fever in children

1. azad82d@gmail.com
azad.haleem@uod.ac
Dr.Azad A Haleem AL.Mezori
MRCPCH,DCH, FIBMS
Assistant Professor
University Of Duhok
College of Medicine
Pediatrics Department
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For
Contact

2. Background
• Feverish illness in children:
• is the most common reason for children to be
taken to the doctor
• is a cause of concern for parents.
• can be a result of a simple self-limiting
infection or a life-threatening disorder.

3. DEFINITION OF FEVER
• Fever is defined as temperature > 37.8°C.
• A fever may be classified as mild (or 'low
grade') if it's between 37.8°C and 38.5°C; or
• high (or 'high-grade') above 38.5°C, very
high: body temperatures in excess of 41°C,
• Fever can be classified depend on whether it
has lasted 7 days or less (acute) or more than
7 days (chronic).

4. Important Notes
• Fever without localizing signs (without a focus),
frequently occurring in a child younger than 3
years old, in which a history and physical
examination fail to establish a cause, although a
diagnosis of occult bacteremia may be suggested
by laboratory studies
• Fever of unknown origin (FUO), which defines
fever for more than 14 days without an identified
etiology despite history, physical examination,
and routine laboratory tests or after 1 week of
hospitalization and evaluation.

5. Important Notes
• Bacteremia is defined as a positive blood culture
and may be primary or secondary to a focal
infection.
• Sepsis is the systemic response to infection that is
manifested by hyperthermia or hypothermia,
tachycardia, tachypnea, and shock.
• Children with septicemia and signs of CNS
dysfunction (irritability, lethargy), cardiovascular
impairment (cyanosis, poor perfusion), and
disseminated intravascular coagulation
(petechiae, ecchymosis) are readily recognized as
toxic appearing or septic.

6. Pathophysiology
• Core body temperature is normally
maintained within 1°C to 1.5°C in a range of
37°C to 38°C.
• Normal body temperature is often considered
to be 37°C .
• Rectal temperatures greater than 38 °C
(>100.4°F) generally are considered abnormal.

7. VARIATION IN TEMPERATURE
• There is normal diurnal variation, with maximum
temperature in the late afternoon.
• Maximum normal oral temperature
• At 6 AM : 37.2
• At 4 PM : 37.7
• Anatomic variation
• Physiologic variation:
• Age
• Sex
• Exercise
• Circadian rhythm
• Underlying disorders

8. Pathophysiology
• The normal body temperature is maintained
by a complex regulatory system in the anterior
hypothalamus.
• Development of fever begins with the release
of endogenous pyrogens into the circulation
as the result of infection, inflammatory
processes (rheumatic disease), or malignancy.

9. Pathophysiology
• Microbes and microbial toxins act as exogenous
pyrogens by stimulating release of endogenous
pyrogens, which include cytokines such as interleukin-
1, interleukin-6, tumor necrosis factor, and interferons
that are released by monocytes, macrophages,
mesangial cells, glial cells, epithelial cells, and B
lymphocytes.
• Endogenous pyrogens reach the anterior
hypothalamus via the arterial blood supply, liberating
arachidonic acid, which is metabolized to prostaglandin
E2, resulting in an elevation of the hypothalamic
thermostat.

10. PHYSIOLOGY OF FEVER
• Pyrogens:
–Exogenous pyrogens:
• Bacteria, Virus, Fungus, Allergen,…
–Endogenous pyrogen
• Immune complex, lymphokine,…
• Major EPs: IL1, TNF, IL6

11. ACUTE PHASE RESPONSE
• Metabolic changes
– Negative nitrogene
balance
– Loss of body weight
• Altered synthesis of
hormones
• Hematologic alterations
– Leukocytosis
– Thrombocytosis
– Decreased
erythrocytosis
• Altered hepatocyte function
(Acute phase reactants)
– C reactive protein(increased)
– Serum amyloid A(increased)
– Fibrinogen(increased)
– Haptoglobin(increased)
– Ceruloplasmin(increased)
– Ferritin(increased)
– Albumin(decreased)
– Transferrin(decreased)

12. DISCOMFORT DUE TO FEVER
• For each 1 °C elevation of body temperature:
–Metabolic rate increase 10-15%
–Insensible water loss increase
300-500ml/m2/day
–O2 consumption increase 13%
–Heart rate increase 10-15/min

13. ATTENUETED FEVER RESPONSE
• Fever may not be present despite infection in:
–Newborn
–Elderly
–Uremia
–Significant malnourished individual
–Taking corticosteroids

