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DIFFERENTIAL DIAGNOSIS OF FEVER
Where and how should we measure body temperature?

Differential

Diagnosis of Fever
Barbara Rath, M.D.
University Childrens Hospital Basel
(UKBB)

What constitutes normal temperature?

What constitutes fever?

What causes fever?

What is Fever of Unknown Origin (FUO)?

Barbara Rath 2007

ath 2007

Barbara Rath 2007

WHERE AND HOW SHOULD WE MEASURE BODY TEMPERATURE?

Barbara R

Thermoscope (Galileo Galilei, 1592): First instrument to measure temperature

Barbara Rath 2007

Thermometer (Santorio Sanctorius, 1592)

Barbara Rath 2007

Curved thermometers for sublingual insertion (BMJ 1912;1:1137)

Barbara Rath 2007

Benjamin Rush (1745-1B8a1rb3a)ra: RAatMh 2o00r7al Thermometer (1812)

THE INFRARED AURAL

THERMOMETER
VARIATIONS
IN SUBLINGUAL

TM thermometersalthough convenienttend to give highly variable readings that correlate poorly with simultaneously obtained oral or rectal readings.

Practice of Infectious Diseases, 6th Ed, 2005, pg 704

TEMPERATURE BY LOCATION

Once outstanding issues are addressed, the tympanic site is likely to become the gold standard for measuring temperature in children.

infrared ear thermometry would fail to diagnose fever in three or four out of every ten febrile children (with fever38C or above).

ITT measurements more accurately reflect core temperatures than any other measurement site during febrile and nonfebrile periods in children.

Mackowiak P A in: Mandel G L, Bennett J E, Dolin R (Eds) Principles and

El-Radhi A S, Barry W: Arch Dis Child 2006; 91: 351-356.

Dodd S R, et al: Clin Epidemiol 2006; 59: 354-57

Nimah M M, et al: Pediatr Crit Care Med 2006; 7: 48-55.

Our findings suggests that infrared ear thermometry does not show sufficient agreement with an established method of temperature measurement to be used in situations where body temperature needs to be me

Difference max vs min = 0.9C or 1.8F

Barbara Rath 2007

Barbara Rath 2007

DIFFERENTIAL DIAGNOSIS OF FEVER

Where and how should we measure body temperature?

What constitutes normal temperature?

What constitutes fever?

What causes fever?

What is Fever of Unknown Origin (FUO)?
Barbara Rath 2007

WHAT IS NORMAL BODY TEMPERATURE?

35.7C (96.2F)

36.0C (96.8F)

36.5C (97.7F)

37.0C (98.6F)

Barbara Rath 2007

37.5C (99.5F)

37.7C (99.9F)

NORMAL CORE TEMPERATURE

Best site(s) to determine true normal core temperature is:

D Hypothalamic artery
D Pulmonary artery
D Rectum (5 cm)
D Sublingual artery (oral) D Tympanic membrane D Temporal artery
D Axillary artery
D Skin (umbilicus)
Barbara Rath 2007

NORMAL BODY TEMPERATURE?

Carl Rheinhold August Wunderlich: Das Verhalten der Eigenwrme in Krankenheiten (Leipzig,1868)
D
D
D
D
D

Analyzed ~million observations on ~25,000 adults

22 cm long, mercury-in-glass thermometer
Used axillary site, twice daily, x15-20 minutes
Temperature oscillates even in health persons according to time of day by 0.5C = 0.9F
Women have slightly higher normal temperatures than men and often show greater and more sudden changes of temperature

Barbara Rath 2007

NORMAL BODY TEMPERATURE?

NORMAL ADULT ORAL TEMPERATURES

37.0C
98.6F

When the organism (man) is in a normal condition, the general temperature of the body maintains itself at the physiologic point: 37C = 98.6F

PROBLEM:
D Tests with one of Wunderlichs thermometers suggest that his instruments may have been calibrated higher than todays instruments by as much as 1.4

* Mackowiak P A, Worden G: Clin Inf Dis 1994; 18: 458-67.

