fever Myths & Facts fever in Children fever in Pediatrics

2. 1

3. incidence
Fever is one of the commonest
symptoms in medicine
Fever accounts for 1/3
of all presenting conditions
in children

4. Definition
it is not a disease
only as a symptom
of underlying disease
But a physiologic response
Fever is ↑ body temperature
> 37.8

5. Fever Hyperthermia
Etiology Endogenous Exogenous environment
Causes infections “bacterial or others”
inflammations
Collagen-vascular diseases
Malignancies
Sun stroke
Heat stroke
Malignant hyperthermia
Drugs e.g. Anticholinergics
Commonest viral infections Sun stroke
Mediators Endogenous pyrogenic cytokines
IL-1 , IL-6 , TNF , ᵅ IF
PGE2
Mechanism ↑ Body temperature ↑ Body temperature
↑ Hypothalmus set point Normal Hypothalmus set point
ttt Antipyretics Water Foments & Bath

7. History
time
grade
diurnal variation
duration
associted symptoms
analysis of Fever regarding

8. Examination
Encephalitis
Pneumonia
Meningitis
UTI
Septic arthritis
Kawasaki disease
to find the focus
do not forget signs of specific diseases

9. investigations
the workup is according to
the focus
Respiratory
CNS
GIT
Skin
Soft tissues
Bones
GU
CVS
Hep
Blood

10. investigations
a full sepsis workup is required
in neonates due to
↑ Risk for Serious Bacterial Infections “SBI”
CBC
CRP
PCT
Blood C&S
Urine C&S
CXR
LP

11. F/U Care
after 2 : 3 days for
Reevaluation of clinical condition
e.g. O.M , Rashes , …etc……
improvement or deterioration
Lab Results e.g. C&S

12. The
Fever Traffic Light
System

13. in 2007 Released
“The Fever Traffic Light System”
according to temperature degree
only

14. Green Yellow Red
Temp “ 0 c” 37.8 : 39 39 : 40 40 : 40.6 40.6 : 42 > 42
Fever grade Low Moderate High Extreme High Seroius
Risk Low Moderate High Fatal
Benefits Yes Yes No No
Discomfort No Yes Yes Yes
Harms No No No Yes
can cause
Brain damage
Risk Factors
try to
keep the
fever in
this range
-----
with ↑ Risk of
Seroius infections
not due to infections
only with extreme
environmental
causes

15. in 2013 Updated
“The Fever Traffic Light System”
to include several parameters
not only temperature degree
But also

16. Green Yellow Red
Risk Low Moderate High
Colors
“Skin , Lips , Toungue”
Normal
Pallor Mottled or Blue
Activity
Mild : Moderate ↓ Severe ↓
Circulation , Hydration
“HR , B.P , CRT , UOP”
Respiration
“↑ RR , ↑ WOB , Grunting , ↓ spO2”
RD I : II RD III : IV
Risk Factors -----
Age 3 : 6 m
Fever > 5 days
Rigors
Joint swelling
Limb swelling
Age < 3 m
Non-Blanching Rashes
any Neurological sign

17. Persistent irritability , Lethargy , unresponsiveness
Persistent vomiting
Bulging Fontanelle
Neck Stiffiness
Status Epilepticus
Focal Seizures
Focal Neurological signs

19. ER Care
ABC
“Airway , Breathing , Circulation”
vital signs
± Antipyretics
± Antibiotics
± Admission

20. Admission
indicated in signs of specific diseases
children with chronic diseases
children in Yellow & Red zones

22. Outpatient Care
do not prescribe Antibiotics
in children with FUO

23. inpatient Care
But
we can use Antibiotics only
if admission is indicated
only for 48 hours
or until -ve C&S

24. inpatient Care
in neonatal period
 double Antibiotics
 Ampicillin , Gentamicin
after neonatal period
 single Antibiotic
 3rd generation cephalosporin

26. use Antipyretics
only in children with
Fever > 39 0 c
discomfort
distress
uncomfortable
unwell

27. ibuprofen & Paracetamol
are the only Antipyretics
recommended for use in children
start with only one of them
ibuporofen or Paracetamol

28. ibuprofen Paracetamol
Dose “mg/kg/dose” 5 : 10 10 : 15
intervals “hours” Q6 Q4
Duration “days” 1 : 2 2 : 3
Anti-inflammatory effect Yes No
Controlled : UnControlled fever “%” 90 : 10% 80 : 20%
Contraindications
Renal diseases
Gastric diseases
Bleeding tendency
Hepatic diseases
SSRI
Varicella
?? Covid 19
infants < 3 m
More Effective Safe

