Afebrile Children Research Articles

Transient Peripheral Leukocytosis in Children With Afebrile Seizures

The purpose of this study was (1) to demonstrate whether peripheral blood leukocytosis accompanies first afebrile seizures without bacterial infection, (2) to investigate the duration of leukocytosis, and (3) to assess the relationship between peripheral blood leukocytosis and seizure characteristics. Complete blood count was routinely obtained from all the patients. Blood and urine cultures were obtained from patients with leukocytosis. On the 24th hour of admission, a second complete blood count was obtained from patients with initial leukocytosis. Sixty-two children aged 4.0 +/- 3.6 years (range, 6 months-13 years)-31 boys (50%) and 31 girls (50%)--enrolled in the study. The findings showed that peripheral blood leukocytosis was found in 8% of afebrile children without status epilepticus and 41.6% of afebrile children with status epilepticus. An interesting finding of the study was that peripheral blood leukocytosis accompanied by afebrile seizures subsided in 24 hours. Transient leukocytosis could be found in children with afebrile seizures without bacterial infection.

Alternating ibuprofen and acetaminophen in the treatment of febrile children: a pilot study [ISRCTN30487061

BackgroundAlternating ibuprofen and acetaminophen for the treatment of febrile children is a prevalent practice among physicians and parents, despite the lack of evidence on effectiveness or safety. This randomized, double-blind and placebo-controlled clinical trial aims at comparing the antipyretic effectiveness and safety of a single administration of alternating ibuprofen and acetaminophen doses to that of ibuprofen mono-therapy in febrile children.MethodsSeventy febrile children were randomly allocated to receive either a single oral dose of 10 mg/kg ibuprofen and 15 mg/kg oral acetaminophen after 4 hours, or a similar dose of ibuprofen and placebo at 4 hours. Rectal temperature was measured at baseline, 4, 5, 6, 7 and 8 hours later. Endpoints included proportions of afebrile children at 6, 7 and 8 hours, maximum decline in temperature, time to recurrence of fever, and change in temperature from baseline at each time point. Intent-to-treat analysis was planned with statistical significance set at P < 0.05.ResultsA higher proportion of subjects in the intervention group (83.3%) became afebrile at 6 hours than in the control group (57.6%); P = 0.018. This difference was accentuated at 7 and 8 hours (P < 0.001) with a significantly longer time to recurrence of fever in the intervention group (mean ± SD of 7.4 ± 1.3 versus 5.7 ± 2.2 hours), P < 0.001. Odds ratios (95%CI) for defervescence were 5.6 (1.3; 23.8), 19.5 (3.5; 108.9) and 15.3 (3.4; 68.3) at 6, 7 and 8 hours respectively. Two-way ANOVA with repeated measures over time revealed a significantly larger decline in temperature in the intervention group at times 7 (P = 0.026) and 8 (P = 0.002) hours.ConclusionA single dose of alternating ibuprofen and acetaminophen appears to be a superior antipyretic regimen than ibuprofen mono-therapy. Further studies are needed to confirm these findings.

Unsuspected Kingella kingae infections in afebrile children with mild skeletal symptoms: the importance of blood cultures.

Unsuspected Kingella kingae infections in afebrile children with mild skeletal symptoms: the importance of blood cultures.

Nebulized Magnesium for Kids with Asthma -- The Jury Is Still Out

Magnesium might be beneficial in asthma treatment because it inhibits calcium uptake and leads to smooth-muscle relaxation. To assess the efficacy of nebulized magnesium, researchers performed a double-blind, randomized study in a convenience sample of afebrile children (age, 5-17 years) who presented to an emergency department …

