Diagnosis and Management of children with fever with reference to IMNCI (Integrated Management of Neonatal and Childhood Illness)

1. Adapted
A practical approach to the child with
Fever
Background, Assessment and Management
Prof. Imran Iqbal
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

3. IMNCI
A Strategy for
Outpatient Case Management
of Children
under five years of age

4. Step 1
General Danger Signs
General Danger Signs indicate severe disease
Presence of any one of the General Danger Signs
means that the child needs to be
referred / admitted to the emergency

5. Check for General Danger Signs
• Unable to drink or breastfeed
• Vomiting everything
• Lethargic or unconscious
• Convulsions
• General Danger Signs indicate severity of illness
• Not diagnostic but suggests acuity of situation

6. Step 2
Assess for
Cough or Difficult Breathing

7. Step 3
Assess for
Diarrhoea

8. Step 4
Assess for
Sore Throat

9. Step 5
Assess for
Ear Problem

10. Step 6
Assess for
Fever

11. Case Scenario
• An 8 year old child presents with fever for the last 5 days.
Fever remains high most of the time. On examination, he has
a temperature of 104 F.
• How will you further evaluate this child to make a diagnosis
and decide about management ?

12. How to measure Body Temperature in Children
CORE body temperature
Older Children
• Thermometer in mouth (under the tongue) for ½ minute
Infants & Small Children
• Thermometer in AXILLA for 2 minutes
(Do NOT add anything to the measurement)
Both of these are almost equal and give CORE body temperature
SURFACE body temperature
• Infra Red Thermal device (usually forehead temperature is taken)
• Observer Hand Feeling (back of fingers placed on forehead, abdomen, axilla)

13. FEVER
• Normal Body Temperature = 37 C
Range of Normal = (36.5 C to 37.5 C)
• Normal Body Temperature = 98.6 F
Range of Normal = (97.5 F to 99.5 F)

14. Grading of Fever
• Low Grade Fever 37.5 – 39 C
99.5 – 102.5 F
• High Grade Fever 39 – 40.5 C
102.5 – 105.5 F
• Hyperpyrexia more than 40.5 C
more than 105.5 F

15. Fever in Children
• Children’s forehead is usually warmer than rest of body
• During rising fever trunk will be warm and extremities cold
• During stable fever, whole body will be warm
• Shivering accompanies rapid rise of fever.
• Shivering is not specific for any cause or diagnosis

16. Is fever Beneficial for human body?
• Fever is an important clinical symptom and sign of illness
• During fever, immune function of leukocytes is increased
• More lymphocyte proliferation and cytokine production is seen
• Growth of infectious microorganisms is inhibited (decreased)

17. Harmful effects of fever?
• During fever, Oxygen demands and O2 consumption is
increased
• Hyperpyrexia can compromise cardio-respiratory and
metabolic functions of the body and can damage the brain
• Children are irritable and anorexic during febrile episodes
• Febrile convulsions (fits during sudden rise of fever) can occur
in children below five years of age

18. How will you Evaluate and Manage the child with Fever?
• Initial assessment
• History
• Examination
• Diagnosis
• Investigations if needed
• Management

19. Brief Initial Assessment
• Unable to drink / Vomiting everything
• Dehydration
• Lethargic or unconcious
• Convulsions
• Airway & Breathing – Respiratory rate, cyanosis
• Circulation – Heart rate, Capillary refill, Pulses
• Vital signs – Pulse, Respiration, Temperature, SpO2

20. History
• How much Fever was present on day 1, day 2, day 3 ?
(gradual or sudden rise?)
• Does the child have associated symptoms of ?
- cough, breathing problem
- vomiting, diarrhea
- skin rashes
- headache, convulsions / fits
• Does the child have pain anywhere in the body ?

21. History of Contact
• Exanthematous fevers
(measles, mumps, chickenpox etc.)
• ARI
• Diarrhea
• Tuberculosis

22. Technique of Physical Examination
• Inspection
• Auscultation
• Palpation

23. Examination of Small Child
• Dehydration
• Skin rashes
• Respiration, chest indrawing
• Eyes – conjunctivitis, jaundice, anemia
• Oral cavity – thrush, ulcers
• Lymph nodes
• Liver, spleen
• Signs of meningeal irritation
• Throat, ears

24. Examination in the Older Child
• Jaundice / Pallor
• Oral cavity & tonsils
• Skin Rashes
• Respiratory rate / chest indrawing
• Cardiac & chest auscultation
• Lymph nodes
• Liver, spleen
• Signs of meningeal irritation

