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Fever is the most common pediatric complaint Most common reason that brought children to the ER Some feel

fever is a marker of death Some feel true fever is harmful

1/3 parents thought 38-40C 2/3 40-41C all thought brain damage >41C

5 - 20% have no localizing signs on examination The majority of children with fever do not have a serious illness

 Fever accounts for 10-20% of pediatric visits to health care providers.  Mortality / Morbidity: Patients with no easily identified source of infection have a small but significant risk of a serious bacterial infection.  If not recognized and treated appropriately this can cause morbidity or mortality.

WBCs work best and kill most bacteria at 38-40C. Neutrophils make more superoxide anion Speed up metabolism for tissue repair

Increases the antiviral effect of Interferons

IFNs are a class of anti-vial proteins that disrupt


viral multiplication

Nonspecific to viral types


Coxsackie and polio virus replication is directly inhibited.

Lower esophageal temp = core body temp Normal core temperature : 37C (98.6F) + 0.8 Axillary temp < oral by 0.5 C Rectal > oral temp by 0.5 C Tympanic membrane ~ oral temperature

not reliable for children < 3 year old


1. Harrisons Internal Medicine 2. http://www.emedicine.com/EMERG/topic377.htm

Diurnal variation = 0.6 - 1.1C Lowest temperature at 6 a.m. Maximum temperature at 6 p.m. Most true fevers follow this diurnal pattern This accounts for increased number of ER visits in the evening

True core temp. central circulation (aorta and pulmonary artery). Esophageal Rectal accurate but impractical

gold standard

Tactile and axillary inaccurate (varies with environmental temperature) Tympanic inaccurate in age < 3 years

The standard definition of fever is a rectal temperature of > 100.4F (38.0C) A life-threatening event occurs in 1% of children presenting with fever

1. Harrisons Internal Medicine 2. http://www.emedicine.com/EMERG/topic377.htm

Fever:
Increase in body temp. > 37.8 C Elevated body temperature mediated by an
increase in the hypothalamic heat-regulating set point

Hyperthermia:
Increase in body temp. > 41 Overrides or bypasses the normal
homeostatic mechanisms

Hypothalamus is body's thermostat, usually set at 37oC.

Infectious agents or toxin ( Endo/Exo) Mediators of inflammation

Fever

Monocyte/Macrophages Endothelial cells and other cell type


Corticosteroid

Increased heat production Increased heat conservation

Pyogenic cytokines IL - 1 alpha and beta TNF, IL- 6, IFNS Enhanced immunity

COX2
Antipyretic

Archidonic Acid PGF2

Anterior hypothalamus Elevation of Thermoregulatory Set point

Tissue damage, release of pyrogens and phospholipids

Archidonic acid NSAID block COX 1 and COX 2 in periphery and CNS
PG3 PG3 PG3

Paracetamol blocks Cyclo-oxygenase in CNS

Fever and Pain


COX 1 is critical to maintain the integrity of platelets,renal function and gastric mucosa.

Interleukin-1 Phospholipids
phospholipase A2

Arachidonic acid
Cyclo-oxygenase

Leukotrienes lipogenase

Endoperoxides

Prostacyclins

Prostaglandins (PGE-2) Fever

Thromboxanes

Fever

considerable discomfort

muscle pains headache nausea aches tiredness

1. HR increase ~ 15 BPM / 1C 2. Metabolic Rate  10-12% / 1C 3. Insensible water loss : 300-500 ml/m2/day 4. Electrolyte & nutritional consequence

The child has a tendency for febrile convulsions Patient has a serious primary disease, for example severe heart, lung or kidney disease. In these cases fever may be harmful

1. CBC

Risk of bacteremia 5 times if total leukocyte > 15,000 increase in bacterial infection, CNT , neoplasm ESR > 100 : suggestive of Kawasaki Tuberculosis CNT Malignancy Newborn : normal CRP have high NPV (99%)

2. ESR, CRP

3. Specific laboratory investigation : culture, X-ray, TT, serology

Fever: Beware
Fever without any clear focal symptoms or focal findings ? possibility of septicaemia of pneumococcal or other aetiology. Fever in a child below 3 - 6 mths of age ? possibility of serious fulminant disease. Observe the child's GC, neurological symptoms and alertness. Hospital level investigations are usually necessary. If you are treating, ensure that parents can contact a doctor easily.
Dr C H Asrani Presentation

Fever: Beware
Fever and rash Meningococcal septicaemia Fever, stomach pain and vomiting Appendicitis & urinary tract infection. Fever and neck pain Possibility of a CNS infection. Fever and joint pain ? purulent joint infection, Rh fever. Prolonged fever Arrange for further investigations.
Dr C H Asrani Presentation

