Sawla General Hospital

Seminar 11

prepared by
Dagnachew
APPROACH TO
FEBRILE
CHILD
CONTENTS
 Introduction
 Definition

 Etiology

 Pathogenesis

 Patterns

 Treatment
 INTRODUCTION

 Fever is the most common presenting complain in pediatrics.

 It's commonest parentral concern in child.
 The majority of child presenting with fever are less than 3 yrs old.
 Definition of fever
 Fever is an elevation of body temperature that exceeds the normal daily
variation and occurs in conjunction with an increase in hypothalamic set
point. (Axillary temperature greater than 37.5)
 fevers that are regulated by the hypothalamus usually not rise above
40°C-safety mechanisms.
 A fever of >41.5 is called hyperpyrexia.
 fever can be caused by a numbers of microorganisims and substance that
are collectivelly is called pyrogens.
 Fever differs from hyperthermia, hyperthermia is an increase in body
temperature over the body thermoregulatory set point ,due to exces-
sive heat production or insufficient thermoregulation.
 hyperthermia is an example of high temperature that is not fever.
 WHAT IS NORMAL TEMPERATURE?
 Rectal :36.6-38oc
 Oral : 35.5-37.5oc
 Axillary : 34.7-37.3oc
 Ear : 35.5-37.5oc
 Etiology of fever
INFECTIONS NON INFECTIONS
 Autoimmune disease
 Bacteremia
 Kawasaki disease
 Meningitis  Juvenile inflammatory arthritis
 UTI  Lupus
 Pneumonia  Inflammatory bowel disease
 Bronchiolitis  Henoch-Schonlein purpura
 URI  Malignacy
 otitis media and etc.  Drug reaction
Pathogenesis of fever
Three mechanis of fever;
1. pyrogen: is raise hypothalamus set point.
 Can be endogenous and exogenous
 ENDOGENOUS include
cytokines interleukins 1 and 6,
tumor necrosis factor α, and
interferons β and γ lipid mediators, like PG-E2
Infectious diseases and drugs, malignancy and
inflammatory diseases can cause fever through the pro-
duction of endogenous pyrogens
Exogenous
 EXOGENOUS PYROGENS or substances that come
fro outside the body include mainly infectious
pathogens and drugs.
 Drugs that are known to cause fever include

 vancomycin,

 amphotericin B, and

 allopurinol.
cont...
2. HEAT PRODUCTION EXCEEDING LOSS
e.g.
  salicylate poisoning

  malignant hyperthermia

3. DEFECTIVE HEAT LOSS

e.g.
 in children with ectodermal dysplasia or
 victims of severe heat exposure.
Patterns of fevers
Classification
 Fever in pediatrics is broadly classified as:
1. Fever in neonates and young infants and
2. Fever in older children.
 Approach and management differ in these two categories.
3. Fever of unknown origin.
Fever without focus on neonates and young inant

 fever without a focus refers to a rectal temperature of ≥38°C, without

other presenting signs or symptoms.
 The etiology and evaluation of fever without a focus depend on the

age of the child.

 Three age groups are typically considered:

 Neonates 0-28 days,

 Young infants 29-90 days, and

 Children 3-36 months.

• Serious Bacterial Infection (SBI) occurs in 7% to 13% of
neonates and young infants with fever.

• In this group, the most common SBIs are:

• UTI (5–13%),
• Bacteremia (1–2%) and
• Meningitis (0.2–0.5%).
 E. coli is the most common organism causing SBI, followed by GBS.
 Increased screening of pregnant women and use of intrapartum an-
tibiotic prophylaxis has led to the decrease in GBS infections.
 less common organisms include:- Klebsiella spp., Enterococcus
spp., S. pneumoniae, N. meningitidis, and S. aureus.
 Listeria monocytogenes is a rare cause of neonatal infections.
 In well appearing infants, viral illnesses are much more common than
bacterial or serious viral infections.
 The most common viruses include:- RSV, enteroviruses, influenza
viruses, parainfluenza viruses, human metapneumovirus, adenovirus,
par echoviruses, and rhinovirus.
 HSV infections should also be considered in febrile neonates <28
days old.
 Neonates with disseminated disease and skin, eye, and mouth (SEM)
disease
 Typically present at 5-12 days of life.
 Neonates with CNS disease generally present at 16-19 days.
 Perinatally acquired HSV may occasionally manifests beyond 28 days
of age.
Approach
 Diagnosing serious illness can be a challenge because bacterial and
viral infections can present with isolated fever or non specific symp-
toms.
 Some neonates and young infants will have signs of systemic illness
at presentation, including:
 Abnormal temperature (hypothermia <36°C, fever ≥38°C),
 Abnormal respiratory examination (tachypnea >60 bpm, respiratory
distress, apnea
 Abnormal circulatory examination (tachycardia >180 bpm, delayed
capillary refill >3 sec, weak or bounding pulses),
 Abnormal abdominal examination,
 Abnormal neurologic examination (lethargy, irritability, alterations in
tone), or
 Abnormal skin examination (rash, petechiae, cyanosis).
Diagnosis
 Protocols were developed to identify infants at lower risk of SBI, so
that they can be managed outside the hospital setting.
 The 3 most widely used are the Rochester, Philadelphia, and Boston
criteria
 keep in mind that these criteria apply only to the well-appearing
child.
Boston Criteria
Investigation
 CBC
 Blood Culture:
 A negative blood culture does not eliminate the risk of bacterial meningi-
tis.
 Don’t forget that approximately 35% of infants with bacterial meningitis
do not have a positive blood culture.
 Urine Analysis
 CSF Analysis
 HSV Testing
 Inflammatory markers
 such as C-reactive protein (CRP) and serum procalcitonin (PCT), particu-
larly in the diagnosis of SBI and, more specifically invasive bacterial in-
fection, IBI (bacteremia and meningitis.
Treatment
 ANTIMICROBIALS
 Commonly used regimens include:
A. A third-generation cephalosporin (typically cefepime),
B. A third-generation cephalosporin and ampicillin, or
C. An aminoglycoside and ampicillin.
 Ampicillin is the preferred treatment of GBS and covers L. monocy-
togenes and many Enterococci spp.
 For neonates 0-28 days, options 2 or 3 have been recommended,
given the risk L. monocytogenes.
 For young infants >28 days, option 1 (third-generation cephalosporin:
cetriaxone) can be a reasonable choice.
 For ill-appearing infants or those with positive CSF Gram stains, ad-
ditional antibiotics may include vancomycin or broad-spectrum an-
tibiotics such as carbapenems.
 Neonates with concern for HSV should be empirically treated with
high-dose acyclovir (60 mg/kg/day).
 Treatment duration and route of antimicrobial administration depend
on the infection.
 PROGNOSIS
 Most infection related mortality and long-term morbidity results from
HSV infection and bacterial meningitis.
 The mortality of bacterial meningitis varies by pathogen, but ranges

