Fever In ChildrenFever In Children

In the name of God

FeverFeverFever

Fever is a common symptom with various diseases in children

Fever DefinitionA centrally mediated elevation of body temperature in response to stress or insultRectal temperature is over 100.4°F (38°C)Oral temperature above 37.5°CAuxiliary temperature above 37.2°C

How to Take Oral (Mouth) How to Take Oral (Mouth) TemperaturesTemperatures

Be sure a child has not had a cold or hot drink in the last 30 minutes. Glass thermometer:

1. shake the thermometer until the mercury line is below 98.6°F (37°C)2. Place the tip of the thermometer under one side of the tongue and toward

the back ,not in front tongue. 3. Have your child hold the thermometer in place with his lips and fingers (not

his teeth)4. He should breathe through his nose, keeping his mouth closed. 5. Leave the glass thermometer in the mouth for 3 minutes.6. see where the mercury line ends.

Digital thermometer1. turn it on.2..4. Same as glass thermometer5. Leave it in the mouth until you hear the correct signal (usually a series of

beeps). 6. Read the temperature.

Fever is an oral temperature over 99.5°F (37.5°C).

How to Take Armpit (Axillary) How to Take Armpit (Axillary) TemperaturesTemperatures

Glass thermometer1. shake it until the mercury line is below 98.6°F (37°C). 2. Place the tip of the thermometer in a dry armpit. 3. Close the armpit by holding the elbow against the chest for 4 or 5

minutes. 4. After 4 or 5 minutes take it out and read the temperature by finding

where the mercury line ends. Digital thermometer

1. turn it on2..3. Same as glass thermometer4. remove it after you hear the signal (usually a series of beeps) and read

the temperature on the screen.

Your child has a fever if the temperature is over 99°F (37.2°C). If you're not sure if it is correct, check it by taking a rectal temperature.

How to Take a Rectal How to Take a Rectal Temperature Temperature

Glass thermometer 1. shake until the mercury line is below 99°F (37.2°C).2. Have your child lie stomach down on your lap. 3. Before you insert the thermometer, put some petroleum jelly on the end of the

thermometer and on the anus. 4. Insert the thermometer gently into the bottom about 1 inch.

If infant, gently insert the thermometer only 1/4 to 1/2 inch.Never try to force it past any resistance. Forcing could damage the bowel.

5. Hold your child still while the thermometer is in.6. leave it in your child's bottom for 2 minutes before you take it out.7. Read the temperature on the thermometer( see the end of the mercury line.)Digital thermometer1. turn it on.2..5. Same As glass thermometer 6. take it out when you hear the correct signal (usually a series of beeps). 7. Read the temperature on the thermometer

If the rectal temperature is over 100.4°F (38°C), your child has a fever.

How to Take a Electronic Pacifier How to Take a Electronic Pacifier TemperatureTemperature

Have your child suck on the pacifier until the temperature stops changing and you hear a beep. This usually takes 3 to 4 minutes.

Read the temperature. Your child has a fever if the pacifier temperature is over 100°F (37.8°C).

How to Take an Ear TemperatureHow to Take an Ear Temperature

If your child has been outdoors on a cold day, he needs to be inside for 15 minutes before taking the temperature. (Earwax, ear infections and ear tubes, however, do not interfere with accurate readings.) Pull the ear backward to straighten the ear canal. Place the end of the thermometer into your child's ear canal and aim the probe toward the eye on the opposite side of the head. Then press the button. In about 20 seconds you can read the temperature. Your child has a fever if the ear temperature is over 100.4°F (38°C).