14. Benefits of fever
• Benefits of fever
– Protective role in the immune system
• Inhibition of growth and replication of microorganisms
• Aids in body’s acute phase reaction
• Enhanced immunologic function of wbc’s
–  lymphocyte response to mitogens
–  bactericidal activity of neutrophils
–  production of interferon
• Promotion of monocyte maturation into macrophages
• Promotion of lymphocyte activation and antibody
production
• Decreased availability of free iron for bacterial replication

15. HOW TO TAKE A CHILD’S
TEMPERATURE
• A child's temperature can be taken:
• from the rectum, ear(> 3 months), mouth(>4
years), forehead (unreliable & > 3 months), or
armpit.
• It can be taken with a glass or digital
thermometer.

16. Thermometers ? Age
In infants under the age of 4 weeks, measure
body temperature with an electronic
thermometer in the axilla.
In children aged 4 weeks to 5 years, measure
body temperature by one of the following
methods:
• electronic (chemical )thermometer in the
axilla
• infra-red tympanic thermometer.

17. • Neonates may not have a febrile response and
may be hypothermic despite significant infection,
• whereas older infants and children younger than
5 years old may have an exaggerated febrile
response with temperatures of up to (40.6°C) in
response to either a serious bacterial infection or
an otherwise benign viral infection.
• Fever to this degree is unusual in older children
and adolescents and suggests a serious process.
Fever & Severity of infection

18. • The fever pattern does not distinguish fever caused by
bacterial, viral, fungal, or parasitic organisms from that
resulting from malignancy, autoimmune diseases, or
drugs.
• Sustained (Continuous) Fever
• Intermittent Fever (Hectic Fever)
• Remittent Fever
• Relapsing Fever:
– Tertian Fever
– Quartan Fever
– Days of Fever Followed by a Several Days Afebrile
– Pel Ebstein Fever
– Fever Every 21 Day
PATTERN OF FEVER

19. • The pattern of fever may vary in different conditions and could assist in
the diagnosis of the cause of the fever. Some of the types of fever are
listed below:
Continuous fever: Fever that does not fluctuate more than 1°C in 24 hours
is called continuous fever. It is seen in conditions like pneumonia, typhoid,
urinary tract infections and infective endocarditis.
Remittent fever: Fever that fluctuates more than 1°C in 24 hours is
referred to as remittent fever. Causes include typhoid and infectious
mononucleosis.
Intermittent fever: Fever that is present only for some time in the day is
called intermittent fever. Malaria caused by Plasmodium vivax results in
fever every third day and that caused by Plasmodium malariae results in
fever every fourth day.
PATTERN OF FEVER

20. • Hectic or septic fever: Fever variation between the highest and lowest
temperatures is very large and more than 5°C. This type of fever is seen in
septicemia.
• Pel Ebstein fever: The febrile and afebrile periods alternate and follow a
definite pattern. For example, in Hodgkin’s disease and other lymphomas,
fever for 3 to 10 days is followed by a fever-free period of 3 to 10 days,
with the same cycle repeating.
• Fever with rigors: Rigor is the shaking or excessive shivering that
accompanies fever. Fever accompanied with rigors are seen in conditions
like malaria, kala azar, filariasis, urinary tract infections, inflammation of
gall bladder, septicemia, infective endocarditis , abscesses and
pneumonia.

21. • Details History:
– Time
– Grade
– Duration
– Diurnal variation
• Associated Symptoms
• Drug History:
• Past history: PMH & PSH
• Family History:
• Travel History
• Physical Examination:
– Vital Signs
– Neurological Exam.
– Skin Lesions,Mucous
Membrane
– Eyes
– ENT
– Lymphadenopathy
– Lungs and Heart
– Abdominal Region
(Hepatomegaly,Splenomeg
aly)
– Musculoskeletal
APPROACH TO FEVER

22. • LABORATORY STUDY:
• Assess the extent and severity of the
inflammatory response to infection
• Determine the site(s) and complications of
organ involvement by the process
• Determine the etiology of the infectious
disease.
APPROACH TO FEVER

23. Clinical assessment of the child with
fever
• Check for any immediately life-threatening
features.
• Use traffic light system to check for symptoms
and signs that predict the risk of serious illness.
• Look for a source of fever and check symptoms
and signs associated with specific diseases.
• Measure and record temperature, heart rate,
respiratory rate, capillary refill time and assess for
dehydration.