Intestinal Protein Loss and Hypoalbuminemia in Children with Pneumonia

ABSTRACTBackgroundIntestinal protein loss has been reported mainly in diseases affecting the gastrointestinal tract. Intestinal protein loss during pneumonia with effusion has not been reported to date. The authors attempted to assess the associations between pneumonia with effusion and intestinal protein loss and hypoalbuminemia in children.MethodsThis was a prospective consecutive case series study of in children hospitalized with pneumonia and effusion during a period of 4½ years. Serum albumin, C‐reactive protein (CRP), and fecal α‐1 antitrypsin (α‐1‐AT) were measured in the first 72 hours of hospitalization. Two control groups were studied: one consisted of 50 febrile children hospitalized because of viral or mild bacterial infections, and the other consisted of 20 afebrile children hospitalized because of convulsive disorders.ResultsSixty‐seven children ages 4 months to 14 years hospitalized with pneumonia and effusion were enrolled in the study. Fifty‐nine percent (40 children) were found to have elevated fecal α‐1‐AT excretion (range, 2–10 mg/g) compared with none in the two control groups (P &lt; 0.000).Fifty‐two percent (35 children) of the children with pneumonia and effusion had mild to moderate hypoalbuminemia (range, 22–34 g/L). Only one child (2%) in the febrile control group had a low albumin of 34 g/L; none were found in the afebrile control group. The level of fecal α‐1‐AT was inversely correlated with serum albumin level.ConclusionsPneumonia with effusion in children is often associated with an intestinal protein loss that can be monitored by measuring gastrointestinal loss of protein, namely fecal α‐1‐AT. In most cases the development of hypoalbuminemia correlates with the development of intestinal protein loss.

Intestinal protein loss and hypoalbuminemia in children with pneumonia.

Intestinal protein loss has been reported mainly in diseases affecting the gastrointestinal tract. Intestinal protein loss during pneumonia with effusion has not been reported to date. The authors attempted to assess the associations between pneumonia with effusion and intestinal protein loss and hypoalbuminemia in children. This was a prospective consecutive case series study of in children hospitalized with pneumonia and effusion during a period of 4(1/2) years. Serum albumin, C-reactive protein (CRP), and fecal alpha-1 antitrypsin (alpha-1-AT) were measured in the first 72 hours of hospitalization. Two control groups were studied: one consisted of 50 febrile children hospitalized because of viral or mild bacterial infections, and the other consisted of 20 afebrile children hospitalized because of convulsive disorders. Sixty-seven children ages 4 months to 14 years hospitalized with pneumonia and effusion were enrolled in the study. Fifty-nine percent (40 children) were found to have elevated fecal alpha-1-AT excretion (range, 2-10 mg/g) compared with none in the two control groups (P < 0.000).Fifty-two percent (35 children) of the children with pneumonia and effusion had mild to moderate hypoalbuminemia (range, 22-34 g/L). Only one child (2%) in the febrile control group had a low albumin of 34 g/L; none were found in the afebrile control group. The level of fecal alpha-1-AT was inversely correlated with serum albumin level. Pneumonia with effusion in children is often associated with an intestinal protein loss that can be monitored by measuring gastrointestinal loss of protein, namely fecal alpha-1-AT. In most cases the development of hypoalbuminemia correlates with the development of intestinal protein loss.

Rapid antigen assay for the diagnosis of pneumococcal bacteremia in children: A preliminary study

Study objective: We determine the sensitivity of a new Streptococcus pneumoniae antigen assay in children with S pneumoniae bacteremia and also determine the specificity of the assay in afebrile children without apparent pneumococcal infection. Methods: We enrolled 2 groups of children, 3 months to 5 years of age, presenting to an urban pediatric emergency department or hospital-based clinic between January 1, 2000, and January 1, 2001. The study group included patients with S pneumoniae bacteremia. The control group included patients without fever or identified focal bacterial infection (other than a urinary tract infection). We excluded from the control group patients with a recent diagnosis (prior 4 weeks) of bacteremia, pneumonia, meningitis, acute otitis media, or other suspected S pneumoniae infection. Results: Ninety-six patients were enrolled: 24 children with S pneumoniae bacteremia and 72 afebrile control patients. The assay produced a positive result in 23 of 24 patients with pneumococcal bacteremia, yielding a sensitivity of 95.8% (95% confidence interval [CI] 78.9% to 99.9%). The test result was negative in 67 of 72 afebrile patients without apparent pneumococcal infection, yielding a specificity in this population of 93.0% (95% CI 83.4% to 97.5%). Conclusion: This S pneumoniae assay demonstrated high sensitivity for the defined bacteremic population, as well as high specificity among afebrile children without apparent pneumococcal infection. Further study in febrile children at risk of pneumococcal bacteremia is needed before the value of the test in children at risk for invasive pneumococcal disease can be determined. [Ann Emerg Med. 2002;40:399-404.]

