power point on pproach to febrile child

1. SEMINAR ON
Approach to a child with fever
Alebachew (R3)
For HO students
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2. OUT LINE
 Objective
 Introduction
 Pathogenesis of fever
Mechanism
 Causes of fever
 Evaluation
Hx,P/e,Ix
 General management approach.
 Classification of fever in pediatrics.
 Reference .
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3. Introduction
 Fever
is an abnormal increase in body temperature that
results from elevation of the hypothalamic set-
point.
Is defined as a rectal temperature ≥38°C.
Normal range 36.6 - 37.9°C rectally.
Peak in the afternoon (5-7P.M) and lowest early
morning (2-6 A.M).
Has both positive and negative effects.
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4. Cont..
 Fever increases the basal metabolic rate by 10-12%
for each degree Celsius elevation of temperature .
This increases oxygen consumption, carbon
dioxide production, and fluid and caloric needs.
 Fluid requirements increase 100 mL/m2/day for
each 1°C rise in temperature above 37.8°C.
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5. Terminology
 Hyperpyrexia
A value >40°C.
 Indicates high probability of hypothalamic disorders or CNS
hemorrhage and should be treated with antipyretics.
 Hyperthermia
Is an abnormal elevation of body temperature that occurs without a
change in the thermoregulatory set point in the hypothalamus.
 This failure of normal homeostasis results in heat production that
exceeds the body's capacity for dissipation.
 Body temperature in patients with hyperthermia does not respond
to antipyretic agents.
 Malignant hyperthermia - susceptible to hyperthermia if
you receive a specific combination of sedatives and
anesthesia for medical procedures.
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6. Pathogenesis
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Pyrogens
Production of IL-1,IL-
6,TNF,IFN-betha,gama by
phagocyte cell in blood,
tissue.
Carried to
anterior
Hypothalamus
Synthesis of
prostaglandins
(PGE2)
Raise hypothalamic
set point for
temperature
fever
induce
induc
e

7. Mechanisms Of fever
1-Pyrogens,
Endogenous pyrogens
o IL-1 , IL-6,TNF-α, IFN-β and IFN-γ.
Exogenous pyrogens
o infectious pathogens and drugs.
Endotoxin
2- Heat production exceeding heat loss (E.g-
salicylate poisoning , malignant hyperthermia).
3- Defective heat loss.
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8. Cont..
 Euthermia
 Hypothalamic set-point
and body temperature
set-point normal.
 Fever
 Hypothalamic and body
temperature set-point
elevated.
 Heatillness
 Hypothalamic set-point
is normal but body
temperature set point is
elevated.
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9. Temperature Measurement
 Site and method of measurement
• Most common sites in clinical practice are
• Rectum,
• Mouth, and
• Axilla
1-Rectal thermometry
Reference/gold standard for measurement of
core body temperature for < 3years of age or
younger.
Contraindicated in patients with neutropenia.
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10. Cont..
2- Oral thermometry
 Is preferred in children who are old enough to
cooperate.
 Is typically 0.6°C (1.0°F) lower than rectal temperature
because of mouth breathing.
Affected by recent ingestion of hot or cold liquids.
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11. Cont..
3- Axillary thermometry
Are commonly used.
Less precise than rectal temperatures.
Correlation axillary temperature is
usually 0.5-0.85°C lower than rectal.
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12. Cont..
4-Contact and noncontact infrared tympanic
membrane (TM) thermometry.
Measure the amount of heat produced by the TM.
Temperature readings are close to core
temperature
5-Temporal artery temperature measurement
 Infrared contact and noncontact forehead
thermometers measure the amount of heat produced
by the temporal arteries.
6- Smart phones
absence of adequate study, they cannot be
recommended for use.
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13. Cont..
When detection of fever is critical for
diagnosis and management, rectal
temperatures should be used in the
child 3 years of age and younger.
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14. Causes of fever
 4 main categories…
 Infectious,
Inflammatory,
Neoplastic
Miscellaneous.
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15. Pattern of fever
1-Intermittent fever- rises for a few hours each days and decline
to normal in the same day before rising again.
2- Sustained fever- is persistent and does not vary by
>0.5°C/day.
3- Remittent fever- is persistent and varies by >0.5°C/day . But
never fall all the way to normal.
4- Relapsing fever- rises for a variable period and
declines to normal for a days before rising again.
5- Tertian fever- occurs on the 1st and 3rd days (E.g- vivax ).
6-Quartan fever- occurs on the 1st and 4th days (E.g- malariae).
