ACEP Policy for Fever Infants and Children Younger than 2 Years of Age in ED

ACEP Policy for Fever Infants and Children Younger than 2 Years of Age in ED from Sun YaiCheng

臨床問題

Q1. 對於發燒超過38℃，2個月到 2歲 well-appearing immunocompetent 的嬰幼兒，哪些是好發 UTI 的風險因子？

A：小於12個月的女嬰，未割包的男嬰，發燒超過 24小時，高燒超過 39°C，未發現呼吸道或其他的感染源 。這些應考慮 U/A 和 U/C﹝建議等級 C﹞

Q2. 對於2個月到 2歲 well-appearing immunocompetent 的發燒嬰幼兒，哪些 urine testing 應用來診斷 UTI？

A：urine leukocyte esterase, nitrites, leukocyte count, or Gram’s stain.﹝建議等級 B﹞

A：發燒嬰幼兒，U/A negative, 若初步診斷 UTI 或懷疑 UTI，留 U/C, 給 antibiotics.﹝建議等級 C﹞

bagged urine U/A+, 有 85% 的 false positive rate, 應再做 catheterization or suprapubic aspiration 的 U/C.

Q3. 對於發燒超過38℃，2個月到 2歲 well-appearing immunocompetent 的嬰幼兒，哪些是肺炎的高風險因子，應照 CXR？ 

A: 咳嗽，血氧低，rales，發燒超過 48小時，高燒超過 39°C，心跳快，呼吸急促。這些情況應考慮照 CXR.﹝建議等級 B﹞

A：發燒嬰幼兒，wheezing 或高度懷疑 bronchiolitis, , physicians should not order a CXR.﹝建議等級 C﹞

Q4. 對於發燒超過38℃，1 到 3個月 well-appearing immunocompetent 的嬰幼兒，哪些是腦膜炎的高風險因子，應做 LP 留 CSF？

A：並無這類風險因子。懷疑腦膜炎，就要做 LP。若懷疑病毒感染，LP 可暫緩，antibiotics 應先不給，除非之後發現其他的細菌感染源。

參考資料

Clinical Policy for Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the Emergency Department With Fever
Ann Emerg Med. 2016;67:625-639.

Slides 圖組：Baby, Don't Cry - Jill Greenberg (15 pics)

Simple Febrile Seizures: A New Guideline

Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure
Subcommittee on Febrile Seizure

Pediatrics 2011;127;389.

A febrile seizure is a seizure that is accompanied by fever, but not CNS infection, in a child aged 6 through 60 months. 

Simple febrile seizures are primary generalized seizures that last for less than 15 minutes and do not recur within 24 hours.

• Lumbar puncture (LP) should be performed only in a child with a seizure, fever, and signs of meningitis (Evidence level B: overwhelming evidence from observational studies).

• LP is an option in any child aged 6 to 12 months with a simple febrile seizure if immunization status is unknown or insufficient for Haemophilus influenzae type b or Streptococcus pneumoniae (Evidence level D: expert opinion, case reports).

• LP is an option in a child with a simple febrile seizure who has received antibiotics (Evidence level D).

• EEG should not be performed in an otherwise neurologically healthy child with a simple febrile seizure (Evidence level B).

• Serum electrolytes, calcium, phosphorus, magnesium, blood glucose, and CBC should not be performed routinely to identify the cause of a simple febrile seizure (Evidence level B).

• Neuroimaging should not be done routinely after simple febrile seizures (Evidence level B).

兒童發燒處置建議 ﹝民眾版﹞

1. 發燒的定義：中心體溫 ≥ 38℃
   
   
2. 體溫的測量：肛溫最接近中心體溫，耳溫與肛溫的相關性很高，但三個月以下嬰兒的耳溫與中心體溫的相關性較差。一個月以下或體重很低的新生兒，不適合量肛溫或耳溫，可考慮量腋溫或背溫。
   