FeverFever in childrenin children

Fever is a controlled in body T over the normal values for an individual

Body T is regulated by thermosensitive neurons located in the preoptic of anterior hypothalamomus

Termoregulatory responses include; increased or decreased sweating extracellular fluid volume regulation behavioral responses

PathogenesisPathogenesis

Endogenous pyrogens including the :

1-cytokines interleukin 1and 6

2-TNF

3-INTERFERON

Exogenous pyrogens including the Microbes and microbial toxins which stimulate macrophages to produce endogenous pyrogens

Endotoxin can directly affec thermoregulation

PathogenesisPathogenesis))con)con)

Increase T is associated with decrease microbial reproduction and increase inflammatory response

Fever may exacerbate ;

cardiac insufficiency in heart disease or chronic anemia

Pulmonary insufficiency in chronic lung disease

Metabolic instability in diabetes mellitus or inborn error of metabolism

Prostaglandins and Prostaglandins and the role of NSAIDsthe role of NSAIDs

Pyrogens and FeverPyrogens and Fever

Actions of endogenous pyrogens in Actions of endogenous pyrogens in fever regulationfever regulation

Heat illnessHeat illness

Situation in witch either environmental stress impair the ability of the central thermoregulatory mechanism to maintain normal body temperature or internal factors produce excessive heat or impair the body’s ability to dissipate metabolism heat

Body temperature is elevated despite a normal set-point in POAH

Example of Heat illnessExample of Heat illness

Hyperthyroidism

Malignant hyperthermia

Anhidrotic ectodermal dysplasia

Pharmacologic agentMedical drug (anticholinergics and phenothiazines)

Street drug

Fever is s friend or enemy?Fever is s friend or enemy?

Fever is a beneficial response in favor the host

Fever may directly impair reproduction or even the survival of an invading microorganism

Moderate fever may enhance the immunologic response

Fever is friend or enemy?Fever is friend or enemy?

High fever can impair the immunologic response

Fever increase the basal metabolic rater by

10-12 % for 1 °C

Increase oxygen consumption

Carbon dioxide production

Increase Fluid and caloric requirements

can precipitate febrile seizures

May be associated with neurological manifestation irritability,delirium,disorientation and hallucinations

Treatment of FeverTreatment of Fever

Anti pyretic drugs should not proscribed routinely to febrile children

WHO recommend the use anti pyretic for children with fever of ≥ 39 C°

The decision to treatThe decision to treat

when the patient is uncomfortable

susceptible To febrile seizure

Critically ill-sepsis or septic shock

Cardiac or respiratory failure

Neurological diseases or injury

Disturbed fluid ,electrolyte status

AcetaminophenAcetaminophen

Is the first line therapy for childhood fever

Rapidly and almost completely absorb from GI

half-life in plasma about 2 hour

Dose 10-15 mg/kg/dose PO/PR Q 4-6 hr

Maximum 5 dose/24 hr

Acetaminophen Side affectSkin rash and allergic reaction occasionally

Neuttropenia ,thrombocytopenia and pancytopenia rarely

Toxic EffectHepatotoxicity

Renal tubular necrosis

Hypoglycemia coma

AcetaminophenAcetaminophen

AAP recommend that rectal Acetaminophen therapy should be avoided unless specifically discussed with the health care provider and that direction be followed

IbuprophenIbuprophen

Inhibit prostaglandin synthetase.

Dose 8-10 mg/kg Q 6-8hr

Side affect

Gastiris

Gastrointestinal apset

Platelets aggregation

Acetaminophen versus IbubrophenAcetaminophen versus Ibubrophen

Acetaminophen: provided greater initial temperature reduction

Ibubrophen:Provided more significant antipyretic effect at 4 hr

Temperature decrement lasted longer

The two drug have equal tolerability

Prostaglandins and Prostaglandins and the role of NSAIDsthe role of NSAIDs

NimesulideNimesulide

A new NSAID is useful in treatment of fever

Was more effective than Acetaminophen for treatment of fever

Appear to be safe as Acetaminophen

Dose 1.5 mg/kg/Dose TID

FeverFever in childrenin children

Fever is a controlled in body T over the normal values for an individual

Body T is regulated by thermosensitive neurons located in the preoptic of anterior hypothalamomus

Termoregulatory responses include; increased or decreased sweating extracellular fluid volume regulation behavioral responses

