LAS VEGAS—It’s an adage as old as Hippocrates: The higher a febrile child’s fever climbs, the more dangerous the cause must be.
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“There’s a concept that the higher the fever, the sicker you must be,” Al Sacchetti, MD, FACEP, said at the rapid-fire session, “Staying Cool with Pediatric Fever.” “The reality of it is: not really. In fact, over 38 [degrees Celsius] or over 39, it really doesn’t matter how high the fever is…the last meningitis case I saw, the kid’s temperature was 100.8 –[degrees Fahrenheit].”
Now, of course, over 106 degrees, more than 50 percent of cases are viral. But Dr. Sacchetti’s overarching point: most fevers without source (FWS) are just that. And, for his part, emergency physician Glenn Hornstein, MD, of Salisbury, Maryland, was perfectly glad to hear the news.
“You want to do what’s necessary in the workup for the patient,” he said. “You don’t want to do too much. That’s what a lecture like this helps reinforce: that we’re doing the right thing for the patient and we’re not harming the patient by doing too much, but doing what’s necessary.”
Emergency medicine veteran Dr. Sacchetti—who joked that when he first gave this lecture now timed at 25 minutes, it took two carousels of slides—said most physicians run through proper workups and checklists for presentations of pediatric fever.
One area of current concern is unvaccinated children, a phenomenon that he’s not seen since early in his career, he said. Fevers in those children need to be treated differently and watched closely. Be aware that the height of the fever changes. Note that if the child presents as toxic, proceed immediately to a septic workup. Also, pay attention to the child’s siblings for potential issues or clues,” he said.
The “physical exam changes in that the kid has to look even better than perfect to send him home,” he said. “Whereas, now if you’re vaccinated, you can take a pukey kid and send him home. You can’t if they’re unvaccinated.”
Still, despite all the tests, all the individual scenarios he presented and all the practice-management algorithms required to guard against rare outcomes, Dr. Sacchetti suggested that clinicians would do well to rely on their exhaustive training and their gut feelings.
“Here’s the kicker,” he added. “If [febrile children] look sick, they are sick. If they look well, they’re probably well—but don’t get too cocky.”