   
3. 危險的病徵：體溫的高低不一定代表疾病嚴重度，兒童生病時，重要的是觀察有無重症的危險病徵。如果出現下列情形，儘速至兒科專科醫師診治：
   
   
• 三個月以下嬰兒出現發燒
• 尿量大幅減少
• 哭泣時沒有眼淚
• 意識不清，持續昏睡、未發燒時燥動不安、眼神呆滯痙攣、肌抽躍、肢體麻痺、感覺異常
• 持續頭痛與嘔吐
• 頸部僵硬
• 咳痰有血絲
• 呼吸暫停、未發燒時呼吸急促、呼吸困難、吸氣時胸壁凹陷
• 心跳速度太慢、心跳不規則
• 無法正常活動，例如不能爬樓梯、走小段路會很喘
• 皮膚出現紫斑
• 嘴唇、手指、腳趾發黑
  
  
4. 退燒的方法：冰枕、溫水拭浴等物理退燒法，並不會改變發炎反應引起體溫定位點的異常上升現象，所以不會有退燒效果，單純注射點滴也沒有退燒效果。各種退燒藥物中，除了阿斯匹靈不可用於18歲以下兒童之外，其他口服與塞劑均可於必要時適量使用。
   
   
5. 後續的處理：一些民眾認為吃退燒藥後如果又燒起來，就表示醫師開的藥沒有效，會在去找其他醫師，造成醫療的浪費。事實上，各種退燒藥的效果都只能維持幾個小時，其目的在帶給兒童短暫的舒適。如果疾病的過程還沒結束，退燒以後又燒起來是很常見的事情。常見的呼吸道或腸胃道病毒感染，其中有些感染可能持續發燒達一週或甚至更久。家長必須注意有無第4項所列的危險病徵，並持續遵從醫矚追蹤治療。

資料來源：台灣兒科醫學會 2011年11月22日

相關文章：Fever in Children Younger Than 5 Years ﹝醫師版﹞

兒科急診十誡

The Ten Commandments Of Pediatric Emergency Medicine

View more presentations from Sun YaiCheng

兒科急診十誡

The Ten Commandments Of Pediatric Emergency Medicine

The Journal of Emergency Medicine,
Vol. 27, No. 2, pp. 193–194, 2004

1.   小孩不是大人的縮小版

Children are not small adults

2.   生病和受傷的小孩會行為退化

Ill and injured children regress

要多花些時間，不要有太高的期待

 
3.   兒科必須同時治療兩位「病人」 （家屬和小孩）

The “patient” might be the one holding the child

4.   把小朋友當一回事

Kids are the real deal

小孩不喜歡來醫院

一般情況下，小朋友不會裝病

5.   實驗檢查和x-ray不能取代完整的病史和理學檢查

Laboratory tests and x-rays seldom beat a good history and physical examination

6.   人多好辦事

Many hands make light work

procedure 前做充分的準備，把事做對，一次做好

7.   確認、確認、再確認

Check and double-check. Then, check again

過敏史、藥物、劑量、左右

8.   小孩也會覺得痛，給予止痛劑

Children feel pain just like you do—treat it

9.   安排回診

Close the loop

10.  你是小孩的代言人

Above all, you are the child’s advocate

兒科急診十誡是急診十誡的補充加強版

急診十誡裡的原則依然適用

The Ten Commandments of Pediatric Emergency Medicine are designed to supplement and augment the Ten Commandments of Emergency Medicine, not to replace them.

The original commandments still hold.

Avoid CT in Kids at Very Low Risk of Brain Injury

Children at very low risk of brain injuries

View more presentations from Sun YaiCheng

Identification of children at very low risk of clinically-important brain injuries after head trauma:
a prospective cohort study

Lancet 2009; 374: 1160–70

Purpose

To identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.

