Fever in Children

Fever in Children : 

Fever in Children CSN Vittal

Fever - from the Latin word febris Pyrexia, or a Febrile response , Ague) : 

is a frequent medical symptom that describes an increase in internal body temperature to levels that are above normal Common oral measurement of normal human body temperature is 36.8±0.7°C or 98.2±1.3°F Fever - from the Latin word febris Pyrexia, or a Febrile response , Ague) Dr CSN Vittal

Fever is present if: : 

Anal or Otic temperature higher than 380 Celsius (100.40 Fahrenheit) Oral temperature is at, or higher than 37.50 Celsius (99.50 Fahrenheit) Axillary temperature is at, or higher than 37.20 Celsius (990 Fahrenheit) Fever is present if: Dr CSN Vittal

What Causes it : 

Fever isn't an illness, but a sign of other problems in the body that trigger the immune system to release chemicals that cause temperature to rise. Endogenous pyrogens What Causes it Dr CSN Vittal

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Dr CSN Vittal

Taking a Temperature : 

Plastic forehead strips - not accurate Glass Mercury thermometers Digital thermometers Taking a Temperature Dr CSN Vittal

Taking a Temperature Oral temperature : 

Only if your child is cooperative, and is 5 years of age or older Younger children may bite and break the thermometer Wait at least 10 minutes after your child drinks hot or cold liquids before taking temperature Put the tip of the thermometer under your child's tongue Tell your child to close his lips tightly but not to bite the thermometer Keep the thermometer in place for 2 to 3 minutes Never leave your child alone with the thermometer in his mouth Taking a Temperature Oral temperature Dr CSN Vittal

Taking a Temperature Axillary temperature : 

Hold tip of thermometer in the middle of the armpit with one hand Use your other hand to hold your child's arm snugly against his side Hold the thermometer in place 3 to 4 minutes Taking a Temperature Axillary temperature Dr CSN Vittal

Taking a Temperature Tympanic (ear) thermometer : 

Indicate if oral or rectal equivalent with a switch near top of the thermometer Put tip of thermometer gently into your child's ear canal Press the start button After one second, a digital reading appears in the small window Taking a Temperature Tympanic (ear) thermometer Pros - very fast reading, easier to use with a fussy child Cons -most expensive needs batteries, needs to be placed in the ear canal correctly for an accurate reading Dr CSN Vittal

Taking a Temperature Rectal thermometer : 

Coat the tip of the thermometer with petroleum jelly and Insert it half an inch into the rectum. Hold the thermometer still for two minutes. Never let go of the thermometer Taking a Temperature Rectal thermometer Pros – Accurate, core temp. Cons –Social acceptance poor Dr CSN Vittal

Approach to Fever : 

Approach to Fever Dr CSN Vittal

Fever in Neonate : 

Suspect - serious bacterial infection (SBI) Fever in Neonate

Fever & Risk of Bacterial Infection : 

Fever & Risk of Bacterial Infection Because of the greater probability of serious bacterial infection, a more aggressive approach to the evaluation and management of fever is warranted in young infants. Dr CSN Vittal

Fever Management – ‘Neonate’ : 

Admit to hospital Chest radiograph Sepsis screening Blood culture Urine culture Lumbar puncture Parenteral antibiotics Fever Management – ‘Neonate’ Dr CSN Vittal

Fever in 1 mo. to 3 years old : 

Fever in 1 mo. to 3 years old

Rochester criteria for Identifying Febrile Infants at Low Risk for Serious Bacterial Infection : 

Infant appears generally well Infant has been previously healthy: Born at term (>/=37 weeks of gestation) No perinatal antimicrobial therapy No treatment for unexplained hyperbilirubinemia No previous antimicrobial therapy No previous hospitalization No chronic or underlying illness Not hospitalized longer than mother Infant has no evidence of skin, soft tissue, bone, joint or ear infection Infant has these laboratory values: Infant has these laboratory values: White blood cell count of 5,000 to 15,000 per mm3 (5 to 15 109 per L) Absolute band cell count of ≤ 1,500 per mm3 (≤ 1.5 109 per L) Ten or fewer white blood cells per high-power field on microscopic examination of urine Five or fewer white blood cells per high-power field on microscopic examination of stool in infant with diarrhea Rochester criteria for Identifying Febrile Infants at Low Risk for Serious Bacterial Infection Dr CSN Vittal

