Kawasaki Disease

Medium sized artery vasculitis in children under five years old.
Unknown aetiology but possibly infection.
Higher risk in Asians, especially Japenese and Koreans.

Signs

#fcem #FOAMed #paediatrics Features of Kawasaki disease. pic.twitter.com/cZkF241IaA

— #hellomynameisDrKirsty (@KirstyChallen) April 21, 2015

or

Symptoms of Kawasaki Disease can be remembered by the mnemonic "CREAM" - http://t.co/4EKqYRMqbP #USMLE #FOAMed pic.twitter.com/zBmzrAXc12

— knowmedge (@knowmedge) January 27, 2014

In the absense of inflammation (high WCC or CRP) Kawasaki is unlikely.
Don't wait for fever >5 days to diagnose it though - it might be incomplete.

https://www.rcemlearning.co.uk/foamed/a-child-with-a-fever/
https://adc.bmj.com/content/99/1/74
https://www.paediatricfoam.com/2017/06/kawasaki-disease-pearls-and-pitfalls/?subscribe=success#blog_subscription-4
http://dontforgetthebubbles.com/kawasaki-disease-beware-the-incomplete/
http://rolobotrambles.com/notjustafever/
https://calgaryguide.ucalgary.ca/wp-content/uploads/image.php?img=2017/05/Kawasaki-Disease.jpg

Urinary Tract Infections in Children

Up to 7% of girls and 2% of boys will have a symptomatic, culture confirmed urinary tract infection (UTI) by the age of six. The prevalence of UTI in febrile infants is approximately 7%. After a UTI, 10-30% of children have scarring

Clinical Features

Infants and children presenting with an unexplained fever of 38°C or higher, for over 24 hours, should have a urine sample tested. Infants and children with an alternative site of infection should not have a urine sample tested. When infants and children with an alternative site of infection remain unwell, urine testing should be considered after 24 hours at the latest.

How to test
Urgent microscopy and culture <3years old

>3 or no microscopy, dipstick testing may act as a substitute

Obtaining a Sample
Clean catch - less likely to be contaminated
Urine bags - useful to rule out, but not to rule in
Urine collection pads
Cotton wool balls, gauze and sanitary towels should not be used to collect urine in infants and children.

Treatments
Upper urinary tract infection - oral antibiotics (cephalosporin or co-amoxiclav) for 7 - 10  days
Lower urinary tract infections - oral antibiotics for 3 days.

Follow Up

< 3month old with UTI: 10% have bacteraemia, 13% have CSF pleocytosis however < 1% have meningitis !! #FOAMped
— Chris Partyka (@chrispartyka) April 19, 2014

References
http://learning.bmj.com/learning/module-intro/urinary-tract-infection-children-diagnosis-treatment-long-term-management-.html?moduleId=10011035&searchTerm=%E2%80%9CUTI%20children%E2%80%9D&page=1&locale=en_GB

http://www.enlightenme.org/the-learning-zone/node/4310
http://guidance.nice.org.uk/CG54/QuickRefGuide/pdf/English
http://dontforgetthebubbles.com/6-pem-papers-change-practice-6-getting-urine-neonates/
http://bestbets.org/bets/bet.php?id=34

Febrile Seizures

Paediatric blue call for a twitching hot tot - you either love them, or hate them. As most of the time the child is pretty much back to normal by the time they arrive in the ED, it's easy to get a bit blaze about Febrile Convulsions or Febrile Seizures.

Febrile seizures: Seizure accompanied by a fever in the absence of inter-cranial infection due to bacterial meningitis or viral encephalitis.

They happen in 3% of children, between 6 months and 3- 5 years of age. The peak incidence is 18 months. Only 6-15% of seizures occur after 4 years. They are normally brief, with a 30-40% risk of a further attack.
10% increased risk if child has first degree relative with febrile seizures
A febrile seizure is more likely the younger the child, the shorter the duration, lower the temp at seizure and family history.  1-2% lifetime risk of epilepsy, same as all kids - complex focal have 4-12% risk

Presentation
- Short duration (<15minutes)
- Single seizure
- Brief post-ictal period
- Fever identified
- Prolonged seizure (5 - 10min) more likely to have a recurrence.

Investigations
Minimal evaluation needed
Urinalysis may be indicated - UTI common cause
Lumbar Puncture - only if child is not well looking, fully immunised, presenting with a simple febrile seizure. It
For complex seizure, consider bacterial meningitis as a cause - it can be difficult to clinically rule it out.

Management
As per departmental policy. Example from Manchester on the CEM website here.
If seizing, follow status epilepticus guidelines.
No evidence on duration of observation, although 24 hours has been suggested.

Advice
Normal seizure advice
Antipyretics do not prevent convulsions but may provide comfort. Diazepam also should not be used as prophylaxis.
 

Sepsis in Children

Sepsis in children is one of those areas that always frustrates me slightly. In adults, sepsis  care is improving and we have clear criteria for diagnosing sepsis. Diagnosing sepsis in children is a little bit harder - and it can be a fine line between a nasty infection, and sepsis. There are probably three important sections to consider under the "sepsis" banner:

• Fever in children
• Meningococcal septicaemia
• Sepsis identification and treatment 

Mortality from paediatric sepsis ranges from 9% to 35%. Aggressive fluid resuscitation early in the course of SIRS results in decreased mortality. The risk of sepsis is inversely related to age. Neonates are at the highest risk, with bacterial sepsis occurring in 1-10 per 1000 live births in the United States.

Risk Factors
- Children with sickle cell have a 400-fold increased risk of sepsis due to pneumococcus and salmonella.  am
- Severe sepsis 15% more common in boys.

Pathogenesis
In children, shock is more likely to be associated with profound hypovolaemia. They often need more aggressive fluid resuscitation than adults.

Recognition of Sepsis

The NICE traffic light guidelines on feverish illness provide a useful structure for assessing children.
Colour - normal, pale, mottled, ashen or blue?
Activity - responds normally, not responding to social cues, appears ill to an HCP
Respiratory - any signs of respiratory distress?
Circulation - any signs of dehydration?
Other - any amber signs, fever for more than 5 days, swelling of a joint

The college has clear standards for managing sepsis and meningitis in children, and fever in children which will be looked at in more detail when we get to the "fever" section.