What is the appropriate management for a 5-year-old child presenting with fever and coffee ground emesis?

Management of a 5-Year-Old with Fever and Coffee Ground Emesis

Immediate Assessment and Stabilization

This child requires immediate evaluation for hemodynamic stability and potential serious bacterial infection, with coffee ground emesis prompting assessment for upper GI bleeding while recognizing this symptom has low predictive value and may mask other serious conditions.

Initial Vital Signs and Clinical Assessment

• Document rectal temperature (≥38.0°C/100.4°F confirms fever) and assess for toxic appearance, respiratory distress, altered consciousness, or signs of shock 1
• Evaluate hemodynamic stability: check heart rate, blood pressure, capillary refill, and mental status 2
• Coffee ground emesis in hemodynamically stable patients often reflects conditions other than significant GI bleeding, including myocardial infarction, sepsis, bowel obstruction, and pulmonary emboli in case series 3
• Assess for signs of dehydration: decreased urine output, dry mucous membranes, poor skin turgor, lethargy 2

Hemodynamic Instability Protocol

If the child shows signs of hypotension, shock, extreme lethargy, or respiratory distress:

• Place peripheral intravenous line immediately and administer normal saline bolus 20 mL/kg rapidly; repeat as needed to correct hypotension 2
• Transfer to emergency department or intensive care unit for further management 2
• Monitor vital signs continuously and correct acid-base and electrolyte abnormalities 2

Differential Diagnosis Priority

Rule Out Serious Bacterial Infections First

Urinary tract infection accounts for over 90% of serious bacterial infections in febrile children aged 2 months to 2 years, with significant long-term sequelae including renal scarring (27-64%), hypertension risk (10-20%), and end-stage renal disease (10%) 1, 4, 5

• At age 5 years, UTI prevalence in febrile children without obvious source is 3-7%, with girls having 8.1% prevalence 2, 4
• Obtain urinalysis via catheterization (NOT bag collection due to 26% contamination rate vs 12% for catheterization) looking for leukocyte esterase, nitrites, or >5 WBCs/hpf 1, 6
• Obtain urine culture before starting antibiotics, as both abnormal urinalysis AND positive culture are needed to confirm UTI 4

Evaluate for Pneumonia

• Consider chest radiograph if the child has cough, hypoxia, rales, tachypnea, tachycardia out of proportion to fever, temperature ≥39°C, or fever duration >48 hours 1, 6
• The combination of these clinical predictors has 94% sensitivity for radiographic pneumonia, which occurs in 7% of febrile children under 2 years 1
• Do NOT obtain chest radiograph if wheezing or bronchiolitis is likely 1, 4

Consider Food Protein-Induced Enterocolitis Syndrome (FPIES)

Given the presentation of vomiting with fever, FPIES should be considered:

• FPIES typically presents with repetitive vomiting 1-4 hours after food ingestion, with lethargy and pallor 2
• Obtain detailed dietary history of foods consumed in the 1-4 hours before symptom onset 2
• If FPIES is suspected and child has >3 episodes of emesis with moderate-to-severe lethargy, this represents a moderate-to-severe acute episode requiring IV access 2

Assess for Meningitis

• Lumbar puncture should be performed if there are clinical signs of meningism, if the child is unduly drowsy or irritable, or systemically ill 2
• At age 5 years (within the 6 months to 5 years febrile convulsion age range), meningitis risk is lower than in younger infants but must not be missed 2

Coffee Ground Emesis Specific Considerations

Clinical Significance and Timing

• Coffee ground emesis without hemodynamic instability, ongoing bloody emesis, or hemoglobin drop does NOT require urgent endoscopy within 24 hours, as timing does not affect morbidity, mortality, ICU admission, hospitalization days, or rebleeding rates 7
• Hemodynamically stable patients with coffee ground NG aspirate and no fall in hemoglobin/hematocrit should be evaluated for non-GI bleeding conditions even as potential GI bleeding is managed 3
• Significantly fewer high-risk bleeding lesions are found on endoscopy in patients with coffee grounds vs bloody NG aspirates 3

Immediate Laboratory Evaluation

• Complete blood count with differential to assess for anemia, thrombocytopenia, or leukocytosis 4
• Basic metabolic panel to evaluate electrolytes and renal function 4
• Consider inflammatory markers (CRP, ESR) if systemic illness is suspected 4

Management Algorithm

If Hemodynamically Stable

1. Obtain urinalysis via catheterization and urine culture immediately 1, 4, 6
2. If urinalysis is positive: start ceftriaxone 50 mg/kg IV/IM daily after obtaining culture 1, 6
3. Assess for respiratory symptoms and obtain chest radiograph if clinical predictors present 1, 6
4. If pneumonia identified: initiate appropriate antibiotics and consider admission if respiratory distress, hypoxia, or inability to maintain oral hydration 1, 6
5. Monitor for resolution of vomiting and ability to tolerate oral fluids 2

If FPIES Suspected (Moderate Severity)

• Consider placing peripheral IV line for normal saline bolus 20 mL/kg, repeat as needed 2
• If age ≥6 months: administer ondansetron intramuscular 0.15 mg/kg/dose; maximum 16 mg/dose 2
• Monitor for resolution about 4-6 hours from onset of reaction 2
• Discharge after 4-6 hours when patient is back to baseline and tolerating oral fluids 2

If All Testing Negative

• Ensure close follow-up within 24 hours or return visit to ED for reassessment 1, 6
• Do NOT assume normal urinalysis excludes UTI if clinical risk factors are present - obtain culture 4
• Consider scheduled (non-urgent) upper endoscopy if coffee ground emesis persists or other concerning features develop 7

Critical Red Flags Requiring Immediate Return

Instruct parents to return immediately if the child develops:

• Altered consciousness or severe lethargy 1, 6
• Respiratory distress 1, 6
• Signs of dehydration (no urine output for 8+ hours, no tears, sunken fontanelle if applicable) 1, 6
• Persistent vomiting preventing oral intake 1, 6
• Petechial or purpuric rash 1, 6
• Fever persisting ≥5 days 1, 6
• Bloody emesis or melena 7, 3

Common Pitfalls to Avoid

• Do NOT rely solely on coffee ground emesis as indicator of significant GI bleeding requiring urgent endoscopy in stable patients 7, 3
• Do NOT use bag-collected urine specimens for UTI diagnosis due to high contamination rates 1, 4, 6
• Do NOT assume one viral infection (if identified) precludes coexisting bacterial infection 4
• Do NOT discharge without ensuring reliable follow-up and parental ability to judge clinical changes 6
• Do NOT overlook serious non-GI conditions (cardiac, renal, infectious) when preoccupied with coffee ground emesis 3

Disposition Planning

• Admit if: persistent vomiting preventing oral intake, signs of dehydration requiring IV fluids, confirmed UTI requiring IV antibiotics in ill-appearing child, pneumonia with respiratory distress, or any hemodynamic instability 2, 1, 6
• Discharge with close follow-up if: well-appearing, tolerating oral fluids, negative initial workup, reliable family with clear return precautions 1, 6
• Ensure urine testing with subsequent febrile illnesses to catch delayed UTI presentations 4