29. to maximize the time
that patient spends
without fever
since 2010
recommended ibuprofen

30. since 2013
Stronger effect , Faster action , Longer duration
in ↓ fever > Paracetamol
does not ↑Risk of Asthma
does not worsen Asthma symptoms
ibuprofen has

31. • has no effect on the Bleeding rate
• used safely postoperative
as Analgesic
• used routinely in O.M with Antibiotics
as Anti-inflammatory
ibuprofen

32. is the only NSAID Licensed for use
in pediatrics as an Antipyretic
with no other alternative
NICE Guidelines since 2009
& WHO since 2012
ibuprofen

33. Diclofenac is not an Antipyretic
actually it can ↓ fever
But it is Licensed in pediatrics only as
Analgesic & Anti-inflammatory
usually used postoperative
only in children > 1 y

34. from all these Researches
ibuprofen
is more potent > Paracetamol
so , unless contraindicated ,
it should be used 1st
as a Single Antipyretic ttt

35. Single Antipyretic ttt
switch to the
other Antipyretic ttt
if no response
discomfort not relieved
or recurs before next dose

36. Single Antipyretic ttt
switch to the
Alternating Antipyretic ttt
if no response

37. Alternating Antipyretic ttt
Q4 of minimum doses
Paracetamol 10 mg/kg/dose
ibuprofen 5 mg/kg/dose

38. Combined Antipyretic ttt
was recommended up to 2006
after 2006 is not more recommended
because the Benefits do not
outweigh the Risks
both drugs simultaneously
at the same time

39. Oral route of Antipyretics
is preferred than Rectal due to
constant absorption
more accurate dose based on B.W

40. accurate dose is critical
50% of patients  incorrect dose
15% of patients  exceeding dose
for accurate dose we need
child
,s age & B.W
accurate measuring device
“syringe”

41. 2

42. Fever
is surrounded by a Lot of myths
most of them are created by parents
But
still some created by doctors

43. there is a conflict between
Myths & Facts

44. Let the following facts
help to put fever into perspective

45. Myth 1
temperature between 37.1 : 37.8 0 c
is Low grade Fever
Fact 1
Fever only if > 37.8 0 c

46. Myth 2
Fact 2
Fever only with thermometer
when a mother feels child head hot
with her hand  there is a Fever

47. Myth 3
Fact 3
Fever is always harmful
Fever has Benefits & Harms

48. Benefits Harms
it is an index of a problem
“to search for & treat”
discomfort
distress
uncomfortable
unwell
it is an index of improvement with ttt
it is a good sign for sick children
it is a defensive mechanism
it “switches on” the immune system
most organisms are mesophilic
that grow better between 30 : 37 0 c
37 0 c is the ideal temperature
for bacterial & viral growth
body fights organisms better in the
prescence of fever upto 400 c

49. Benefits Harms
Fever ↓ iron level 
this ↓ bacterial & viral growth
↑ metabolic rate
↑ HR , ↑ COP
↑ O2 consumption , ↑ CO2 production
high Risk for child with chronic diseases
especially CardioPulmonary diseases
also pateints with Neurologic diseases ,
, Metabolic disorders , Epilepsy
due to ↑ Risk for Seizures with Fever

50. Myth 4
Fact 4
Fever > 40 0 c is very serious , dangerous
, cause brain damage
Fever due to infections
does not cause brain damage
only Environmental temperature > 42 0 c
can cause brain damage

51. Myth 5
Fact 5
the more high the Fever ,
the more serious the
infection
Fever may be 40 0 c with mild infection
e.g. Roseola , Tonsillitis
& may be 38 0 c with serious infection
e.g. Meningitis , Encephalitis

52. Myth 6
Fact 6
without Antipyretics ;
Fever will keep going higher
the body will ↓ the temperature
by itself
Antipyretics are helping agents
only

53. Myth 7
Fact 7
any Fever
should be treated with Antipyretics
discomfort
distress
uncomfortable
unwell
Fever > 39 0 c
use Antipyretics
only in children with

54. Myth 8
Fact 8
with Antipyretics ;
Fever must come down to normal
Antipyretics ↓ the temperature
1 : 2 0 c only

55. Myth 9
Fact 9
with Antipyretics ;
Fever must come down immediately
Antipyretics ↓ the temperature
within 30 : 60 minutes