Fever

> 2 weeks > 380C

Documented fever
1 week in hospital

Negative diagnostic evaluation during

Fever

> 2 weeks > 380C

Documented fever

1. CBC
- WBC if < 3,000 suggesting Dengue infection > 15,000 suggesting Leptospirosis (severe form) - platelet if decrease suggestive DHF, leptospirosis (severe form of leptospirosis with thrombocytopenia usually have WBC elevation) - Malarial pigment

2. Serum creatinine > 2 mg/dl 20% of leptospirosis elevate Cr. 3. Evidence of aseptic meningitis leptospirosis / Rickettsia 4. Weil-felix test, IFA or IIP for Rickettsia leptospira titer 5. Stool C/S, BM C/S for typhoid 6. Sterile pyuria : TB kidney & Kawasaki

1. Repeat PBS for malaria 2. Empiric treatment with cotrimoxazole for typhoid fever 3. If not improve Doxycycline which effective for : Lepto, Scrub, murine typhus, Mycoplasma defervescence within 48 hr.

Algorythm for the Diagnosis of FUO

Complete history and physical assesment Positive findings Order appropriate and specific No diagnostic testing
CBC, electrolytes, LFT, blood culture, urinalasysis, urine culture, ESR, PPD skin test, chest radigraph

Positive results No

CT of abdomen / pelvis with contrast Assign most likely category

Order appropriate follow-up diagnostic testing

Infection Malignancies Autoimmune (NIID) Miscallenous

Remember

Most Children Have Common Illness With Uncommon Presentation

Infection Malignancy Collagen-vascular disease, Drugs (barbiturates, antibiotics, antihypertensives, antiarrhythmic, phenytoin, antihistamine, salicylates, cimetidine, bleomycin, allopurinol),  Factitious fever  Inflammatory bowel disease,  Subacute thyroiditis    

 Most common infectious FUO:

Salmonellosis Infectious mononucleosis Hepatitis TB

 Consider kawasaki disease

History I
Obtaining an accurate history from the parent or caregiver is important; the history obtained should include the following information: Fever history: What was child's temperature prior to presentation, and how was temperature measured? Consider fever documented at home by a reliable parent or caregiver the same as fever found on presentation. (Accept parental reports of maximum temperature.) Fever at presentation:
If the physician believes the infant has been bundled excessively, and if a repeat temperature taken 15-30 minutes after unbundling is normal, the infant should be considered afebrile. Always remember that normal or low temperature does not preclude serious, even lifethreatening, infectious disease.

History II
Current level of activity or lethargy Activity level prior to fever onset (ie, active, lethargic) Current eating and drinking pattern Eating and drinking pattern prior to fever onset Appearance: Fever sometimes makes a child appear rather ill. Vomiting or diarrhea Ill contacts Medical history Immunization history (especially recent immunizations)
Urinary output - Number of wet diapers

Physical I
While performing a complete physical examination, pay particular attention to assessing hydration status and identifying the source of infection. Physical examination of every febrile child should include the following: Record vital signs.
Temperature: Rectal temperature is the standard. Temperature obtained via tympanic, axillary, or oral methods may not truly reflect the patient's temperature. Pulse rate Respiratory rate Blood pressure

Physical II
Measure pulse oximetry levels.
Pulse oximetry may be a more sensitive predictor of pulmonary infection than respiratory rate in patients of all ages, but especially in infants and young children. Pulse oximetry is mandatory for any child with abnormal lung examination findings, respiratory symptoms, or abnormal respiratory rate, although keep in mind that respiratory rate increases when children are febrile.

Record an accurate weight on every chart.


All pharmacologic and procedural treatments are based on the weight in kilograms. In urgent situations, estimating methods (eg, Broselow tape, weight based on age) may be used.

Physical III
During the examination, concentrate on identifying any of the following:
Toxic appearance, which suggests possible signs of lethargy, poor perfusion, hypoventilation or hyperventilation, or cyanosis (ie, shock) A focus of infection that is the apparent cause of the fever Minor foci (eg, otitis media [OM], pharyngitis, sinusitis, skin or soft tissue infection) Identifiable viral infection (eg, bronchiolitis, croup, gingivostomatitis, viral gastroenteritis, varicella, hand-foot-and-mouth disease) Petechial or purpuric rashes, often thought to be associated with invasive bacteremia Purpura, which is associated more often with meningococcemia than is the presence of petechiae alone

Causes I
Several common bacteria cause serious bacterial infections (SBI). S pneumoniae
S pneumoniae is the leading cause of nearly all common bacterial upper respiratory tract infections (eg, pneumonia, sinusitis, OM). This organism is the most common cause of meningitis in the United States. It is the most common cause of occult bacteremia.

N meningitidis H influenzae type b L monocytogenes E coli

Causes II
E coli
E coli is the most common cause of urinary tract infections (UTIs).

Among febrile children with UTIs, 75% have pyelonephritis, with consequences that, if missed, include renal scarring in 27-64% of patients, a 23% risk of hypertension, a 10% risk of renal failure, and a 13% risk of preeclampsia as adults.