Barbara Rath 2007

* Mean, Median: 98.2F

Mackowiak P A et al: JAMA 1992;

268: 1578-80
Barbara Rath 2007

NORMAL RECTAL TEMPERATURE

HEALTHY INFANTS & CHILDREN
AGE
< 3 MOS
3 MOS
6 MOS
1 YEAR
3 YEARS
5 YEARS
7 YEARS
9 YEARS
11 YEARS
13 YEARS

TEMPERATURE F & C (SD)

99.5
99.4
99.5
99.7
99.0
98.6
98.3
98.1
98.0
97.8

(0.8)
(0.8)
(0.6)
(0.5)
(0.5)
(0.5)
(0.5)
(0.5)
(0.5)
(0.5)

37.5
37.4
37.5
37.6
37.2
37.0
36.8
36.7
36.7
36.5

(0.4)
(0.4)
(0.3)
(0.2)
(0.2)
(0.2)
(0.2)
(0.2)
(0.2)
(0.2)

Watson E H: Growth and Development of Children (1978); Herzog L W, Coyne L J: Clin Pediatr 1993; 32:
Barbara Rath 2007

Normal body temperature is a range of values, affected by:

Age: Infant > child > adolescent, adult
Sex: females > males (mean: 0.2C, 0.3F)
Race: Black > Caucasian (mean: 0.1C, 0.1F)
Time of day: afternoon > early morning
Level of Activity: post-exercise > resting
Meals: hot > cold; chewing, smoking
Ambient temperature
Placement within site of measurement
Duration of measurement (Hg thermometers)
Nature & calibration of device used

Barbara Rath 2007

SITE

MEAN

RANGE

C
F
C
NORMAL TEMPERATURES
vs SITE

AXILLARY

36.4

97.5

34.7 37.3

SUBLINQUAL

36.6

97.9

35.5 37.5

RECTAL

37.0

98.6

36.6 37.9

El-Radhi A S, Barry W: Arch Dis Child 2006; 91: 351-356

Barbara Rath 2007

TYPICAL DAILY TEMPERATURE FLUCTUATION (PO, ADOLESCENT)

Richardson G S, et al: Sleep 1982; 5 (SBuaprbpa2ra):RSa8th2

2007

DIFFERENTIAL DIAGNOSIS OF FEVER

Where and how should we measure body temperature?

What constitutes normal temperature?

What constitutes fever?

What causes fever?

What is Fever of Unknown Origin (FUO)?

Barbara Rath 2007

HISTORY OF FEVER
Sumerian (2500 BC): inflammation or hot thing meaning fever

Egyptian (1700 BC): fever

Chinese (2nd Century): hot disease

Barbara Rath 2007

WHAT IS FEVER?
PHYSIOLOGIC DEFINITION

A state of elevated core temperature which is often, but not necessarily, part of the defensive responses of multicellular organisms (host) t
- IUPS Commission for Thermal Physiology (2001)

Barbara Rath 2007

WHAT IS FEVER? CLINICAL DEFINITION

A pyrogen-mediated rise in body temperature above the normal range

Barbara Rath 2007

A failure of thermoregulatory homeostasis due to uncontrolled heat production1, inadequate heat dissipation2, or defective thermoregulatio

Maligna
N

WHAT TEMPERATURE = FEVER?

37C (98.6F)

37.7C (100F) D 38C (100.4F)

D 39.1C (102.4F)

38.3C (101F)

Barbara Rath 2007

WHAT TEMPERATURE = FEVER?

D

PEDIATRIC LITERATURE

Rudolphs Pediatrics
The temperature most commonly used to define fever threshold in children is 38C (100.4F), rectal, although lower oral temperatures in adolescents an
What do
Textbook of Pediatric Emergency Medicine
D For the appropriately dressed child who has been at rest 30 minutes, rectal temperature of 38C (100.4F)
Pediatric and

ER Residents
Think ?

Barbara Rath 2007

Survey: 132 Pediatric Programs, 38 Emergency Medicine Programs

Baraff L J: Management of the febrile child: A survey of pediatric and
emergency medicine residency directors. Pediatr Inf Dis J 1991; 10: 795
Barbara Rath 2007

WHAT TEMPERATURE = FEVER?

& MORE PEDIATRIC LITERATURE.