PathogenesisPathogenesis

Endogenous pyrogens including the :

1-cytokines interleukin 1and 6

2-TNF

3-INTERFERON

Exogenous pyrogens including the Microbes and microbial toxins which stimulate macrophages to produce endogenous pyrogens

Endotoxin can directly affec thermoregulation

PathogenesisPathogenesis))con)con)

Increase T is associated with decrease microbial reproduction and increase inflammatory response

Fever may exacerbate ;

cardiac insufficiency in heart disease or chronic anemia

Pulmonary insufficiency in chronic lung disease

Metabolic instability in diabetes mellitus or inborn error of metabolism

Fever Fever

Fever is a common manifestation of infectious disease but is not predictive of severityMany infections are usually benign in normal hosts Sepsis ,meningitis pneumonia ,osteoarticular infections , pyelonephritis may have significant morbidity or mortalityMost febrile episodes can be diagnosed by careful history and physical examination and few lab tests

TheThe causescauses of fever of fever

Infectionvaccines ,

endocrine disorders, genetic disorders , metabolic disorders , immunologic and rheumatologic disorders

tissue injury, malignancy , drugs granulomatous diseases , inflammatory diseases

factitious fever

Clinical ManifestationClinical Manifestation

Causes of very high T )>41) include : central fever , malignant hyperthermia drug fever , heatstroke

T lower than (<36) can be sepsis and more commonly with cold exposure , hypothyroidism , or overuse of antipyretic

Intermittent fever , sustained fever , Remittent fever , Relapsing fever , periodic fever

Type of feverType of feverIntermittent fever - Fever that touches normal for a few hours during the day. It is seen in malaria, acute pyelonephritis, local boils and furuncles. tuberculosis, lymphoma, and juvenile rheumatoid arthritis (JRA)Remittent fever - Fever that fluctuates between 1.5 degree F in 24 hours without touching normal. viral infections but also may occur with bacterial infections (especially endocarditis), sarcoid, lymphoma, and atrial myxoma.Continuous fever - Fever that does not touch normal and fluctuates less than 1.5 degree F in a day. It is seen in enteric fever, Bacterial endocarditis, viral pneumonia. Typhoid fever, typhus, brucellosis, and many other infections

FeverFever Prone to RelapseProne to Relapse

1. Infectious causes

2. Noninfectious causes Behcet disease , crohn disease , SLE

3. Periodic fever syndromes:familial Mediterranean fever cyclic neutropenia Hyper igD syndrome (PFAPA)

periodic fever aphthous stomatitis pharyngitis - adenopathy

Febrile Patients Febrile Patients at increased Risk at increased Risk for for Serious Baterial infectionsSerious Baterial infections

Immunocompetent patient: Neonates(28 days) infants<3 mo Infants and children 3-36 mo Hyperpyrexia(>40) Fever with petechiaeImmunocompromised patients: Sickle cell disease -Asplenia Complement / properdin deficiency-

Agammaglobulinemia AIDS – Malignancy Congenital heart disease Central venous line

TreatmentTreatment

fever<39 in healthy children do not require treatment

Antipyretic therapy dose not change the course of infection

Antipyretic therapy is beneficial in high-risk patients

Hyperpyrxia indicates risk of;

severe infection ,hypothalamic disorders ,CNS hemorrhage

FeverFever without localizing signs without localizing signs

usually acute onset present for< 1 wk.

Young infants limited signs of infection and difficult to distinguish between bacterial and viral infection.

