Fever and Shivering: Frequency and Role in Predicting Serious Bacterial Infection
Fever and Shivering: Frequency and Role in Predicting Serious Bacterial Infection
Febrile shivering in the pediatric population is assumed to be related to a Severe Bacterial
 Infection (SBI). Research supporting this assumption is scant. The purpose of this study is
 to describe the frequency of febrile shivering in the pediatric population arriving at the
 emergency department and to define its role in predicting a SBI.
Background: Fever is a common complaint and lacking localizing signs poses a diagnostic
 dilemma, mostly, but not only, in children under 3 years of age. Recent years studies found
 common clinical markers for a Serious Bacterial Infection (SBI) to be ineffective in
 confirming or ruling out a suspected SBI in an environment with low prevalence of SBI such as
 developed countries. Shivering (chills, rigors) during a febrile illness is a common
 complaint in children but it's true incidence is unknown. It is assumed that shivering
 appears more frequently in children with SBI but only one study in the pediatric population
 was found to support this assumption. No studies were found to describe the frequency of
 shivering in the emergency department. Study purpose: To describe the frequency of febrile
 shivering in the pediatric population arriving at the emergency department and it's relation
 to a Severe Bacterial Infection. Participants: Children in the age range of 3 months to 18
 years presenting with fever. Intervention: During the study time frame the frequency of
 febrile shivering will be documented . Patients with febrile shivering who meet the inclusion
 criteria, a sepsis workup will be done including blood samples for inflammatory markers,
 blood culture, urinalysis and urine culture when a urinary tact infection is suspected. Other
 systems (CSF sampling, joint fluid aspiration, stool culture, chest x ray) will be examined
 according to an appropriate history and clinical suspicion. The same work up will be done in
 next consecutive patient presenting with fever without shivering. Results: The frequency of
 febrile shivering, positive cultures, lobar pneumonia in a chest x ray. A comparison between
 the study and the control group will be made. Categorical variables will be compared using
 the Chi square test or Fisher exact test (as appropriate). Continuous variables will be
 compared using the student t test or Mann Whitney test. The relation between a bacterial
 infection and clinical variables will be analyzed using a logistic regression. Study group
 size: This is a pilot study. Investigators will use a convenience sample of all children
 admitted with shivering during the study period.

 Safety: All examinations will be held by the emergency department organic staff in the same
 routine methods done otherwise outside the study settings. The emergency department and
 hospital protocols for patients identification and infection control will be carried out
 before invasive procedures. Ethics: Parents will be asked for their agreement to answer a
 questioner as part of the study and their agreement will be documented. Informed consent will
 be asked for each patient, of the legal guardian. The study will be held according to the
 ethics rules of the Helsinki declaration and was approved by the local Ethics board. Access
 to the database will be restricted to the study investigators. The database will be encrypted
 by a password. After gathering the data and before statistical analysis information
 identifying the patients will be removed. The importance of the study: Fever in children is a
 common complaint frequently posing a dilemma on the extent of workup needed beyond clinical
 evaluation. This study aims to examine the frequency of shivering among children presenting
 to the ED with fever , its ability to predict the risk of severe bacterial infection.
Inclusion Criteria:

 -  fever at least during the last day

 -  shivering during current febrile illness

 -  no shivering during current febrile illness if recruited to the control group
 Exclusion Criteria: (for cases and controls)

 -  immune deficiency

 -  antibiotics treatment up to 48 hours before the presentation

 -  presentation following febrile convulsion

 -  non Hebrew speaking guardians