Rapid antigen assay for the diagnosis of pneumococcal bacteremia in children: A preliminary study

Study objective: We determine the sensitivity of a new Streptococcus pneumoniae antigen assay in children with S pneumoniae bacteremia and also determine the specificity of the assay in afebrile children without apparent pneumococcal infection. Methods: We enrolled 2 groups of children, 3 months to 5 years of age, presenting to an urban pediatric emergency department or hospital-based clinic between January 1, 2000, and January 1, 2001. The study group included patients with S pneumoniae bacteremia. The control group included patients without fever or identified focal bacterial infection (other than a urinary tract infection). We excluded from the control group patients with a recent diagnosis (prior 4 weeks) of bacteremia, pneumonia, meningitis, acute otitis media, or other suspected S pneumoniae infection. Results: Ninety-six patients were enrolled: 24 children with S pneumoniae bacteremia and 72 afebrile control patients. The assay produced a positive result in 23 of 24 patients with pneumococcal bacteremia, yielding a sensitivity of 95.8% (95% confidence interval [CI] 78.9% to 99.9%). The test result was negative in 67 of 72 afebrile patients without apparent pneumococcal infection, yielding a specificity in this population of 93.0% (95% CI 83.4% to 97.5%). Conclusion: This S pneumoniae assay demonstrated high sensitivity for the defined bacteremic population, as well as high specificity among afebrile children without apparent pneumococcal infection. Further study in febrile children at risk of pneumococcal bacteremia is needed before the value of the test in children at risk for invasive pneumococcal disease can be determined. [Ann Emerg Med. 2002;40:399-404.]

A randomized safety and tolerability trial of artesunate plus sulfadoxine-pyrimethamine versus sulfadoxine-pyrimethamine alone for the treatment of uncomplicated malaria in Gambian children

Artemisinin derivatives, such as artesunate, have a short half-life and very rapid anti-malarial activity. Theoretically, using such agents in conjunction with well-established anti-malarial drugs such as sulfadoxine-pyrimethamine may reduce the rate of drug resistance. Such a combination has not previously been used in Africa. We have conducted a pilot safety trial of artesunate (4 mg/kg for 3 days) given with a single dose of sulfadoxine-pyrimethamine (25 mg/kg sulfadoxine) compared to sulfadoxine-pyrimethamine alone among 40 Gambian children with uncomplicated malaria. Both regimens were safe and well tolerated and there were no adverse experiences attributed to the combination. The addition of artesunate resulted in a higher proportion of afebrile children and children with a negative blood film on Day 2, and a reduction in the proportion of gametocyte carriers, when compared to sulfadoxine-pyrimethamine alone.

Palpation as a method of fever determination in Malawian children who are less than 5 years old: how reliable is it ?

Fever is a common occurrence in children who are < 5 years old and palpation of the forehead may or may not be a reliable method for determining fever in such children. In a study of 1120 Malawian children of this age attending outpatient's clinics, each child's mother and a clinical officer (CO) were asked to palpate the child's forehead and decide whether the child was febrile (felt warm or very warm) or afebrile (felt normal). The rectal temperature of each child was then taken using a thermometer and the child considered febrile if this temperature was > or = 38 degrees C. Using palpation, mothers judged 973 (86.9%) of 1120 children to be febrile and CO judged 565 (50.4%) of 1118 to be febrile, whereas thermometer readings indicated 410 (36.7%) to be truly febrile. False-positives (i.e. afebrile children judged to be febrile by palpation) accounted for 574 (59.0%) of the 973 children who were considered febrile by their mothers and 228 (40.4%) of the 565 children so considered by CO; mothers reported significantly more false-positives than CO (P < 0.05). False-negatives (i.e. febrile children judged to be afebrile by palpation) accounted for 11 (7.5%) of the 147 children who were considered afebrile by their mothers and 73 (13.2%) of the 553 children so considered by CO; CO reported significantly more false-negatives than mothers (P < 0.05). Overall, mothers were as likely as CO to misjudge a child (721/1120 v. 781/1118; P > 0.05). Although the sensitivity of mothers and CO in determining fever was similar (97.3% v. 82.2%; P > 0.05), CO gave a higher degree of specificity than the mothers (67.8% v. 19.2%; P < 0.000001). Although the present results indicate that palpation is not a reliable method of determining fever in children who are < 5 years old, caregivers should continue to use palpation as a useful first step in deciding when a child needs to be referred.