Pediatrics (Osborn, DeWitt, First)

D The most commonly accepted minimum temperature defining fever is 38C (100.4F).
Current Pediatric Therapy
D fever is defined as rectal temperature above 38C (100.4F).
Nelsons Pediatrics
D No definition given
Barbara Rath 2007

WHAT TEMPERATURE = FEVER? THE PEDIATRIC ID LITERATURE

Principles and Practice of Pediatric Infectious Diseases

In general, values higher than 37.8C (100F) are considered
Textbook of Pediatric Infectious Disease
D Generally, the accepted range of rectal temperature is 36.1C to 37.8C (97F to 100F)..Clearly, a body temperature slightly above an
Pediatric Infectious Diseases. Principles and Practice
D No definition given
D

Barbara Rath 2007

WHAT TEMPERATURE = FEVER?

THE JOURNALS.

Contemporary Pediatrics (1997)

Rectal temperature >38 C (100.4 F)

Tympanic temperature >38 C (100.4 F)
D Oral temperature >37.8 C (100 F)
D Axillary temperature >37.2 C (99 F)
D

Berlin C W Jr: Fever in children. A practical approach to management

Fever as an AEFI The Brighton Collaboration Case Definition

Barbara Rath 2007

Fever is defined as the endogenous elevation of at least one measured body temperature
of >= 38 C.

The value of >38C is accepted as reflecting an abnormal elevation of temperature, irrespective of device, anatomic site, age, or environmental conditions.

While it is recognized that this value is to some extent arbitrary, it is based upon a conservative interpretation of definitions proposed and used by clinicians, investigators, and the public at large.

FEVER vs NORMAL ADULT ORAL TEMPS

37.0C
98.6F

S. Michael Marcy et al., Vaccine 2004; 22: 551-556

Barbara Rath 2007

*
38 C
100.4 F

* Mean, Median: 98.2F

Mackowiak P A et al: JAMA 1992;

268: 1578-80
Barbara Rath 2007

INDIVIDUAL VARIATIONS AND THE DEFINITION OF FEVER

Statement:
D She always runs a low temperature and 37.5 is a fever for her
Response:
D You will never convince the caregiver to the contrary, so work with it: There are no data to confirm or refute this observation.

Barbara Rath 2007

DIFFERENTIAL DIAGNOSIS OF FEVER

Where and how should we measure body temperature?

What constitutes normal temperature?

What constitutes fever?

What causes fever?

What is Fever of Unknown Origin (FUO)?
Barbara Rath 2007

WHAT CAUSES FEVER?

Sumerian (3000 BC)
Evil spirits (Nergal & Ashakka)
Egyptian (1700 BC)
D Demonic possession
Chinese (1000 BC)
D Imbalance of good and evil
Indian (800 BC 1000 AD)
D Fire demons Takman & Yakshma
D Disturbances of the humours: bile, air, phlegm
Greek and Roman (400 BC 200 AD)
D Excess of phlegm vs blood, yellow bile, black bile
D Excess of yellow bile vs phlegm, blood, black bile
Medieval (500 1350 AD)
D Demonic possession
Renaissance (1300 1600 AD)
D Fermentation and putrefaction in the blood and gut
18th Century
Friction from blood rushing through the vessels; inflammation..
D

Barbara Rath 2007

Barbara Rath 2007

Barbara Rath 2007

Non-Infectious Causes
Hyperthyroidism

Cerebral Hemorrhage

Hodgkin Disease

Drug Fever

Pulmonary Infarction

Dermatomyositis

Hypernephroma

Bronchogenic CA

Reginoal Ileitis

Myocardial Infarction

Aplastic Anemia

Pheochromocytoma

Leukemia

Periatrieritis Nodosa

Fracture

Thrombophlebitis

Rheumatic Fever
Rheumatic Arthritis

Infectious causes
Meningitis
Infectious Mononucleosis
Tracheobronchitis Pneumonia Subphrenic Abscess Infectious Exanthema Appendicitis Osteomyelitis
Septic Arthritis

Cerebral Abscess
Sinusitis
Dental Abscess Tuberculosis
Subacute Bacterial Endocarditis
Empyema Pyelonephritis Diverticulitis Prostatic Abscess
Cellulitis

PATHOGENESIS OF FEVER

Acetaminophen, Ibuprofen

Mackowiak P A:BAarrbcahraInRtatMh e2d0017998; 158:1870-1881

TRUE NORMAL CORE TEMPERATURE

Best site(s) to determine true normal core temperature is:
D Hypothalamic artery
D Pulmonary artery
D Rectum (5 cm)
D Sublingual artery (oral) D Tympanic membrane D Temporal artery
D Axillary artery
D Skin (umbilicus)
Barbara Rath 2007

DIFFERENTIAL DIAGNOSIS OF FEVER

Where and how should we measure body temperature?