Approximately 13-15% of end-stage renal disease is believed to be related to undertreated childhood UTIs.

Lab Studies I
Recommended laboratory studies for children with fever of unknown etiology are based upon the child's appearance, age, and temperature. (Begin IV or IM antibiotic administration for all infants who appear ill once urine and blood specimens are obtained. Perform the following for children who do not appear toxic: Perform a complete blood count (CBC) with manual differential. Draw and hold blood cultures, pending receipt of CBC results. Send blood culture for analysis if white blood cell (WBC) count exceeds 15,000 or if absolute neutrophil count (ANC) exceeds 10,000. Perform urinalysis (UA) by bladder catheterization and urine culture based on the following criteria:
All males younger than 6 months and all uncircumcised males younger than 12 months All females younger than 24 months and older female children if symptoms suggest a UTI

Consider cerebrospinal fluid (CSF) studies and culture. (Obtain CSF if meningitis is suspected.) Consider obtaining a stool culture to measure fecal WBCs and stool guaiac for diarrhea.

Lab Studies II
Perform the following for children who appear toxic:
Perform a CBC with manual differential. Send blood cultures. Consider obtaining a chest radiograph. Chest radiography should be performed for patients with a WBC count greater than 20,000. Perform UA by bladder catheterization and urine culture based on the following criteria:
All males younger than 6 months and all uncircumcised males younger than 12 months All females younger than 24 months and older female children if symptoms suggest a UTI

Obtain CSF and perform studies and culture if any suspicion of meningitis exists. (Administer antibiotics before performing the lumbar puncture [LP] if any delay is anticipated.) Consider obtaining a stool culture to measure fecal WBCs and stool guaiac for diarrhea. Admit these patients for further treatment; pending culture results, administer parenteral antibiotics (see Treatment).

Imaging Studies

Chest radiography is part of any thorough evaluation of a febrile child.

Chest radiography is indicated when the patient has tachypnea, retractions, focal auscultatory findings, or oxygen saturation level (SO2) on room air of less than 95%.

Although viral etiologies are considered the cause of most pediatric pneumonias, 51% of pediatric patients with pneumonia have serologic evidence of bacterial infection.

Chest radiographs should be obtained if WBC is >20,000. One study found a high correlation with WBC greater than 20,000 and pneumonia, even with a lack of clinical findings suggestive of pneumonia.

Medical Care
For children who appear ill, conduct a complete evaluation to identify occult sources of infection. Follow the evaluation with empiric antibiotic treatment and admit the patient to a hospital for further monitoring and treatment pending culture results. Patients aged 2-36 months 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.

ROCHESTER LOW RISK CRITERIA <60 DAY


Dagan R et al., J Ped 1988; 112: 355-60

Infant appears well, non-toxic Infant has been previously well * born at term (>37 weeks) * no antenatal or perinatal antimicrobial therapy * no treatment for unexplaind hypebilirubinemia * not hospitalized longer than the mother at birth * no previous hospitalization * no recent antibiotic use * no chronic or underlying diseases Infant has no evidence of bacterial infection * no skin, sift tissue, bone, joint, or ear infection The following laboratotry parameters are met: * WBC count 5000-15000/mm3 * absolute band count <1500 * urinanalysis WBC count <10/hpf * stool WBC count <5/hpf(if infant has diarrhea)

Review of Systems (ROS)

prolonged fever and weight loss (cancer)

myalgias, arthralgias (connective tissue disease)

dyspnea, cough (TB, multiple pulmonary emboli, sarcoidosis)

abdominal pain (intra-abdominal abscess, IBD, cancer)

Other diagnostic testing


if focal neurological signs - CT head to rule out abscess, cancer if lethargy, confusion - LP to rule out meningoencephalitis, cancer if lymphadenopathy - HIV titer; lymph node biopsy to rule out lymphoma, cancer if cough, dyspnea - bronchoscopy, consider gastric aspirate for AFB, consider V/Q scan if hepatosplenomegaly or abdominal pain - CT abdomen if cardiac murmur - echocardiography if hepatic dysfunction - liver biopsy
review of liver biopsy can be found in N Engl J Med 2001 Feb 15;344(7):495, commentary can be found in N Engl J Med 2001 Jun 28;344(26):2030

Other diagnostic testing II

if headache, tenderness over temporal artery - temporal artery biopsy if bone pain - bone scan, metastatic bone series, protein immunoelectrophoresis if guaiac-positive stool - colonoscopy or barium enema and sigmoidoscopy if hematuria - renal ultrasound, IVP, cystoscopy bone marrow exam in suspected lymphoma, leukemia, miliary TB gallium scan and exploratory laparotomy rarely helpful

   

Safety. Wide therapeutic window. Short duration of action. Side effect: Over dosing either intentional or accidental.

According to WHO paracetamol is the drug of first choice Ibuprofen is a useful 2nd line drug No other NSAID should be prescribed for children with high grade fever and used with caution

Thanks