Don't assume that febrile illnesses aren't serious

Effects might last more than a week

Children with febrile illnesses might have more serious outcomes than you expect, according to new research on 322 children presenting with fever who were discharged from a pediatric ED. The researchers contacted caregivers by telephone seven to 10 days after the ED visit and learned that 38.9% of children remained febrile for five days or longer, and impairments in activity, oral intake, sleep, and behavior persisted longer than 2.5 days.1

"Most emergency department staff, not just nurses, often refer to febrile illnesses as 'mild' or 'minor,'" says Rakesh D. Mistry, MD, MS, the study's author and ED physician at Children's Hospital of Philadelphia. "Many of these children tend to be triaged as nonurgent and just shuttled in and out of EDs as rapidly as possible."

However, the study shows that there are often substantial effects of fever and febrile illnesses for more than a week, says Mistry. "In most cases there is little that we can do to change these outcomes," he says. 'But I think it is important for nurses and physicians to realize that febrile illnesses may not be as benign as previously believed."

When children with fever are discharged from the ED, there is a tendency to assume that the illnesses resolve without consequence, but 23.7% children in the study had repeat visits for their illness, says Mistry. "Think about that for a minute: Nearly one in 4 children had a nonscheduled return visit," he says. "We must realize that the ED is one aspect of the continuum of care, and these illnesses need ongoing care in many instances."

When discharging children with febrile illnesses, explain to parents that many children are affected for more than four days, either with fever or other functional impairments, advises Mistry.

"If parents are aware of this potential, it could possibly decrease their stress level over their child's illness, and even decrease health care revisitation," he says. "Anticipatory guidance is essential to emergency medicine practice, and we must properly inform parents what to expect." Febrile children should not be discharged if they are ill or toxic-appearing, are immunosuppressed, or have a presumed life-threatening infection, adds Mistry.

Also emphasize the importance of antipyretics in the home care of these children, says Mistry. "We found that despite the fact that children experienced prolonged fever, longer than five or even seven days, parents were rarely administering adequate dose frequency of acetaminophen or ibuprofen," he says.

Adequate antipyresis could reduce febrile periods and functional impairment, explains Mistry. "This could in turn reduce revisits to health care, since these outcomes often are the impetus for caregivers to seek health care again," he says.

Do these interventions

Look for these signs that a child's febrile illness may be becoming life-threatening: Lethargy and/or altered mental status; prolonged seizures with hypoxia or any oxygen compromise including apnea, mottling, or pallor; petechial rashes; and tachycardia with hypotension, says Sarah Riley, RN, MSN, nurse manager of the ED at Cook Children's Medical Center in Fort Worth, TX. (See related story, at the end, for questions you should ask at triage.)

Consider the child's age, as a 2-year old with a fever of 101° F is much different than a 3-week old with the same temperature, she says. "With the febrile neonate, a much more extensive work-up and much more severe illness can be anticipated than the toddler," says Riley. Also take into consideration if the fever is subjective or objective, says Riley. "Many families come to the ED with complaints of fever, but the temperature has never been taken," she adds.

Key indicators include skin color, temperature, level of consciousness, and oxygenation, says Riley. "Any deviations in these are a red flag for the ED nurse that the patient's condition is deteriorating and causes should be quickly identified and treated," she says.

For example, if a child presents with a history of headache and fever for the past two days, the eruption of a petechial rash with these associated symptoms should alert you that meningitis is a possible diagnosis, says Riley. "With the rash, a later symptom, the ED nurse would then take a different care path than from the patient with just a fever, thus anticipating a rapid deterioration."

Reference

1. Mistry RD, Stevens MW, Gorelick MH. Short-term outcomes of pediatric emergency department febrile illnesses. Ped Emerg Care 2007; 23:617-623.

Sources

For more information about febrile illnesses in pediatric patients, contact:

  • Rakesh D. Mistry, MD, MS, Division of Emergency Medicine, Children's Hospital of Philadelphia. Phone: (215) 590-1000.
  • Sarah Riley, RN, MSN, Nurse Manager, Emergency Department, Cook Children's Medical Center, Fort Worth, TX. Phone: (682) 885-4901. E-mail: sarahri@cookchildrens.org.

Ask these questions for children with fever

If a child presents with fever or chief complaint of fever, always ask these questions, says Michelle Schnedler, RN, associate nurse manager for the Emergency Center at William Beaumont Hospital in Royal Oak, MI:

  • When did the fever start?
  • Is your child acting differently or not as active as normal?
  • Did you give the child any medications for the fever? If so, what time? "This is important, to avoid overdosing in the ED," says Schnedler.
  • Is the child experiencing any vomiting, diarrhea, and/or poor appetite?
  • When is the last time your child urinated, and how many times today?
  • Has your child been exposed to any illnesses or infections?
  • Is anyone else in the home sick?

Signs that a child's condition is serious or potentially life-threatening include listlessness, decrease in mental status, respiratory distress, poor perfusion, bulging or sunken fontanel under six months in age, development of a rash, poor feeding, and constant vomiting and diarrhea, says Schnedler.

Kimerlie Stover, RN, BSN, CPN, manager of the ED and observation unit at Children's Hospital of Michigan in Detroit, says, "You want to know the child's hydration status, to be sure they are drinking and keeping fluids down." Offer popsicles, Stover says. "These are a good source of fluid, plus the coolness will help with the fever."

Signs of dehydration include decreased urine output, dark circles around eyes, sunken fontanel in infants, and "generally looking like a limp dish rag," says Stover.

Ask if their immunizations are up to date as well, says Stover. "Immunization status is always important when looking at children," she says. "HIB immunizes against some meningitis bugs. Pertussis could be an issue for those not immunized."

Also ask whether activity level has changed with the fever, advises Stover. "Low activity level could warrant further investigation to make sure nothing more serious is going on, like a bacterial infection that would need antibiotic therapy," she says.

Sources

For more information on questions to ask about fever at triage, contact:

  • Michelle Schnedler, RN, Associate Nurse Manager, Emergency Center, William Beaumont Hospital, Royal Oak, MI. Phone: (248) 898-113. E-mail: michelle.schnedler@beaumonthospitals.com.
  • Kimerlie Stover, RN, BSN, CPN, Manager, Emergency Department and Observation Unit, Children's Hospital of Michigan, Detroit, MI. Phone: (313) 745-5210. E-mail: KStover@dmc.org.