The Sick Infant: Five Deadly Misconceptions

Todd Wylie, MDUniversity of Florida

Department of Emergency MedicineJune 25 - 27, 2009

Case 1

• 6 month female with fever to 103.6

Misconception

Immunizations have eliminated the need to perform any laboratory

studies on febrile infants!

Febrile InfantProtocol

Febrile Infant

Immunization Status?

Case 2

• 4 month male with 1 day history of high fever and lethargy

Misconception

1) Kids are just small adults!

2) Kids are a totally different species!

Sepsis

• What’s different?

Sepsis

• What’s similar?

Case 3

• 3 month female– 3 days of fever, cough,

rash, conjunctivitis

Misconception

Kids will read the textbook prior to presenting with a myriad of signs and symptoms!!

Kawasaki Disease• Five or more days of

fever

Kawasaki Disease

• 4 out of 5– Conjunctivitis– Rash– Extremity

changes– Cervical

adenopathy– Mucositis

Incomplete (“Atypical”) Kawasaki Disease

• Lack sufficient clinical signs to fulfill the classic criteria

Incomplete (“Atypical”) KawasakiDisease

• Age

• Newburger JW, Takahashi M, Gerber MA, et al. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Statement for Health Professionals…Pediatrics 2004; 114: 1708-1733.

• Prevalence

Incomplete (“Atypical”) KawasakiDisease

• Age

• Genizi J, Miron D, Spiegel R, Fink D, Horowitz Y. Kawasaki Disease in Very Young Infants: High Prevalence of Atypical Presentation and Coronary Arteritis. Clin Pediatr 2003; 42: 263-267.

• Coronary artery abnormalities

Case 4

• 8-day old female with poor feeding, fever, and grunting respirations

Misconception

The sick neonate has been adequately treated with antibiotics alone

Neonatal HSV

Skin-Eye-Mouth CNS Disseminated

Onset (days) 5-11 days 8-17 days 5-11 days

Clinical findings

Vesicles Irritable, Lethargy

Seizures

Jaundice

Resp. distress

Irritable

Mortality untreated

Up to 70% progress

50% 90%

Mortality treated

0 15% 54%

Neonatal HSV

Neonatal HSV

The Prevalence of Neonatal Herpes Simplex Virus Infection Compared with Serious Bacterial

Illness in Hospitalized Neonates

Caviness AC, Demmler GJ, Almendarez Y, Selwyn BJ.J Pediatr 2008;153:164-9

Neonatal HSV

• When should we start empiric acyclovir treatment in sick neonates?

• Clear index of suspicion for HSV– Skin vesicles– Seizures– Elevated hepatic

transaminases

Neonatal HSV

• When should we start empiric acyclovir treatment in sick neonates?

• Sepsis-like picture– Respiratory distress– Hypothermia– Lethargy – Appears more ill than

would be expected

Neonatal HSV

• When should we start empiric acyclovir treatment in sick neonates?

• CSF pleocytosis– Mononuclear cell

predominance

Neonatal HSV

• When should we start empiric acyclovir treatment in sick neonates?

• Age < 21 days and fever?

Case 5

• 9 month male presents following a generalized seizure…noted to have fever to 103.4

Misconception

1) You don’t have to do a spinal tap anymore!

2) You always have to do a spinal tap!

Febrile Seizure and Meningitis

• What is the risk of meningitis in patients with a febrile seizure?

Febrile Seizure and Meningitis

• Indications for a spinal tap