What constitutes normal temperature?

What constitutes fever?

What causes fever?

What is Fever of Unknown Origin (FUO)?

Barbara Rath 2007

FUO IN CHILDREN
Fever of unknown origin
is characterized by daily fever persisting for more than 3 weeks.
infectious,
rheumatologic disorders, and
malignancy.

Chronic episodic fever of unknown origin

is characterized by fever lasting for a few days to a few weeks, followed by a fever-free interval and a sense of well-being.
Mediterranean fever,
the hyper-immunoglobulin D syndrome,
familial Hibernian fever,
Behcet disease,
the syndrome of periodic fever,
aphthous stomatitis, pharyngitis and adenitis, and
cyclic neutropenia.

Barbara Rath 2007

Barbara Rath 2007

Barbara Rath 2007

ALSO RULE OUT:

Hay Fever
Cabin Fever
Island Fever
World Cup Fever
Saturday Night Fever

Know where to look!!!

Barbara Rath 2007

Barbara Rath 2007

Clinical Vignettes..

Barbara Rath 2007

CASE #1: NEONATE WITH FEVER

A 3 week old boy comes to your office because he slept through his noon feeding time, seems sleepier than usual to the parents, and had
What else would you like to know or do?

YOUR NEXT STEP IS.?

D

Admit, start antimicrobial Rx (cefotaxime + ampicillin

or ceftriaxone + ampicillin or gentamicin + ampicillin)
D Admit, get lab studies, and start antimicrobial Rx
D Admit, observe without lab studies or antimicrobials
Get lab studies and await results to decide if pt needs admission or can be followed from home

Barbara Rath 2007

10

LAB STUDIES YOU COULD ORDER ARE?

CBC and differential

D UA/UC
D Blood culture
D CSF analysis and culture
D Chest P-A & lateral radiograph
Sedimentation rate (ESR) D C-reactive protein (CRP) D Procalcitonin
D IL-6 or IL-8
D CD11b, CD64
D Granulocyte colony stimulating factor
D

Barbara Rath 2007

Mishra U K, et al: Arch Dis Child Fetal Neonatal Ed 2006; 91: F208-F212

CASE #1: NEONATE WITH FEVER (CONTD)

Lab results:
D CBC: 7,600 WBC with 44N, 47L, 7M, 2E; Hgb 11/33
D Cath UA: yellow, cloudy. Sp gr 1.010, pH 7.0. Sugar, protein, ketones, bili all neg. Hgb 1+, LE 1+, nitrite neg. Micro: WBC 10-25/HPF, bacteria few.
D CSF: clear, 1 RBC, 4 WBC (2 PMNs), sugar 52, protein 69, Gram stain neg.
D Chest film: normal
D

Two days later lab reports >100,000 E coli in the urine

Barbara Rath 2007

10

THE VALUE OF THE LABORATORY IN EVALUATION OF NEONATAL INFECTION

Tests and Panels for Early Onset Neonatal Sepsis
D PPV: 5% - 69% (Mean: 36%)
D NPV: 93% - 100% (Mean: 97.5%)
Tests and Panels for Late Onset Neonatal Sepsis
D PPV: 71% - 93% (Mean 79%)
D NPV: 75% - 97% (Mean 86%)

Weinberg G A, DAngio C T in Remington J S, Klein J O: Infectious Diseases of the Fetus and Newborn Infant, 6th Ed, 2006, Pg 1216.
Barbara Rath 2007

THE VALUE OF THE LABORATO

the usefulness of a test will depend above all, on the clinical condition of the baby. If the baby is really very sick, the test will not give v