56. Myth 10
Fact 10
the most important is
child general condition
not the body temperature
with Antipyretics ;
if the Fever does not come down
to normal ; the cause is serious

57. Myth 11
Fact 11
Antipyretics do not work
if the temperature > 40 0 c
& we shuould ↓ the temperature 1st
with Water Foments & Bath
Antipyretics can act
directly
even in high temperature

58. Myth 12
Fact 12
Water Foments & Bath
is very beneficial
it is of choice in ttt of
Hyperthermia
But in ttt of Fever it is associated with
↑ discomfort ,↑ heat production , ↓ heat
Loss

59. Myth 13
Fact 13
Fever = Antibiotics
Fever may be due to a Lot of
causes
ttt of Fever = ttt of cause
Antibiotics = ttt only for bacterial infections
the commonest cause in
children
is viral infections

60. Myth 14
Fact 14
feed if a Cold & starve if a Fever
it is a very old myth for centuries from the middle ages
when people believed there were 2 kinds of illnesses
illnesses caused by Cold 
needed to be Fueled  so ↑ eating was recommended
illnesses caused by Fever 
needed to be Cooled down  so ↓ eating was recommended

61. Myth 15
Fact 15
if Fever is not treated well ;
Febrile Seizures will occur
Antipyretics
do not prevent Febrile Seizures
unpreventable

62. Myth 16
Fact 16
any ↑ in temperature will cause Febrile
Seizures
usually it occurs in the 1st day of
Fever
may not occur with 40 0 c
may occur with 38 0 c
unpredictable

63. Myth 17
Fact 17
anyone can have Febrile Seizures
it occurs in 4% only of
children
from 6 m to 5
y

64. Myth 18
Fact 18
Febrile Seizures are very harmful
while it is one of the most horrible
events that parents can see
“Scary to Watch”
But they are usually self Limited
stop within 5 minutes

65. with no permenant harm
with no ↑ Risk for
Developmental Delay
Learning Disabilities
Seizures without Fever

67. Step 1
stay Calm

68. Step 2
do not try to stop his movements

69. Step 3
make the child comfortable
put anything soft like a folded jacket
under head
remove any tight clothing
around neck

70. Steps
4 5 6 7
avoid injury to
Lung
“aspirations”
teeth eye Child overall
turn child to
the side
remove
anything from
the mouth
remove
eye glasses
±
remove
nearby objects
sharp & hard

71. Steps
8 9
monitoring
video recording Look at a clock or watch
if other person is available to see seizure start & end

72. Step 10
time
< 5 minutes > 5 minutes
take the child to
the doctor
,s clinic
call an ambulance
or go to the hospital ER
But slowly immediately
which is faster

74. addressed a clinical report on pediatricians
“Fever Phobia”
they found 65% of doctors have concepts
that Fever > 40 0 c is harmful
& may cause brain damage or death
in 2011

75. Fever Phobia
is worse than Fever itself
misconceptions about the dangers of Fever are
shared by the Parents & Physicians
very common

76. unwarranted fears
unnecessary stress
Lost sleep for parents
sometimes doctors modify their
correct medical decisions
only for parents satisfaction

78. Advice 1
Fever is Beneficial
the most important is
child general condition
not the body temperature
as long as child
active , play , run , eat

79. Advices
2 3 4
High Fever grade does not
correlate with worsen cause
the severity
of illness
the course
of illness
Long term
neurological
complications

80. Advice 5
Tepid Sponging
“Water Foment & Baths”
is not more recommended
except in environmental causes
dress child normally
do not under-dress
or over-wrap

81. Advice 6
But parents can get up in the night
to monitor him
± to relieve discomfort
give ibuprofen or Paracetamol
& do not give Diclofenac
do not awake the child
to take Antipyretics

82. Advice 7
Sick Leave
to keep the child
away from school or nursery

83. Advice 8
Regular Fluids
breast milk
if the infant is breast-fed

84. Advice 9
monitor for signs of dehydration
sunken eyes
depressed fontanelle
dry mouth
absence of tears

85. Advice 10
monitor for appearance of
Non-blanching Rash

87. signs of dehydration
if parents can not F/U the child
refusal of feeding
if admission is indicated
chronic
specific
zones

89. Fever , itself , does not endanger
a generally healthy child
Fever is a physiological mechanism
that actually has Beneficial effects
in fighting infection

90. the 1ry goal of ttt should be
not to ↓ the Fever
& normalize the body temperature
improvement of the child
,s comfort
& relieve the discomfort
treat the patient condition
not the degree of Fever