7-Periodic fever- describe fever syndromes with a regular periodicity.
8-Double quotidian fever- fever that peaks twice in 24 hr.
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16. Evaluation
 History
 Onset (acute , chronic)
 Pattern of fever
 Cough , chest pain (Pneumonia).
 PND, Orthopenia,palpitation,fatigability (ARF, IE, myocardities).
 Headache ,neck stuffiness , vomiting,irritability  mengitis
 Ear pian , discharge ototis media
 Rash  (meningococcemia , IE).
 Travel history (malaria ,VL, Hepatitis, Typhoid Fever ,Tuberculosis
, Amebiasis).
 Medications ( vancomycin, amphotericin B, allopurinol).
 Past medical history(chronic illness).
 Vaccines hx.
 Exposures (daycare, school, family, pets, playmates) .
 Decreased appetite, bone pain , weight loss  malignancy
 Dysuria, back pain  febrile UTI.
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17. Cont..
 Physical examination
• Vital signs
Tachycardia
Relative bradycardia (typhoid fever, brucellosis,
leptospirosis).
Pulse oximetry  (cardiac, respiratory origin).
• Anthropometry
• Head to toe…
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18. Cont..
 Eye
 Conjunctivitis,uveitis (Kawasakidisease,SLE), polyarteritis
nodosa, JIA, Sarcoidosis).
 Chorioretinitis  CMV
 Atrophic spots focal granulomas of the retina and choroid
Histoplasmosis .
 Ears, Nose, and Throat
 Teeth and gums  dental abscess.
 Tympanic membranes , mastiod tenderness  AOM.
 Nares ( inflamed mucosa and purulent discharge) 
common cold.
 Exudative and non exudative pharyngitis  (EBV, tularemia
, leptospirosis and CMV).
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19. Cont..
 Neck
Adenopathy  (CMV,EBV, systemic JIA , RVI,
Lymphoma, leukemia, TB lymphadenitis).
 RS
Localized chest finding  (pneumonia,…).
 CVS
 Cardiac lesion(E.g-MR,AR) (IE , ARF , viral
myocarditis).
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20. Cont..
 Abdomen
 Masses or hepato-splenomegaly  (malaria ,VL ,lymphoma ,
leukemia).
 Abdominal tenderness (peritonitis,PID).
 GUS
 Coast vertebral angle tenderness  febrile UTI.
 Musculoskeletal
 Warmth, tenderness ,or swelling of joints septic arthritis,
ARF,…).
 Pain on palpation over a bone (neoplastic infiltration,
sickle cell anemia).
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21. Cont..
 Skin
Evanescent , salmon-colored macular rash over the
trunk and joints JIA.
 Heliotropic rash of the upper eyelids, Gottron
sign  Dermatomyositis.
Malar rash , photosensitivity in sun-exposed areas 
SLE.
Splinter hemorrhages or Janeway lesions (painless,
small, erythematous or hemorrhagic lesions on the
palms and soles)IE.
 CNS- nuchal rigidity, meningial signs.
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22. Cont..
 Laboratory studies (case based).
Rapid antigen testing.
polymerase chain reaction (PCR).
Stool.
Blood: CBC, blood culture, CRP, ESR, procalcitonin,BF.
Urine.
 LP (CSF).
 CXR.
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23. General management approach
 Encouraging good hydration
 External cooling
 Antipyretic agents.
Fever with temperatures <39°C in healthy
children generally does not require
treatment.
Should be treated only in select
circumstances.
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24. Cont…
 Indications to start antipyretics
Shock,
Underlying neurologic or cardiopulmonary disease, or
other condition with increased metabolic rate (eg,
burn, postoperative state).
Alteration in fluid and electrolyte balance.
High fever  ≥39°C .
Discomfort / child's caregiver is concerned.
Major head trauma.
Post cardiac arrest.
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25. Cont..
The most common antipyretics are
Acetaminophen -10-15 mg/kg/dose every 4 hr, and
Iibuprofen - in children >6 mo old at 5-10 mg/kg/dose
every 8 hr.
Combining or alternating therapy
Do not suggest combining or alternating therapy
with acetaminophen and ibuprofen to treat fever in
children.
Although combining or alternating acetaminophen and
ibuprofen may be more effective than either agent
alone in reducing fever, it is not clear that this
reduction is clinically significant.
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26. Mechanism of action of antipyretics
 It is now clear that most antipyretics work by
inhibiting the enzyme cyclooxygenase and reducing
the levels of PGE2 within the hypothalamus.