BUT, what about the baby that i

Chiems

11

ROCHESTER LOW-RISK CRITERIA FOR SERIOUS BACTERIAL ILLNESS (0-3 MO)

Hx: Term (>37 Weeks) No antimicrobials Never hospitalized
No unexplained hyperbilirubinemia No chronic or underlying illness
Not hospitalized longer than mother PE: Appears generally well
No evidence skin, bone, soft tissue, joint,
or ear infection Lab: WBC 5000-15,000
Absolute band <1500 Spun urine <10 WBC/HPF
Stool <5 WBC/HPF (if diarrhea)

Barbara Rath 2007

TAIWAN LOW-RISK CRITERIA FOR SERIOUS BACTERIAL ILLNESS (0-28 DAYS)

PE:
D Appears well
D No evidence ear, eye, soft tissue infection
LAB:
D WBC 5,000 15,000
D Absolute band <1500
D Spun urine <10 WBC/HPF
D CRP <20 mg/L
D [ESR <30 mm/hr]

Chiu C-H et al: Pediatr InBfearcbtarDa iRsaJth 12900974;13:946-949 & 1997;16: 59-63

12

MANAGEMENT OF THE FEBRILE INFANT

Decisions on management of febrile (or afebrile) infants should be based mostly on an overall clinical impression, not a single clinical meas
Clinical observation has been objectified to some extent in the Young Infant Observation Scale and the Yale Observation Scale

Barbara Rath 2007

YOUNG INFANT OBSERVATION SCALE (0-2 MO)

AFFECT
D Smiles or not irritable (1)*
D Irritable, consolable (3)
D Irritable, not consolable (5)
RESPIRATORY STATUS & EFFORT
D No impairment, vigorous (1)
D Mild-moderate compromise (tachypnea, retractions, grunting) (3)
D Respiratory distress or inadequate effort (apnea, respiratory failure (5)
PERIPHERAL PERFUSION
D Pink, warm extremities (1) D Mottled, cool extremities (3) D Pale, shock (5)
* No infant who smiled had an SBI
Bonadio W A, et al: PediaBtarrbIanrfa DRaisthJ201097 93; 12: 111-114

13

EFFICACY OF LOW-RISK CRITERIA FOR EXCLUDING SERIOUS NEONATAL BACTERIAL INFECTIONS

Taiwan Criteria
D PPV: 33.6%
D NPV: 99.2% (bacteremia/meningitis: 100%)
Afula Criteria
D PPV: 32%
D NPV: 99.4%
Rochester Criteria
D PPV: 27%*, 35%, 12%
D NPV: 94%*, 97%, 99%
Young Infant Observation Scale (7)
D PPV: 37%
D NPV: 96%
* Ferrera P C, et al: Am J Emerg Med 1997; 15: 299-302
Gara G, et al: Acad Emerg Med 2005; 12: 921-925.
Jaskiewicz J A, et al: PediBaatrribcasra1R9a9t4h;29040:7 390-396

Ooooooops

11-month old male infant with 12 hr Hx low grade fever, irritability, intermittent crying. PE: alert, playful, smiling. Red pharynx, left TM red
5 hrs later: T 39.9C, increasingly lethargic, bulging fontanelle.
CSF cloudy, 8,200 WBC, sugar 45 mg%, protein 160 mg%, Gram-positive diplococci seen. Culture
grew S pneumoniae penicillin-R

Baptist E C: Meningitis in the child with a smile. Arch Pediatr Adolesc Med1995; 14Ba9rb:a1ra1R7a9th 2007

Barbara Rath 2007

CASE #2: FEVER IN AN 18-MONTH OLD

An 18-month old girl is brought to your office on a Thursday morning with a fever for 4 days up to 103.8F by TM thermometer. Her parents tell you she first felt warm when
ROS: Otherwise normal
PMH: Non-contributory. Immunizations up to date.
Family Hx: All well
Social Hx: No travel, friends are well.