Palpation as a method of fever determination in Malawian children who are less than 5 years old: how reliable is it?

Fever is a common occurrence in children who are < 5 years old and palpation of the forehead may or may not be a reliable method for determining fever in such children. In a study of 1120 Malawian children of this age attending outpatient's clinics, each child's mother and a clinical officer (CO) were asked to palpate the child's forehead and decide whether the child was febrile (felt warm or very warm) or afebrile (felt normal). The rectal temperature of each child was then taken using a thermometer and the child considered febrile if this temperature was ≥38°C. Using palpation, mothers judged 973 (86.9%) of 1120 children to be febrile and CO judged 565 (50.4%) of.1118 to be febrile, whereas thermometer readings indicated 410 (36.7%) to be truly febrile. False-positives (i.e. afebrile children judged to be febrile by palpation) accounted for 574 (59.0%) of the 973 children who were considered febrile by their mothers and 228 (40.4%) of the 565 children so considered by CO; mothers reported significantly more false-positives than CO (P < 0.05). False-negatives (i.e. febrile children judged to be afebrile by palpation) accounted for 11 (7.5%) of the 147 children who were considered afebrile by their mothers and 73 (13.2%) of the 553 children so considered by CO; CO reported significantly more false-negatives than mothers (P < 0.05). Overall, mothers were as likely as CO to misjudge a child (721/1120 v. 781/1118; P > 0.05). Although the sensitivity of mothers and CO in determining fever was similar (97.3% v. 82.2%; P > 0.05), CO gave a higher degree of specificity than the mothers (67.8% v. 19.2%; P < 0.000001). Although the present results indicate that palpation is not a reliable method of determining fever in children who are < 5 years old, caregivers should continue to use palpation as a useful first step in deciding when a child needs to be referred.

Maternal screening of childhood fever by palpation.

Fever is a common chief complaint for the pediatric emergency patient. It has been reported that a mother's tactile examination of a child, as historical information, offers little useful information. The study objective is to determine whether mothers can accurately detect the presence or absence of a fever without using a thermometer. The study is a prospective comparison of historical information with measured temperature, performed over a two-month period. The settings are in two inner-city university hospital emergency departments. Mothers of children less than 10 years old who presented to the emergency department with any chief complaint were selected as subjects. The interventions were interviewing the mother and the performance of routine vital signs on the child. Three hundred and twenty-two mothers participated. Of 124 febrile children, 104 mothers accurately detected a fever in their children (sensitivity 84%), while of 198 afebrile children, 150 mothers accurately detected the absence of fever (specificity 76%). We conclude that mothers are able to provide accurate information about the presence or absence of fever in their children by touch and without the use of a thermometer. Thus emergency physicians should heed the historical statements of mothers presenting with only the subjective complaints of fever and no history of thermometer use.

Subacute sinusitis: Are antimicrobials necessary?

Background: The need for antimicrobials in the treatment of subacute sinusitis was evaluated in 96 afebrile children who were prescribed antimicrobial (amoxiicillin, amoxicillin clavulanate pottassium, or trimethoprim-sulfamethoxazole) or no antimicrobial medication in addition to a decongestant and saline nasal spray for 3 weeks. Methods: Response was determined by complete clearing of the initial radiologic abnormalities or in the case of mucosal thickening by a significant decrease in thickness to <6 mm within the maxillary sinuses associated with improvement of the clinical signs and symptoms of sinusitis. If there was evidence of partial clearing by radiograph, the same therapy was continued for another 3 weeks. Nonresponders demonstrated no change or worsening of clinical and radiologic findings. Results: Sixty-seven of the 96 subjects (70%) responded: 58 (87%) in 3 weeks and 9 (13%) in 6 weeks. Fifty-five of the responders were in the antimicrobial treatment group, and 12 were prescribed no antimicrobial medication. Twenty-nine of the 96 subjects (30%) did not respond to treatment; 22 received an antimicrobial and seven received no antimicrobial medication. Conclusions: The number of responders and nonresponders was similar in the antimicrobial- and nonantimicrobial-treated groups (p = NS), and no single antimicrobial medication demonstrated greater treatment effectiveness.