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Toxic appearance Clinical presentation characterized by lethargy, evidence of poor perfusion, cyanosis, hypoventilation or hyperventilation Lethargy Poor or absent eye contact; failure of child to recognize parents or to interact with persons or objects in the environment Dr CSN Vittal

Patients aged 2-36 monthsGeneral Guidelines in Management : 

May not require admission if they meet the following criteria Patient was healthy prior to onset of fever. Patient has no significant risk factors. Patient appears nontoxic and otherwise healthy. Patient's laboratory results are within reference ranges defined as low risk. Patient's parents (or caregivers) appear reliable and have access to transportation if the child's symptoms should worsen Patients aged 2-36 monthsGeneral Guidelines in Management Dr CSN Vittal

Fever without source – Temp : < 39 C or 102.2 F Patients aged 2-36 months – Not Toxic : 

Careful physical examination to identify potential focal infection (e.g., pneumonia, abscess, cellulitis, sinusitis, otitis media, osteomyelitis, impetigo, lymphadenitis, strep. pharyngitis) Consider no antibiotics No tests or antibiotics if infant or young child looks well and no possible bacterial source is identified Schedule a follow-up appointment within 24-48 hours and instruct parents to return with the child sooner if the condition worsens. Hospital admission is indicated for children whose conditions worsen or whose evaluation findings suggest a serious infection. Fever without source – Temp : < 39 C or 102.2 F Patients aged 2-36 months – Not Toxic Dr CSN Vittal

Conditions not to be missed : 

UTI Pneumonia Meningitis Febrile seizure Malaria Enteric fever Parental & Physician preference Conditions not to be missed Dr CSN Vittal

Fever without source – Temp : > months 39 C or 102.2 F Patients aged 2-36– Not Toxic : 

Urine culture in all infants and children < 2 years of age who are prescribed empiric antibiotics10 Consider radiograph if infant or child is asymptomatic and has a WBC count >20,000 per mm3 Stool culture if blood and mucus are in the stool, or there are >5 WBCs per high-power field on microscopic examination of stool Blood culture Empiric antibiotic therapy e.g., ceftriaxone 50 mg per kg IM or IV Follow-up: within 24 to 48 hours Fever without source – Temp : > months 39 C or 102.2 F Patients aged 2-36– Not Toxic Dr CSN Vittal

General Guidelines in ManagementPatients aged 2-36 months –Toxic : 

Admit child for further treatment; pending culture results, administer parenteral antibiotics. Initially administer ceftriaxone, cefotaxime, or ampicillin/sulbactam (50 mg/kg/dose). General Guidelines in ManagementPatients aged 2-36 months –Toxic Dr CSN Vittal

Fever in Older Children : 

Fever in Older Children

Advise to Parents Treat Fever - Without Medication : 

Child has a fever yet is content, eating, drinking, or playing, they may not need medication. Dress them in lightweight clothing or remove clothing to allow heat loss through the skin. Use a lightweight blanket if they feel cold or are shivering. Try to keep your child quiet - activity increases body temperature. Give your child extra fluids to prevent dehydration or extra loss of water. Make sure your child's room is a comfortable temperature - not too hot or too cold Advise to Parents Treat Fever - Without Medication Dr CSN Vittal

Advise to Parents Treat Fever - With Medication : 

Medication is only needed to make child comfortable. If your child is sleeping, don't wake them up to give medicines. If the fever is high enough to need medication, your child will waken. Always give your child medication for fever if he has had febrile seizure (seizures when your child has a fever) Advise to Parents Treat Fever - With Medication Give your child a sponge bath with lukewarm water only if fever is higher than 104° F and fever is not decreased 30-60 minutes after medication is given-- NEVER LEAVE HIM ALONE IN THE TUB Stop the sponge bath if your child starts to shiver Never use rubbing alcohol for baths or sponging Antipyretic therapy

Therapeutic trial in undiagnosed fever : 

