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
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