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Ridgeview and the Ridgeview Continuing Medical Education Program are proud to present the Ridgeview Podcast: CME Series. Quality, portable and on-demand continuing medical education, featuring a variety of our exceptional physicians, providers and other staff from Ridgeview and it's affiliates. Hosting the program are Fred Demeuse, PA-C and Jason Hicks, PA-C. Thanks for tuning-in, downloading and listening! 

 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview & Ridgeview Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Sep 11, 2020

This podcast presents, Dr. Patrick Carolan, a pediatric emergency medicine physician with Minneapolis Children's Hospital and Clinics of Minnesota, who discusses the evaluation of fever in the neonate and young infant. 

Enjoy the podcast!

Objectives:  
  Upon completion of this podcast, participants should be able to:

  • Recognize the implications of fever in the young infant.
  • Discuss the differential diagnosis of fever and critical illness in the young infant.
  • Implement new concepts in risk stratification for evaluating fever in young infants.

CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org.

To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.

 CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

SHOW NOTES:

CHAPTER 1:
Today we are talking about fever in the pediatric population, specifically those in the under 3-months of age. Dr. Pat Carolan of Children's Hospitals of Minnesota  will help us demystify fever in this age group. 

Going back to the mid-70s, there was a search for criteria to find high-risk vs low-risk pediatric fevers. In the original study out of Boston, it was identified that 10% of the patients under age 2, with WBC greater than 15, and a temperature greater than 38.9C, had severe bacteremia. This was the first set of criteria focused on identifying high-risk infants. With the intro of HIb vaccine in the the late 80s-early 90s, and the pneumococcal vaccine in the mid-90s, there is a much lower prevalence of these infections. The few cases that occur now are due to those who have not received or are non-responders to the vaccine. The shift in study of pediatrics has now been to better differentiate high-risk vs low-risk febrile infants.

What is considered a fever? The traditional definition of fever is a temperature over 100.4F. Pediatric fevers can be broken down into 3 groups. Those in 0-28 days are high-risk and regardless of a positive RSV or influenza test, get a full work up - including blood, urine, csf, cultures, antibiotics, and admission.  What if they are 0-28 days and they have otitis media or RSV? The clinical exam of otitis media in this aged population would be difficult, and even if the clinician had confidence in a focal finding, those at this age group are still at significant risk and would get a full work up. RSV would be unusual in a 2-week old and even if positive , that would be an usual finding, and again these neonates would still get a full work up. The rates of bacteremia in studies have shown that a full work up is warranted. Infants at 3-months are lower-risk, and in general, can usually be managed as outpatients with lab work. Risk for infants in the 2nd month of life is harder to determine and they are the target of risk stratification tools discussed later in this podcast. These are the "tweeners". Initially, assessment of these infants include that across the room pediatric triage triangle. How are they reacting to stimulus? What does their skin color look like? What is their body tone? Have the parents noted whether the infant is engaged in feeding? Are they tachycardiac? Infants can present with fever, but some infants that are septic, can present afebrile or hypothermic. Remember, it is important not to overlook a potential differential diagnosis, including congenital ductal lesions or metabolic abnormalities.

CHAPTER 2:
Risk stratification tools vary, but utilize biomarkers such as procalcitonin and CRP as key features of the pathways. Each tool mentioned today, PECARN, Stepwise and Rochester, all have high sensitivity and high-negative predictive values. Choosing the appropriate tool depends on the patient population, ability to run specific biomarker tests, and comfort level in the subsequent interpretation. For example, the availability of a facility to run a procalcitonin would determine whether a particular stratification tool could be used. The most recent study, conducted by PECARN or the Pediatric Emergency Care Applied Research Network, is a large, multicenter study that uses procalcitonin, absolute neutrophil count and urine analysis as the base of its pathway. The PECARN is structured as a decision tree, formatted in a way, to quote Dr. Carolan that "helps decision making in the trenches."

Differentiating between the terms "serious" vs "invasive" infections.
Serious infections include, but are not limited to bacterial, bone and joint infections, and UTIs. Invasive includes pneumococcal meningitis and HIB. In the simplest terms, invasive infections are of greater concern, and is "the stuff we want to treat immediately". Bacterial organisms of concern include: group B strep and gram negative organisms for neonates, pneumococcus and more rarely, HIV at 1-month and older. E.Coli, especially as a uro pathogen and Listeria, though rarer, makes the list of concern as well. An important viral organism of concern is Herpes Simplex Virus, which depending on the facility, is an add on order when running CSF. HSV has 3 main types, the most devistating a CNS infection, which presents with fever and seizures - whether focal or generalized. Pleocytosis, or WBC greater than 16 in CSF, is abnormal in those less than 28-days of age. WBC greater than 10 is abnormal for 2-3 months of age. An absence of pleocytosis does not exclude a central nervous infection by HSV.

CHAPTER 3:
At 2-months of age, infants that meet low-risk criteria, can be treated as an outpatient - if next day follow-up can be assured. Conservative treatment for those with a UTI that have an abnormal urine and positive biomarker, would get blood cultures, LP and antibiotics. The odds ratio is low, but gram negative CNS infections can be devastating and require extended treatment of antibiotics. The stratification tools, PECARN, Stepwise, and Rochester, help guide practice for these 2-month old infants or "tweeners", but it can still be difficult to decide whether or not to do an LP. There is still a place for practitioner gestalt, and if something feels not quite right, an LP is appropriate.

Some infants are brought to the ER with reports of a fever, but upon presentation are afebrile. If a rectal temp performed at home, then it is regarded as a true fever, and the age appropriate work up should be started. Empiric treatment for infants include: Ampicillin and Cefotaxime. Cefotaxime is the go to for 3rd generation cephalosporin, instead of Rocephin, which can cause a rise in bilirubin in young infants. For those under 3-weeks, Acyclovir coverage is added till HSV is ruled out. Vancomycin would be used for those beyond 2-weeks of life with pneumococcus or staph infection with sepsis. Tamiflu is started for infants with positive influenza greater than 2-weeks and under 2-years of age, per CDC recommendations. For those infants who are not vaccinated, the plan of care does not change for those under 3-months or greater that are vaccinated. Intuitively, it would be suggested that they are at higher risk, but there is little data bout this specific group.

Thanks for listening.