Therapeutic trial in undiagnosed fever Trial with chloroquine (considering epidemiology) Trial with broad spectrum antibiotics should not be considered without relevant investigations to rule out serious infections such as UTI, Meningitis, Typhoid or Pneumonia. If the response to the first antibiotic is poor, another drug may be tried. If two drugs have failed, it is logical to reconsider the diagnosis rather than change the antibiotic. Do not try empirical treatment for tuberculosis except in life-threatening situations, wherein treatment must be completed for full conventional period, unless another cause for fever is found out during the trial period. Steroids should never be used for undiagnosed fever Dr CSN Vittal

Empirical choice of antibiotic in fever : 

Empirical choice of antibiotic in fever Do not prescribe an antibiotic without presumptive diagnosis. Routine investigations must be carried out to support the diagnosis. As clinical diagnosis of Bacterial infection in office practice is rarely possible within the first 2-3 days of fever, (except in case of Tonsillitis or otitis) prescribing antibiotic is not recommended during this period. If antibiotic is justified then, for most community infections, oral amoxycillin, or cotrimoxazole is sufficient (first line drugs). Injectable antibiotics are almost never needed in office practice. Newer antibiotics are not recommended for routine community acquired infections. Dr CSN Vittal

Clinical approach to partially treated fever : 

Clinical approach to partially treated fever Clinical picture might have been modified by prior therapy. If etiologic evidence is based on reasonable evidence, dosage & compliance of drug is checked. In case of suspected drug resistance, change of therapy is justified. If the disease has never been diagnosed and the therapy is empirical, failure of response may be due to wrong diagnosis. It is best to continue empirical therapy while investigations are repeated to arrive at the right diagnosis. Dr CSN Vittal

Interpretation of laboratory tests in partially treated fever : 

Interpretation of laboratory tests in partially treated fever Lab tests need to be repeated in patients who continue to be febrile even after few days of therapy Some tests may be modified by therapy. E.g. WBC counts, peripheral smear for malarial parasites, urinalysis and bacterial culture. Persistence of high ESR in spite of treatment suggests uncontrolled active disease. So is persistent eosinopenia, hence change in therapy may be indicated. Change from neutrophilic response to lymphocytic response in peripheral smear indicates recovering bacterial infection, hence to continue the same antibiotic. Improving laboratory tests with no clinical response should alert the physician to the possibility of complications. Clinical improvement with persistent abnormal tests warrants close observation without change in the antibiotic Dr CSN Vittal

Antipyretic therapy : 

Paracetamol (Acetamniophen):15 mg/kg /dose q 4 h Ibuprofen : 12 mg/kg /dose q 8 h Mefanamic acid – 2.5 mg/kg/ dose q 8 h Nimesulide – 4 mg/kg/dose q 8 h Aspirin - Do not use Aspirin for fever (it has been related to a serious illness, Reye's Syndrome) Antipyretic therapy

Nimesulide : 

Irish Medicines Board (IMB) suspends Nimesulide containing drugs Singapore Health Science Authority suspends Nimesulide containing drugs On September 21, 2007 the EMEA has concluded that the benefits of these medicines outweigh their risks, but that there is a need to limit the duration of use to ensure that the risk of patients developing liver problems is kept to a minimum. Therefore the EMEA has limited the use of systemic formulations (tablets, solutions, suppositories) of nimesulide to 15 days. Nimesulide Dr CSN Vittal

Management of Fever in Children – Danger Signals : 

Changes in behaviour Severe headache Constant vomiting or diarrhea Skin rash Dry mouth Sore throat that doesn't improve Earache that doesn't improve Stiff neck Fever comes and goes over several days Stomach pain High-pitched crying Swelling on the soft spot on the head Irritable Unresponsive or limp Not hungry Wheezing or problems breathing Pale Whimpering Management of Fever in Children – Danger Signals Dr CSN Vittal

Summary : 

Summary The treatment of fever needs to be individualised, based on current knowledge of the effectiveness and risks of interventions The child (and the parents) should be the focus of care, not the thermometer The focus on home care is particularly important with increasing numbers of children being cared for on an ambulatory basis Recognitions of danger signs is essential. Dr CSN Vittal