The prediction rule for children < 2 years 

• Normal mental status 
• No scalp haematoma except frontal 
• Loss of consciousness < 5 s 
• Non-severe injury mechanism
• No palpable skull fracture 
• Normal behavior per patient 

Severe mechanism of injury: 

• motor vehicle crash with patient ejection
• death of another passenger, rollover
• pedestrian or bicyclist without helmet struck by a motorised vehicle
• falls of more than 0.9 m
• head struck by a high-impact object

NPV: 100% 
Sensitivity: 100% 

The prediction rule for children > 2 years

• Normal mental status
• No loss of consciousness
• No vomiting
• Non-severe injury mechanism
• No signs of basilar skull fracture
• No severe headache

Severe mechanism of injury:

• motor vehicle crash with patient ejection
• death of another passenger, rollover
• pedestrian or bicyclist without helmet struck by a motorised vehicle
• falls of more than 1.5 m
• head struck by a high-impact object

NPV: 99.95%
Sensitivity: 96.8%

Neither rule missed neurosurgery in validation populations

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4月24日 補充 中文摘要 (by zeno)

兒童頭部外傷，若是六項因素都沒有，可以不用切CT ！
Tintinalli's Emergency Medicine, 7E, p891

一、小於2歲的預測因子

1. 意識改變（昏迷指數14分或有躁動、嗜睡、重複問相同問題、反應變慢）
2. 除了前額之外的區域有頭皮血腫
3. 失去意識5秒以上
4. 嚴重的受傷機制（汽機車相撞且被彈射出去、車子翻覆或其他乘客死亡、走路或騎腳踏車被行進中的車輛撞到、從大於0.9公尺的高度跌落、頭部被高速物體擊中）
5. 觸診可摸到顱骨骨折
6. 主要照顧者注意到有行為異常

二、2歲以上的預測因子

1. 意識改變（昏迷指數14分或有躁動、嗜睡、重複問相同問題、反應變慢）
2. 嘔吐
3. 有失去意識
4. 嚴重的受傷機制（汽機車相撞且被彈射出去、車子翻覆或其他乘客死亡、走路或騎腳踏車被行進中的車輛撞到；從大於1.5公尺的高度跌落、頭部被高速物體擊中）
5. 熊貓眼、耳後區域瘀血等顱底骨折的表徵
6. 嚴重頭痛 

 (99.95-100% 陰性預測值； 96-8100% 敏感度)

Sudden Infant Death Syndrome

Sudden Infant Death Syndrome from Sun YaiCheng

Sudden Infant Death Syndrome (SIDS)
N Engl J Med 2009; 361:795-805


Definition

Sudden death of an infant or young child, which is unexpected by history, and in which a thorough post mortem examination fails to demonstrate an adequate cause of death.

Triple-Risk Model of SIDS

1. Intrinsic risk factors

• Genetic

• Male sex
• Polymorphism in the gene encoding the promoter region of the serotonin transporter
• Black or Native American race or ethnic group

• Developmental

• Prematurity

• Environmental

• Perinatal exposure to smoking
• Parental smoking, ethanol intake, or drug use
• Socio-economic disadvantage

2. Extrinsic risk factors

• Sleeping on the side or in prone position
• Soft bedding
• Bed sharing
• Mild infections, including colds

5 Steps in the Putative Terminal Respiratory Pathway Associated with SIDS

Recommendations for Risk Reduction and Counseling

• Putting infants to bed in the supine position on a firm mattress, preferably with a pacifier and in a shared room (but in a separate bed).
• Prone and side sleeping, overheating, bed sharing, soft bedding, and smoking by mothers during pregnancy or around infants should be avoided.
• Home cardio-respiratory monitoring of apnea and bradycardia is not recommended because it has not been shown to prevent SIDS.

Safe sleeping positions

Safe clothes and bedding

Safe sleeping dos and don'ts

嬰兒猝死 (sudden infant death syndrome) 的危險因子，下列敘述何者錯誤？【96急專】

（Ａ）早產
（Ｂ）母親抽菸
（Ｃ）父母親低社經地位，教育水準低
（Ｄ）冬天易發生
（Ｅ）高齡母親    X

 急診醫學科專科醫師甄審筆試試

Fever in Children Younger Than 5 Years

Fever in Children Younger Than 5 Years from Sun YaiCheng

Assessment and Initial Management of Feverish Illness in Children Younger Than 5 Years
Summary of NICE Guidance
BMJ 2007;334:1163-1164


Traffic light system for identifying risk of serious illness

Management by a non-pediatric practitioner


Management by a pediatric specialist