from 4–15%.
FEVER IN THE OLDER CHILD
 History & Physical Examination are reliable to establish a diagnosis
in this age group.
 Occult infections (like UTI) may be present, and screening for such
infections should be guided by age, gender, and degree of fever.
Diagnosis
 Potential causes of fever in older infants and children can be catego-
rized into:
 Infections
 Inflammatory (ARF, SLE, IBD, HSP, etc.);
 Oncologic (leukemia, lymphoma, solid tumors);
 Endocrine (e.g., thyrotoxicosis); and
 Medication-induced causes (e.g., Salicylate toxicity
OCCULT BACTERIAL INFECTIONS
 Infants and children age 2-24 mo merit special consideration because

they have limited verbal skills, are at risk for occult bacterial infec-
tions, and may be Otherwise asymptomatic except for fever.
 OCCULT URINARY TRACT INFECTION
 Among children 2-24 mo old without Sx or physical examination
findings that identify another focal source of infection, the prevalence
of UTI may be as high as 5–10%.
 The highest risk of UTI occurs in females and uncircumcised males,
with a very low rate of infection (<0.5%) in circumcised males..
General Approachs
A. OVERALL APPEARANCE AND VITAL SIGNS
 Children who are ill or appear toxic or who have abnormal V/S (e.-

tachycardia, tachypnea, hypotension): focused P/E to evaluate for the

Presence of an IBI.
 Detailed history and P/E can be performed in the well-appearing

child.
B. SYMPTOMS
I. Characterization (degree & duration) of fever is important.
 For children with prolonged fever, determine whether the fever has

been episodic or persistent.

 Patients with prolonged fever may harbor:

▪ Occult infections,
▪ UTI,
▪ Bone or soft tissue infections,
▪ Have an inflammatory or oncologic condition, or kawasaki disease
II. Look for the presence of symptoms that may indicate an etiology for
the fever
 Symptoms should be elicited for each body system: e.g.

 HEENT: headache, ear pain, sore throat, neck pain or swelling,

 R/S: difficulty breathing, chest pain,
 GIT: abdominal pain,
 GUT: the presence of dysuria, urinary frequency, or back pain
 IGS: rash or changes in skin color,
 MSS: extremity pain or difficulty with ambulation (including refusal to bear
weight in a young child), and overall activity level
C. PHYSICAL EXAMINATION
 Vital signs.

 careful evaluation of each body system.

D. INVESTIGATION; that's based on the;

 The overall appearance

 Vital signs of the child,

 The presence of specific Sx or P/E findings, and

 age.
MANAGEMENT
 GENERAL PRINCIPLES
 Supportive care, like antipyretics and adequate hydration, for all
children with fever.
 Children with viral infections generally require supportive care
only, except for children at higher risk of severe or complicated
disease with influenza virus.
 Antibiotics should be reserved for children with evidence of bacte-
rial infection
 Classification of fever

Acute:- fever less than last 7 days Chronic:- fever last more than 7 days.
 meningitis  Abscess
 otitis media  salmonella infections
 mastoiditis
 osteomyelitis
 infective endocarditis
 septic arthritis  rhumatic fever
 acute rhumatic fever  miliary TB
 skin and soft tissue infection  brucellosis
pneumonia
Can also be classified as fever with rash and without rash.

 FEVER WITH RASH

 Bacterial and viral infections are frequently associated with a
rash and fever in children.
 Most exanthems are self-limited and resolve in 7 to 10 days
and only symptomatic treatment is needed.
 Vaccinations have significantly decreased the incidence of
measles, rubella, varicella, and their congenital
complications.
Fever of unknown origin
 children with a temperature >38°C documented by a healthcare
provider and for which the cause could not be identified after at least
8 days of evaluation.
 Whereas, Fever without a source (FWS)
 o is fever where the source has not yet been identified and is differen-
tiated from FUO by the duration of the fever.
ETIOLOGY
 The many causes of FUO in children are:
 Infectious,
 Rheumatologic (connective tissue or autoimmune),
 Auto-inflammatory,
 Oncologic,
 Neurologic,
 Genetic,
 Factitious
THANK YOU