FeverFever without localizing signs without localizing signs

Infants< 4 wk are at risk for;

late-onset bacterial diseases

Perinatally acquired herpes simplex virus

Acquire community pathogens

InfantsInfants <<3mo with fever3mo with fever

Fever in this age should always suggest the possibility of serious bacterial disease

Pyelonephritis is more common in uncircumcised boys ,neonate and infants with UT anomalies and young girls

Other bacterial diseases include:

, pneumonia , omphalitis ,mastitis skin and soft tissue infection. otitis media

InfantsInfants <<3mo with fever3mo with fever

Viral infection is identified in 70%

Bacteremia is present in 5%

Serious bacterial infection are present in 10-15% in T > 38

Approach to febrile infants <3 moApproach to febrile infants <3 mo

Careful history and physical examination Toxic infants must prompt hospitalizatIion

and immediate parenteral antimicrobial therapy

after B /C , U/C ,LP

Ceftriaxone 50- 80mg/day or cefotaxim 50mg/kg/dose and ampicillin 50/kg/dose.

If CSF IS abnormal vancomycin 15/kg/ dose should be given

ApproachApproach to febrile infant< to febrile infant< 3mo (con)3mo (con)

2-Infants with fever unlikely to have a serious bacterial infection if;

appear generally well and previously healthy

No evidence of skin, soft tissue, bone , joint and ear infection

Who have WBC 5000-15000 and band <1500 * and U/A normal

Occult Bacteremia in children 3-36 m0Occult Bacteremia in children 3-36 m0

¤* Occurs in 1.5% well appearing in this age with fever

Bacteremia is present in 11% pneumonia and 1.5% otitis media or pharyngitis

S,pneumoniae , N,menigitidis and salmonella .

S,Pneumonia account for 90% of cases.

Occult Bacteremia in children 3-36 Occult Bacteremia in children 3-36 m0m0

Risk factors include :

T>39 or greater ,WBC 15000

an elevated band count ESR + and CRP +

Occult bacteremiaOccult bacteremia (con)(con)

Without therapy occult bacteremia may;

■ Resolve spontaneously

■ May persist

■ May lead to localized infection

pnemococcal bacteremia spontaneous resolution occur in 30-40% in all patients

Occult bacteremiaOccult bacteremia (con)(con)

H ,influenza type b bacteremia is with a higher risk of localized serious infection.

Fewer than 5% of these bacteremia can be transient.

Fever with petechiaeFever with petechiae

Independent of age , with or without localizing signs indicates high risk for bacterial infections .

serious bacteria infection 8-20%

meningococcal sepsis or meningitis 7-10%

Managemen t includes ;

prompt hospitalization ,B/C ,CSF/C, and administration parenteral antimicrobial agent

Fever with sickle cell diseaseFever with sickle cell diseaseChildren should be hospitalized;

if seriously ill , T>40, WBC<5000 0r>30000 or pulmonary infiltration ,or severe pain

The increased risk is due to: functional asplenia , defect in the properdin

pathway

S,pneumoniae H, influenzae type b , Salmonella sepsis, meningitis, pneumonia, osteomylitis.

Prevention of pneumococcal sepsis is ; long term penicillin therapy and pneumococcal

and H,inflenza vaccine.

Treatment of occult bacteremiaTreatment of occult bacteremia

Toxic-appearing infants without focal signs:

must hospitalization and prompt

antimicrobial therapy after B/C ,U/C, CSF/C

Treatment of occult bacteremiaTreatment of occult bacteremia

for Non toxic-appearing infants with T>39:

1. B/C and give ceftriaxon a single dose 50mg/kg

2. if the WBC is 15000 or greater obtain B/C and ceftrixon

If the child,s condition deteriorate or new symptoms develop the infants must return immediately .

Treatment occult bacteremiaTreatment occult bacteremia) ) con)con)

If the child develops a localized infection therapy is directed toward the specific pathogen and site

If the child appears well ,afebrile ,and physical findings is normal with B/C+ , should receive 7-10 days of oral antibiotic

Treatment occult bacteremiaTreatment occult bacteremia) ) con)con)

1. If the child appears ill and continues fever with no identifiable focus of infection.or

2. IF B/C is H,influenzae or N, meningitidis

The child should have a repeat B/C ,LP, and treatment in hospital with appropriate antimicrobial agents

Fever of unknown Fever of unknown originorigin “FUO”“FUO”