CASE #2: FEVER IN 18-MONTH OLD (CONTD

The enhanced urinalysis (hemocytometer count of unspun urine + Gram stain) was normal (no organisms and <10 cells/mm
The next day she still has a fever, but that afternoon the mother calls back concerned because a rash bro
On PE you note a faint pink macular rash most prominent on the neck and trunk, slight on the face and extremities. The child is now afebri
Barbara Rath 2007

Barbara Rath 2007

CASE #2: FEVER IN 3-36 MONTH OLD

(CONTD)

The most likely diagnosis is infection due to:

HHV 6

HHV 7

Echovirus 16(Boston exanthem), 9, 11, 25, 27, 30

Coxsackievirus A6, A9, B1, B2, B4, B5

D Adenovirus

1, 2, 3, 14

D Parainfluenza

D Rotavirus
D Parvovirus

B19

Cherry J D in Feigin, Cherry, Demmler, Kaplan Eds):

th
Textbook of Pediatric Infectious DiseBaasrebas,ra5
RaEtdhit2io0n0,7Pg 772.

Barbara Rath 2007

Barbara Rath 2007

Krugman S, Katz SL, Gershon AA, Wilfert CM. Infectious diseases of children. 9th ed. St. Louis, Missouri: Mosby Year Book Inc. 1992.
Barbara Rath 2007

DOES TEMPERATURE MATTER? SIGNIFICANCE OF FEVER 41.1C

Of no predictive value

Clinical assessment reliably identified those children with hyperpyrexia and serious complicationsand should be used to guide management decisions
Bonadio W A, et al: Pediatr Inf Dis J 1989; 8: 120-122

Highly febrile young children need to be evaluated as thoroughly and carefully as any other febrile child but do not merit special consideration.
Alpert G, et al: Pediatr Inf Dis J 1990; 9: 1611-63

We advise treatment with antibiotics for all children with hyperpyrexia who

do not have a confirmed viral illness and for all children with hyperpyrexia and a confirmed viral illness who are ill
Trautner B W, et al: Pediatrics 2006; 118: 34-40

Barbara Rath 2007

DOES A HIGH WBC COUNT MATTER?

Children 2-24 mo old (mean: 10 mo), 1992-1994, T38.5C
Leukocytosis (LK): 15,000 24,999 (n = 94)
Extreme leukocytosis (EL): 25,000 (n = 69)
Diagnoses

D
D

DiagnosisLKEL

Proven SBI LK vs EL:

17% vs 25%
Proven + Probable
SBI: 35% vs 52%
Hospitalized:
31% vs 49%
25,000-29,999:
RR SBI: 1.36
30,000:
RR SBI: 1.73

*Periorbital cellulitis (3), meningitis, cellulitisB,amrbaarsatoRiadtihtis2,0o07steo, septic arthritis (1 each)

Otitis
Media
Viral Syndrome

41%
18%

9%

Pneumonia

13%

15%

UTI

12%

13%

7%

5%

Gastroenteritis

37%

Aseptic meningitis

2%

6%

Adenitis

2%

6%

Bacteremia

1%

2%

Other*

4.6%

7%

CASE #3: 1

A 16-year old boy comes to your office with his father who is concerned because the boy had a fever for several days, but today woke up with a fever to 40C, flu
R

All immun
Fa
Social Hx: n

CASE #3: 16 YEAR OLD BOY WITH FEVE

PE: On examination you confirm the high fever, pulse of 132; BP 97/65; sick-looking young man. Sa02: 89%. Right knee is mildly swollen a

Barbara Rath 2007

Barbara Rath 2007

Barbara Rath 2007

Barbara Rath 2007

CASE #3: 16 YEAR OLD BOY WITH FEVER (CONTD)

Labs & X-ray
WBC: 9700, 43% N, 28% B, 20% L, 9% M, toxic
granulations noted; Hgb 15.3, Pl 120,000
D UA: 8-10 RBC / HPF
D ESR: 85 mm/hr, CRP: 47
D D dimers (+), fibrin split products (+)
D ALT: 52, AST: 38
D Serum albumin: 2.43 g/dL
D Na: 125
D Creatinine 2.0; BUN 20
D Chest radiograph: bilateral nodular densities

Barbara Rath 2007

SOME POSSIBLE ETIOLOGIES

D NEISSERIA MENINGITIDIS
GROUP A STREPTOCOCCUS D STAPHYLOCOCCUS AUREUS D SALMONELLA TYPHOSA
D RICKETTSIA RICKETTSII D ERHLICHIA CHAFEENSIS D LEPTOSPIRA SPP
D

