICP, shock, respiratory failure, focal neurological signs or seizures, coagulopathy/thrombocytopenia, local skin infection, purpura where meningococcal infection is suspected.
· Head CT recommended if there are focal neurological signs.
· Analgesia: Non-pharmacological techniques should be used where possible. All children should have some form of local anesthetic, whether topical or subcutaneous (up to 0.4 ml/kg lidocaine). There is good evidence that the infant struggles less and the success rate is higher when one uses local anesthesia. May use oral sucrose for infants < 3 months.
- Equipment: At least one trained assistant to hold the child, sterile gloves, sterile drapes and procedure tray, betadine or chlorhexidine, 2ml syringe, 25G needle, CSF tubes, spinal needle (22G or 25G bevelled spinal needles with stylet)
- Position: Child be lying on their side or sitting up with maximum flexion of the spine (curl into fetal position). Avoid over flexing the neck as this may cause respiratory compromise. Aim for the L4-L5 or L5-S1 interspace, where the top of the iliac crests intersect the spine. The conus medullaris finishes near L3 at birth, but at L1-2 by adulthood.
- Preparation: Wash hands and put on sterile gloves. Prepare the skin with betadine or chlorhexidine. Place sterile drapes. Allow time for the skin preparation to dry. Take the tops off the tubes. Infiltrate the skin with local anesthetic.
- Procedure: Position the needle in the midline with the bevel pointing towards the ceiling (lateral decubitus position) or to the side (sitting). Pierce the skin with the needle and pause. Reorientate and aim for the umbilicus. Several studies have demonstrated that advancing the needle with the stylet removed (after passing through the skin) is associated with greater procedural success and fewer traumatic lumbar punctures. Advance the needle into the spinous ligament where you will meet resistance. Continue to advance the needle until there is a fall in resistance. Remove the stylet. If CSF is not obtained replace the stylet and advance the needle slightly then recheck for CSF. If blood stained fluid is obtained collect some for culture. If it clears it can be used for a cell count. If it fails to clear another attempt at a different level may be required. Replace the stylet and remove the needle and stylet. Apply brief pressure to the puncture site and place a bandage.
Key points to the diagnosis, treatment, dispo, etc.
(info from Emergency Medicince Cases http://emergencymedicinecases.com/episode-48-pediatric-fever-without-source/)
- ~ 20% of kids in the ED will have fever without an identifiable source, and a small number of children will have an occult, serious bacterial infection (SBI).
- UTIs are the most common occult SBI.
- By definition, fever is an oral temperature >38°C, or rectal temperature >38°C. Get a rectal temp in toddlers, infants and neonates.
- The temperature is not as important as the fever durationin predicting bacteremia. Correct the fever, and if the child’s vital signs and clinical picture continue to be worrisome after their fever has been corrected, then SBI should be suspected.
- Heart rate increases by ~10 beats/min and respiratory rate by 5 breaths/min for every Celsius degree (1.8 degree of Fahrenheit) of fever >38°C.
- The parent’s touch has been shown to be fairly accurate for identifying children with fever, and those brought in for reported “tactile fever” should receive the same workup.
- What to ask: Duration of fever? Recent surgeries and underlying medical diseases? Previous infections? Immunization status? Mother’s GBS status and any prophylactic antibiotic?
- Physical exam: Behavior and mental status? Watch them walk to eval for septic arthritis/osteomyelitis. Examine the fontanels, skin, joints, and abdomen carefully.
- Sources to look for: urine, skin (cellulitis), abdomen (appendicitis, abscess), joint (septic arthritis), meningitis.
- Peds UTI:
- Risk factors include history of previous UTI, temp >39°C without an apparent source and >24h, ill appearance, female gender, uncircumsized boys and non-black race, h/o suprapubic tenderness, dysuria/frequency/low-back pain or new-onset incontinence in potty-trained children.
- Who to test (per JAMA guideline article 3): < 3 months:check urine in all babies with fever without source; 3-24 month: check all girls, and boys if >1 risk factor, or if circumcised and >2 risk factors; >24 months: check all girls, all symptomatic uncircumcised boys, and circumcised boy who had several symptoms suggesting UTI.
- Obtaining urine: <2 months: catheterization, send culture always; >2 months of age to toilet trained: bag urine okay to screen by microscopy, however if >10-20 white cells present, a sterile culture needs to be obtained by catheter; toilet-trained kids: obtain midstream urine.
- Renal u/s or VCUG? All with first time UTI need an ultrasound. VCUG only if there is hydronephrosis.
- Treatment: If hospitalized, IV ampicillin (100mg/kg/day divided q6h) plus gentamicin (5mg/kg/day divided q8h to q12h) or cefotaxime (150mg/kg/day divided q8h).
NOTE: do not give ceftriaxone to infants <28 days due to possibility of acute bilirubin encephalopathy
- Indications for CXR in Pediatric Fever Without a Source? Fever >5 days, cough >10 days, persistently high (>40) temp, white count >20.
- Baraff Practice Guidelines by age:
- <28 days: full septic workup (LP, labs, blood/urine culture, UA, CXR) is recommended with initiation of empiric antibiotics – don’t let the inpatient team talk you out of a full workup (10% of febrile neonates with documented RSV have concomitant SBI)
- 29 days to 90 days
- toxic appearing: full septic workup and empiric antibiotics
- well appearing
- option 1: blood, UA/UCx, BCx, LP, ceftriaxone IM à return in 24 hours
- option 2: UA/UCx, blood, BCx – return in 24 hours (LP if WBC <5 or >15)
- >90 days
- toxic: full septic workup and empiric antibiotics
- Temp <39C: no testing indicated, return if fever >48 hours
- Temp >39C: BCx if WBC >15 and no PCV; UCx if M <6m, Uncirc <12m, F<2y, or UA positive; ceftriaxone if WBC >15 and no PCV; return if fever >48h
- When to give acyclovir? (60mg/kg/day divided q8h). To be honest, it’s better to give to any patient you are empirically treating for meningitis and letting the in patient team discontinue it as testing returns.
- age < 3 weeks
- vesicles presents on exam
- history of seizures
- toxic or ill appearance
- CSF pleocytosis or red blood cells
- Maternal history of herpes
Take Home Points
- <28 days = FULL work-up
- 28-90 days = FULL work-up minus LP, unless toxic-appearing or WBC abnormal
- If you are going to treat with antibiotics, you should probably do the LP
- If you are treating with antibiotics, consider adding acyclovir
- Baby LPs are difficult: having a good holder makes all the difference
- When in doubt, get Pediatrics on board to help with disposition
- Pediatric Doses: one-time dosing in the ED
- Ampicillin: 50-75mg/kg
- Gentamicin: 5mg/kg
- Cefotaxime: 50mg/kg
- Ceftriaxone: 100mg/kg (meningitis dosing)
- Vancomycin: 15mg/kg
- Acyclovir: 20mg/kg