 Recently, other mechanisms of action
Reduce pro inflammatory mediators,
Enhance anti-inflammatory signals at sites of
injury,
Boost antipyretic messages within the brain.
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27. Mechanism of action of PCM
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28. External cooling
 Is the treatment of choice for heat stroke and other
forms of heat illness in which rapid cooling is
necessary to prevent end-organ damage.
 Do not routinely suggest external cooling for
temperature reduction in previously well infants and
children with a febrile illness.
 In RCT comparing the combination of tepid
sponging and antipyretic therapy to antipyretic
therapy alone, the added benefit of tepid sponging in
temperature reduction was short-lived, and sponging
was associated with increased discomfort.
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29. Cont..
 External cooling may be used as an adjunct to
antipyretic therapy for children in whom more rapid
and greater reduction of body temperature is
necessary than can be achieved with antipyretic
agents alone.
 In such cases, antipyretic agents should be
administered at least 30 minutes before external
cooling to reset the thermoregulatory set-point,
without which external cooling will result in an
increase in heat production.
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30. Cont..
 Possible indications for concomitant
antipyretic administration and mechanical
cooling…
Uncertainty about the cause of elevated temperature
(heat illness versus fever).
Fever combined with a component of heat illness (eg,
from over-wrapping, hypovolemia, or drugs such
as atropine).
 Underlying neurologic disorder, in which the child may
have abnormal temperature control and poor response
to antipyretic agents.
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31. Cont..
 When mechanical cooling is necessary to treat fever,
we suggest sponging with comfortably warm or
tepid water around 30°C.
 Sponging is more effective than immersion because
evaporation from the skin augments heat loss.
 N.B- Alcohol should not be used because its fumes
are absorbed across the alveolar membrane and
possibly across the skin, resulting in CNS toxicity.
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32. Fever in the pediatric population
 Is usually grouped in to 4 categories:
Fever Without a Focus in the Neonate
and Young Infant.
 Fever in the Older Child.
Fever with out source (FWS).
Fever of unknown origin (FUO)
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33. 1-Fever Without a Focus in the Neonate
and Young Infant
• Refers to a rectal temperature of >/=38°C
without other presenting signs or symptoms.
• Age groups
Neonates 0-28 days,
 Young infants 29-90 days.
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34. Etiology and Epidemiology
• Serious bacterial infection ( 7% - 13%).
UTI ( 5–13%)  The most common.
Bacteremia (1–2%) and
 Meningitis (0.2–0.5%).
• The most common organism.
 Escherichia coli first
GBS  the second .
• less common organisms
Klebsiella spp.,
Enterococcus spp.,
Streptococcus pneumoniae ,
 Neisseria meningitidis , and
Staphylococcus aureus
• Rare  Listeria monocytogenes .
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35. Diagnosis
 Traditionally,
– All neonates <60 or <90 days of age were hospitalized.
 Underwent laboratory evaluation
 Blood, urine, CSF and stool cultures,CXR.
 Received empirical antibiotics ,, HSV evaluation,
 Empirical antiviral agents.
 But ,Protocols were subsequently developed to identify
infants at lower risk of SBI.
 The 3 most widely used criteria are…
 The Rochester,
 Philadelphia, and
 Boston criteria
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37. Cont..
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38. Cont..
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39. 2-Fever in the Older Child
 Pediatricians can rely more readily on symptoms
and physical examination findings to establish a
diagnosis.
• Potential causes
– Common
• viral (most common ) and
• bacterial infections
– less common
• Inflammatory,
• Oncologic,
• Endocrine, and
• Medication induced
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40. 3-Fever of Unknown Origin(FUO)
• Is defined as 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
• Is usually an uncommon presentation of a
common disease.
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41. Cont…
• FUO has 4 Subtypes…
Classic FUO - >38°C , >3 wk, >2 visits or 1 wk in hospital.
Healthcare associated FUO - ≥38°C , >1 wk, not
present or incubating on admission.
Immune deficient FUO - ≥38°C , >1 wk, negative
cultures after 48 hr.
HIV-related FUO -≥38°C , >3 wk for outpatients,
>1 wk for inpatients, HIV infection confirmed.
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42. 4-Fever without a source (FWS).
• A temperature >38°C where the source has
not yet been identified with in 7 days.
• Can progress to FUO if no cause is elicited
after 7days of evaluation.
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43. Reference
• Linda S. Nield, Deepak Kamat, Nelsone text
book of pediatrics 21st edition fever, chapter
201.
• Up-to-date 2022.
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