Barbara Rath 2007

CASE #3: 16 YEAR OLD BOY WITH FEVER

Pt started on ceftriaxone, vancomycin, gentamicin
Blood culture grew out S aureus, methicillin-R

Severe staphylococcal sepsis in adolescents*

D 90% with bone and/or joint infection
90% with pulmonary septic emboli, pneumatocoeles, and/or parapneumonic effusions
D 30% bacterial venous thrombophlebitis
D 50% Renal failure
D DIC
D Skin lesions: urticaria, e multiforme, papular-pustular

* Gonzalez B E, et al: Pediatrics 2005; 115: 642-648

Barbara Rath 2007

SCENARIO #4: Hes had a fever, but hes

been teething...

Signs and symptoms significantly associated 4 days before to 3 days after teething are:

Biting

Irritability

Drooling

Wakefulness

Rash on face

Appetite (solids)

Sucking

Ear-rubbing

Gum-rubbing

Temp Elevation*

*Day of emergence vs before: 17% vs 12% >100F; 6% vs 3% >101F

Macknin M L, et al: Pediatrics 2000; 105:747-752

Barbara Rath 2007

Scenario #5: His temperature was around

39
- Fever Detection by Palpation

~60% of parents use palpation as the usual method of fever

assessment

85% - 99% believe they can detect fever by palpation

Actual accuracy of parental palpation for fever:

D

Sensitivity: 77%1, 84%2, 90%3 , 74%4

Specificity: 82%, 76%, 78%, 86%

Positive predictive value: 59%, 72%, 69%, 71%

Negative predictive value: 85%, 91%, 91%, 94%

1. Katz-Sidlow R, et al: Ped Acad Soc Meeting; May 2, 2006; 2. Graneto J W, Soglin D F:
Ped Emerg Care 1996; 12: 183-184; 3. Ernst T N, Philp M: Amer J Dis Child 1985; 139:
546; 4.Banco L, Veltri D: Amer J Dis Child 1984; 138; 976-978.
Barbara Rath 2007

Scenario #5: His temperature was around

39..*
If it is important to know the real temperature (and it may not be) ask:
D Where did you take the temp?
D What kind of thermometer did you use?
D How long did you leave it in place?
D Around? Was it below 39 or above?

ANXIOUS PARENTS
170 parents of young febrile children who presented to a pediatric emergency
department (ED) with fever;
* Translation: Im worried and I want you to worry too.
Barbara Rath 2007

90-item questionnaire (State Trait Anxiety Inventory)

Parents were asked what they had previously thought about and how they felt
about the ED process.

(1)

Mean parental anxiety was 50.1 (95% CI 48.1, 52.2), significantly elevated from
adult standards (p < 0.0001).
A multivariate model comprising:
feeling "not at all" well rested,
(2) having no other children,
(3) having thought about a blood test, and
(4) feeling worried about trusting the physician was
associated with elevated anxiety.
In conclusion, parents of febrile young children in the ED are very anxious.
Parkinson GW, Gordon KE, Camfield CS, Fitzpatrick EA. Anxiety in Parents of Young Febrile Children in a
Pediatric Emergency Department: Why is it El evated? Clinical Pediatrics 1999;38(4):219.
Barbara Rath 2007

SUMMARY
Normal body temperature varies widely
Fever can be arbitrarily defined as a temp of 38C (100.4F) at any site using any approved instrument
Teething may be associated with minimal elevation in temperature
Palpation is not an accurate way to determine presence of fever, but its not bad for its absence

Barbara Rath 2007

SUMMAR
Overall clinical impression, supported by laboratory or imaging studies, rather than height of temperature or abnormal lab

Barbara Rath 2007

Acknowledgements
S MICHAEL MARCY, MD CLINICAL PROFESSOR OF PEDIATRICS
UNIVERSITY OF CALIFORNIA LOS ANGELES UNIVERSITY OF SOUTHERN CALIFORNIA SCHOOLS OF MEDICINE
Team Lead, Brighton Collaboration Fever Working Group, Member, Brighton Collaboration Steering Committee

Barbara Rath 2007