Fever of 101F for longer than three weeks or

Fever of uncertain diagnosis for more than one week in a hospitalized patient

Etiology of FUOEtiology of FUO

“A fever of unknown origin is more likely to be the unusual presentation of a common disorder than the common presentation of a rare disorder”

Etiology of FUOEtiology of FUO

Infections

Autoimmune

Malignancy

Others (incl.. factitious fever, drug fever, sarcoid)

Never determined:

Causes of bacteraemia and Meningitis Causes of bacteraemia and Meningitis in young children in young children

Under 1 month old Group B streptococcus Escherichia coli (and other enteric Gram negativebacilli) Listeria monocytogenes Streptococcus pneumoniae Haemophilus influenzae Staphylococcus aureus Neisseria meningitides Salmonella spp

1-3 months old Streptococcus pneumoniae Group B streptococcus Neisseria meningitidesSalmonella spp Haemophilus influenzae Listeria monocytogenes

Over 3 months old Streptococcus pneumoniae Haemophilus influenzae Neisseria meningitides Salmonella spp

Clinical and laboratory “low risk”criteria for Clinical and laboratory “low risk”criteria for children younger than 3 months with fever and no children younger than 3 months with fever and no focus of infectionfocus of infection

Clinical criteria Born at term (gestational age ≥ 37 weeks) with uncomplicated nursery stay Previously healthy infants No toxic manifestations No focal bacterial infection (except otitis media)

Laboratory criteriaWhite blood cell count 5-15 × 109/l, < 1.5 × 109 band cells/l, or band/neutrophil

ratio < 2 Normal urine analysis results (negative Gram stain of unspun urine, negative leucocyte esterase and nitrite, fewer than five white blood cells per high power field) When diarrhoea is present, no haem and fewer than five white blood cells per high power field Fewer than 8 × 106 white blood cells/l in cerebrospinal fluid, if lumbar puncture is performed, and negative Gram stain findings in cerebrospinal fluid No infiltrate on chest radiograph

Parenteral antimicrobials used to treatParenteral antimicrobials used to treatchildren with fever and no focus of infectionchildren with fever and no focus of infection

Children younger than 3 months

Ampicillin 100-200 mg/kg/day intravenously in divided doses every 6 hours plus gentamicin 7.5 mg/kg/day in divided doses every 8 hours Or ceftriaxone, 50 mg/kg/day in a single dose Or cefotaxime, 150 mg/kg/day in divided doses every 8 hours

Children older than 3 months

Ceftriaxone, 50 mg/kg/day in a single dose Or cefuroxime, 150-200 mg/kg/day in divided doses

every 6-8 hours

Pointers to referral and dmission to Pointers to referral and dmission to hospitalhospital

Febrile infants 7 days of age or less

High risk (see box 2) febrile infants 28-90 days of age

Toxic looking febrile children up to 36 months of age

Summary pointsSummary pointsThe main bacterial causes of infections in children aged under 1 month are group B streptococcus, Escherichia coli (and other enteric Gram negative bacilli), Listeria monocytogenes ,Streptococcus pneumoniae , Haemophilus influenzae,Staphylococcus aureus, Neisseria meningitides, andSalmonella spp

Most bacterial infections in children over 3 months are caused by S pneumoniae (in non-immunised children), N meningitidis, or Salmonella spp

All febrile children under 3 years old who have toxic manifestations should be admitted tohospital, be fully investigated for sepsis and meningitis, and receive antimicrobial treatment

The risk of bacterial infection is very low in children over 24 months old who seem well, andfollow up without laboratory tests or treatment with antimicrobials is generally adequate

In 3-24 month old children antimicrobial treatment is initiated if foci are found; if no identifiable source is found and the child seems well, no diagnostic tests or antibiotics are generally needed

Most febrile infants under 1 month old and all those under 7 days should be admitted to hospital and treated with antimicrobials; however ,observation in hospital without antimicrobials or outpatient management is an option in selected low risk cases