Missed appendicitis in a pediatric emergency department

Appendicitis is the most common cause of abdominal pain requiring surgery in children. Missed appendicitis is also a frequent cause of professional liability in an emergency department (ED). A retrospective review of all patients with appendicitis diagnosed in the ED was undertaken to identify: 1) how many patients required more than one visit to diagnose appendicitis and 2) the clinical characteristics that distinguished the patients who visited twice from patients who were diagnosed on the first visit. A total of 87 patients with appendicitis were seen by pediatricians in the ED from 1987 to 1989. The patients included 43 girls and 44 boys (mean age, 8.9 years). Six patients (7%) were seen twice before the diagnosis of appendicitis was made. They returned to the ED on average 29 hours after the first visit. The ED discharge diagnosis of the six "missed" patients included: probable Campylobacter (n = 1), viral urinary tract infection (n = 1), gastroenteritis (n = 2), and abdominal pain (n = 2). The six missed patients were different from the other patients with appendicitis. They were more likely to have a normal appetite, to have diarrhea, and to be afebrile. All the patients had at least two of the four following signs and symptoms: vomiting, tenderness, guarding, and right lower quadrant (RLQ) pain. At the time of surgery, 23/81 (28%) of the one-visit group had a ruptured appendix, whereas 3/6 (50%) of the missed patients had a ruptured appendix. 1) Seven percent of the patients were seen twice in our ED before the diagnosis of appendicitis was made.(ABSTRACT TRUNCATED AT 250 WORDS)

Physicians Treating Their Own Children

To determine the types of health care interventions physicians provided to their own children, identify those conditions most often treated by physician-parents, compare the differences in treatment practices among physician groups, and explore the reasons physicians give for treating their own children. Questionnaire. University-affiliated teaching hospital in Iowa City, Iowa. Three hundred fifty-three physicians in residency and fellowship training and faculty who were parents of children aged 18 years or younger. None. The majority of physicians reported treating their afebrile child for acute illness. Fifty-five percent of physicians reported that they rarely or never treated their febrile child (temperature > 38.3 degrees C) without consultation with the child's physician. Only 47% of physicians reported that they always performed a physical examination on their child before treating. Physician-parents were more likely to auscultate the child's chest or perform otoscopy and less likely to obtain urine samples or throat swabs for culture before treating. Sixty-two percent of physicians reported that they have never performed routine health maintenance examinations on their own children, but 29% referred their children to a specialist. Medications were prescribed for their children by 65% of physicians. Neither gender nor level of training influenced the treatment practices of physician-parents. Primary care physicians were less likely to contact the child's physician for advice in treating their febrile child than were subspecialists. Pediatricians more often treated their afebrile and febrile children, performed physical examinations and laboratory studies, and prescribed medications than did other primary care physicians. Convenience was the most important reason physicians gave for treating their own children. Physicians frequently treat their own ill children, prescribe medications for them, and self-refer them to specialists largely for the sake of convenience.

Malaria in a rural area of Sierra Leone. II. Parasitological and related results from pre- and post-rains clinical surveys.

The prevalence of Plasmodium falciparum in a cohort of over 900 nought to seven-year-old children living in a rural area of Sierra Leone was found to be approximately 61%, both before and after the rainy season. Plasmodium malariae rates measured in the same children were approximately 12%, and P. ovale rates averaged about 1%. Spleen rates averaged 44% for the two surveys; the age prevalence spleen profiles closely matched those for P. falciparum. The overall gametocyte rates for both P. falciparum and P. malariae were roughly one fifth of the prevalence rates for the asexual parasites. However, whilst there was no difference between the P. falciparum gametocyte rates at the two surveys, the P. malariae rate was significantly higher post-rains when compared with the pre-rains result. Spleen size did not increase with increased parasite density. There was a statistically significant difference between the geometric mean P. falciparum trophozoite densities of febrile and afebrile children both before and after the rainy season, but there was little seasonal difference in the means for the febrile children or in those for the afebrile children. Antimalaria antibody levels, measured by ELISA and IFAT, showed no significant differences at either survey. The levels found were high for all age groups, indicating that exposure to malaria begins at birth. Our results indicate that, in the area studied, malaria is hyperendemic and is probably transmitted perennially.