25. FEVER (10 common problems)
• Runny nose, Cough, Flu
• Sore throat, Ear pain
• Fast breathing, chest indrawing
• Vomiting , Diarrhoea
• Pain abdomen, vomiting
• Headache, Vomiting, convulsions
• Skin rashes
• Burning micturition
• Pain and swelling of joints
• No localising signs

26. Possible Diagnosis in the Febrile Child
20

27. Respiratory Symptoms And Signs
• Fever + Runny nose/cough = ARI (cough and cold)
• Fever + cough +Fast breathing /chest indrawing = ARI (Pneumonia)
• Fever + Sore throat / inflamed tonsils = Tonsillitis / Pharyngitis
• Fever + Ear pain / Ear discharge = Otitis media

28. Abdominal Symptoms And Signs
• Fever + Vomiting + Diarrhea = Gastroenteritis
• Fever + Pain abdomen + Jaundice = Hepatitis
• Fever + Pain abdomen + tenderness = Appendicitis, Peritonitis
• Fever + Splenomegaly = Malaria, Typhoid

29. CNS Symptoms and Signs
• Fever + fits / unconcious = Meningitis,
= Febrile seizures
= Encephalitis
= Cerebral malaria
• Fever + SOMI = Meningitis
• Fever + Bulging Fontanel = Meningitis, Intracranial Hemorrhage

30. Skin Symptoms and Signs
• Fever + Cough + Maculopapular Rash =Measles
• Fever + Vesicular Rash = Varicella
• Fever + Purpuric Rash = Meningococcemia
• Fever low + Macular Rash = Rubella
• Fever subsided + macular rash = Roseola infantum
• Fever + subcutaneous swelling = abscess

31. Fever with Lymphadenopathy
• Fever + tender lymph nodes = Acute lymphadenitis
• Fever + chronic non-tender lymph nodes = Tuberculosis
Lymphoma
• Fever + soft tender swelling = Pyogenic Abcess
• Fever + soft non-tender swelling = Tuberculous (cold) abcess
• Fever + lymphadenopathy + Purpura = Acute Leukemia

32. Musculoskeletal Symptoms and Signs
• Fever + Limping Gait = Osteomyelitis
Pyogenic Arthiritis
• Fever + Pain in joints = Juvenile Idiopathic Arthritis
• Fever + Spine deformity = Spinal tuberculosis

33. Urinary Symptoms and Signs
• Fever + Urine problems = UTI

34. Fever without Other Manifestations
• Fever + No localizing signs = Septicemia
Typhoid
UTI
Malaria
• Prolonged Fever (more than 14 days) = Typhoid
Tuberculosis
Collagen disorders
Lymphoma / Leukemia

35. Investigations in the Febrile Child
• CBC (Hb, TLC, DLC)
• CRP
• ICT Malaria
• Typhidot test
• Urine Examination
• X-ray Chest
• USG abdomen
• Liver function Tests
• Blood / Fluid cultures
• CSF examination
• CT / MRI scans

36. Management of the Febrile Child
• Symptomatic Management
• Supportive Management
• Specific Management
• Manage Complications

37. Symptomatic Management of the Febrile Child
• Keep exposed
• Antipyretics
Paracetamol = 10 – 15 mg/kg
Ibuprofen = 5 – 10 mg/kg
• Tepid Water Sponging

38. Nutritional Management of the Febrile Child
• Increased fluids
• MAINTAIN CALORIC INTAKE
• Small frequent feeds
• Give usual diet which the child likes. Do not stop roti.
• IV Fluids if frequent vomiting, severe anorexia or hypoglycemia

39. Specific Management of the Febrile Child
• Treat the cause after the diagnosis
• Follow standard treatment guidelines
• Consider focus of infection, possible infecting organisms and
antibiotics effective against the micro-organisms
• Avoid overuse of Antibiotics
• Treat the Complications

40. PREVENTION

41. PREVENTION
• WASH HANDS
• Drink only clean / boiled water
• Mother’s milk, unpolluted top feeds
• Eat thoroughly cooked food
• Use Masks
• Keep social distance with Respiratory patients
• AVOID crowds and gatherings
• AVOID cold drinks, sour foods
Improve your protection
• Vaccination

42. EPI gives Protection against following Diseases
• Tuberculosis
• Diphtheria
• Pertussis
• Tetanus
• Hepatitis B
• Polio
• Rota virus
• Pneumococcal diseases
• Hib
• Measles

43. Other Vaccines available in Pakistan
• Measles, Mumps, Rubella
• Varicella
• Hepatitis A
• Typhoid
• Meningococcal vaccine
• Influenza