24. The Traffic Light System
Tool for identifying the likelihood of serious illness
Children with only symptoms and signs in the
‘green’ column are at low risk
Children with one or more symptom or sign in the
‘amber’ column are at intermediate risk
Children with one or more symptom or sign in the
‘red’ column are at high risk

25. Traffic light system:
Colour Normal colour of skin, lips and tongue
Activity
Responds normally to social cues
Content/smiles
Stays awake or awakens quickly
Strong/normal cry/not crying
Hydration
Normal skin and eyes
Moist mucous membranes
Other None of the amber or red symptoms or signs

26. Traffic light system:
Colour Pallor reported by parent/carer
Activity
Not responding normally to social cues
Wakes only with prolonged stimulation
Decreased activity
No smile
Respiratory
Nasal flaring
Tachypnoea: RR> 50/min age 6-12 months,
RR> 40/min age >12 months
Oxygen saturation ≤ 95% in air
Crackles
Hydration
Dry mucous membranes
Poor feeding in infants
CRT ≥3 seconds
Reduced urine output
Other
Fever for ≥5 days
Swelling of a limb or joint
Non-weight bearing/not using an extremity
A new lump >2cm

27. Traffic light system:
Colour Pale/mottled/ashen/blue
Activity
No response to social cues
Appears ill to a healthcare professional
Unable to rouse or if roused does not stay awake
Weak/high pitched/continuous cry
Respiratory
Grunting
Tachypnoea: RR>60 /min
Moderate or severe chest indrawing
Hydration Reduced skin turgor
Other
Age 0-3 months, temperature ≥38°C
Age 3-6 months, temperature ≥39°C
Non blanching rash Bulging fontanelle
Neck stiffness Status epilepticus
Focal neurological signs Focal seizures
Bile-stained vomiting

28. Management of children 3 months
to 5 years
 Perform test for urinary
tract infection.
 Assess for pneumonia.
 Do not perform routine
blood tests or chest X-ray.
Perform (unless deemed unnecessary)
 urine test for urinary tract infection
 full blood count
 blood culture
 C-reactive protein.
Perform chest x-ray if fever higher than 39°C
and white blood cell count greater
than 20 x 109/litre.
Consider lumbar puncture if child is younger
than 1-year old.
Perform:
 blood culture
 full blood count
 urine test for urinary tract infection
 C-reactive protein.
Consider the following, as guided by
clinical assessment:
 lumbar puncture in children of all ages
 chest X-ray
 serum electrolytes
 blood gas.
Consider admission. If admission is not necessary
but no diagnosis has been reached, provide a safety
net for the parents/carers.
If no diagnosis is reached,
manage the child at home with
appropriate care advice.
Assess: look for life-threatening, traffic light and specific diseases symptoms and signs

29. Management of children under
3 months
Assess: look for life-threatening, traffic light and specific diseases symptoms and signs
Observe and monitor:
 temperature
 heart rate
 respiratory rate.
Perform:
 full blood count
 C-reactive protein
 blood culture
 urine test for urinary tract infection
 chest X-ray if respiratory signs are present
 stool culture if diarrhoea is present.
Admit, perform lumbar puncture and start parenteral antibiotics if the child is:
 younger than 1-month old
 1–3 months old appearing unwell
 1–3 months old and with a white blood cell count of less than 5 or greater than 15 x 109/litre
 Whenever possible, perform lumbar puncture before the administration of antibiotics

30. • Antipyretics used only in children with:
• Discomfort – uncomfortable.
• Distress
• Unwell
• Fever > 39 °C
ANTIPYRETICS

31. • Acetaminophen is generally a first-line antipyretic
due to being well tolerated with minimal side
effects.
• Pediatric dose: 10-15mg/kg q4-6h.
• Ibuprofen:
• 5-10 mg/kg/dose orally every 6 to 8 hours as needed.
• Diclofenac: is not antipyretic but can decrease fever it
licensed as analgesic and anti-inflammatory only in child >
one year.
• Aspirin is no longer used for lowering fever in children
because it can interact with certain viral infections (such as
influenza or chickenpox) and cause a serious disorder called
Reye syndrome.
ANTIPYRETICS

32. Antipyretics and ILLNESS
• Antipyretics may prolong course of illness??
– Adults with rhinovirus shed the virus longer
– Children with varicella have delayed time for
lesions to crust (about 1 day)
– Children with malaria take longer to clear
parasites (75 vs 59 hours)

33. “Fever is nature’s engine
which she brings into the
field to remove her
enemy”
Thomas Sydenham
English Physician
1624 - 1689
thank you for your attention