1991 Research Forum Abstracts.

76 in afebrile children and 72 in febrile children. It took an average time of 3 minutes and 20 seconds for the pacifier thermometer to display a steady-state temperature. The correlation coefficient between supralingnal and rectal temperatures was 0.78. The mean difference between supralingual and rectal temperatures was 0.70~177176 Using supralingnal temperatures adjusted upward by 0.7~ the pacifier thermometer was 78% sensitive and 97% specific for detecting fever (positive predictive value, 97%; negatwe predictive value, 82%). The majority of parents (74%) contacted by telephone after their ED visit were very satisfied with the pacifier thermometer. Conclusion: The pacifier thermometer provides reasonably good correlation with rectal temperatures when recorded measurements were adjusted upward by O.7~ (1.3~ Although readily accepted by parents, a significant number of children (26%) refused to take the pacifier. The additional cost of the thermometer and the ~ne required for a final temperature determmation may make the device impractical for most clinical setlmgs.

Prolactin and Cortisol Levels in Various Paroxysmal Disorders in Childhood

The hormonal response of the anterior pituitary to various epileptic and nonepileptic events in children was studied. Postictal serum prolactin and cortisol levels were measured in 17 children with epilepsy, 23 with febrile seizures, and 10 with syncope or breath-holding spells. The levels were compared with those of 30 children with nonspecific fever, and 23 afebrile children served as control subjects. Significantly higher (P less than .01) prolactin levels (26.5 +/- 3.3 ng/mL, mean +/- SEM) were found in the epileptic group, compared with levels in children with febrile seizures (13.2 +/- 1.0 ng/mL), fever (11.2 +/- 0.9 ng/mL), syncope (7.3 +/- 0.9 ng/mL), and the control group (7.9 +/- 0.6 ng/mL). In contrast, serum cortisol levels were nonspecifically elevated in the epileptics and patients with febrile seizures or fever only. These findings suggest that elevated prolactin levels may be found after epileptic seizures and much less after febrile seizures, but not after breath-holding spells or syncopal events. Cortisol secretion appears to be nonselectively triggered by all stressful events, such as epileptic and febrile seizures, and fever. Elevated prolactin levels (greater than 15 ng/mL) associated with seizures may help in differentiating epileptic from febrile seizures or syncope.

Behavioral Aspects of Temperature-Taking

Ear thermometry addresses two basic psychological aspects of fevers. The first one is obvious: the battle of the rectal temperature can be eliminated by ear thermometry. The second one addresses the overtreatment of tactile fevers. Tactile temperature taken by feeling the forehead occurs in 50% to 90% of homes. Half of warm foreheads occur in afebrile children who are warm because they're releasing heat generated by a recent activity or bath. If an actual temperature were measured, these children wouldn't be mislabeled as having fever and unnecessarily treated.

The Inaccuracy of Axillary Temperatures Measured with an Electronic Thermometer

Temperatures were measured using an electronic thermometer in an emergency department to determine the relationship between oral or rectal and axillary measurements. A total of 164 data pairs were obtained--95 in afebrile children, and 69 in febrile children. The correlation coefficient was .74 for oral-axillary pairs, and .70 for rectal-axillary pairs. The mean difference between oral and axillary temperatures was 1.17 degrees C +/- 0.72 degrees C, and between rectal and axillary temperatures was 1.81 degrees C +/- 0.97 degrees C. Using 37.4 degrees C (greater than or equal to 2 SDs) axillary as the upper limit of normal, the sensitivity, specificity, and positive and negative predictive values were calculated for detecting a fever. The sensitivity was 46%; specificity, 99%; positive predictive value, 97%; and negative predictive value, 72% for combined oral-axillary and rectal-axillary data. It was concluded that axillary temperatures are not sensitive enough to determine a fever when measured with an electronic thermometer. Electronic thermometers should be used to determine oral or rectal temperatures; axillary temperatures may be misleading and should be abandoned in the outpatient setting.