Dr. Rashmin Cecil provides an in-depth approach to pediatric patients presenting with fever, defining fever and discussing its classifications and measurement methods. The document emphasizes the importance of evaluating fever patterns, responses to medications, and inter-febrile behavior to diagnose underlying causes effectively. It highlights the clinical challenges faced by practitioners in managing fever, while stressing the need for careful observation and rational use of antibiotics.

2. DR. RASHMIN CECIL
APPROACH TO
PEDIATRIC PATIENT
WITH
FEVER

3. • WHAT IS FEVER ?
• “Fever is controlled increase
in the body temperature over
normal value for an
individual.”

4. • DEFINITION OF FEVER :
• Fever is defined as a core temperature of > 38c.
• Temperatures in infants and children should be
measured rectally as axillary and tympanic
membrane temperatures are unreliable.
• An infant or child with a recent history of
documented fever but afebrile at the time of
presentation should be considered a febrile child.

5. • Range of normal body temperature:
(36 - 38º C) or (97 - 99 º F)
• PUO : [Pyrexia Unknown Origin]
• Children with a fever documented by
healthcare provider & for which cause could
not be identified after 3 weeks of evaluation
in O.P.D or in hospital admitted cases after
1 week of evaluation are known as PUO.

6. FEVER WITHOUT FOCUS :
A child with fever of recent onset
with no obvious historical or
physical explanation for the fever is
said to have fever without source
(FWS).

7. • Mercury thermometer is the best.
• Others are :
1. Digital
2. Ear
3. Rectal Thermometer
4. Low - reading Thermometer
5. Strip Technique
How to measure temprature ?

8. Where (part of the body)
to be measured?
• Ideally : Rectal
• Theoretically : Oral
• Practically : Axilla (Skin)
• Time : measure for at least 2 minutes
0.4º C (0.7 ºF) < ORAL 0.4 º C (0.7 ºF) > ORAL
Skin Temperature : Rectal (Ear drum ) :

9. GRADES OF FEVER
(TEMPERATURE)
TEMP: Cº TEMP: Fº
HYPOTHERMIA < 35º < 95º
SUBNORMAL 35º – 36.7º 95º - 97º
NORMAL 36.7º - 37.2º 98º - 99º
MILD FEVER 37.2º - 37.8º 99º - 100º
MODERATE
FEVER
37.8º - 39.4º 100º - 103º
HIGH FEVER 39.4º - 40.5º 103º - 105º
HYPERPYREXIA > 40.5º > 105º

10. : TYPES OF FEVER :
TYPES FEATURES
• Continuous
Fever
• Temperature never touching
normal
• Daily fluctuations are less
than 1 ºC.
• Remittent /
Hectic Fever
• Temperature never touches
Normal & fluctuations are >
2 ºC/ day

11. • INTERMITTENT
FEVER
• Temperature touches the
normal level.
• *Daily : Quotidian
• *Every alternate day:
Tertian
• *After every 2 days:
Quartan
• Others: Pel ebstein
• Step ladder Pattern
: TYPES OF FEVER :

12. STAGES OF FEVER
• [1] The PRODROMAL Stage : (may be Absent)
• [2] The Stage of ONSET or INVASION : (Initial
or pyrogenetic phase)
• [3] The Stage of Fever DEVELOPMENT :
(Fastigium)
• [4] The Stage of DECLINE : ( Defervescence or
Termination)

13. Infection, microbial toxins
Mediators of Inflammation,
Immune reaction
Pyrogenic cytokines
IL-1, IL-6, TNF, IFN
Microbial Toxins
FEVER
Heat Conservation
Heat Production
Elevated
Thermoregulatory
Set point
Hypothalamic
Endothelium
PGE2 Cyclic AMP
PATHO-
PHYSIO-
LOGY
Monocytes/Macrophages,
Endothelial Cells
& others

14. • Fever is one of the most common
symptom faced by practitioner.
• Fever is a common diagnostic
and therapeutic challenge.
Clinical Importance of fever :

15. • Parents expect correct diagnosis and
prompt control of fever.
• As against this, for the treating doctor,
it is almost impossible to diagnose the
cause of fever for the first 2-3 days.

16. • In this common scenario,
irrational antibiotic use and
unnecessary laboratory tests are
rules in routine office practice,
triggered by the fear of missing
serious illness.

17. • Identifying the cause of fever
depends on localization, which
takes 2-5 days

18. Inquire about
1. Behavior
2. Urine output
3. Convulsions
4. Profuse vomiting
5. Severe Abdominal pain
:: Assessment of Seriousness ::

19. • Specially Look For
1. Disproportionate HR and RR
2. Capillary Refill time
3. Differential Body Temperature
4. Chest retraction
5. Meningeal signs
6. Faucial Membrane
:: Assessment of Seriousness ::

20. :: Analysis in office practice ::
Nature of fever at onset
Response to PCM
Rhythm of fever
Trends of fever
Inter-febrile period
Localization
1
2
3
4
5
6

21. • [1] High fever :
• Viral Fever
• Bacterial infection
• Acute tonsillitis, Acute Bacillary Dysentery,
UTI
• Malaria
• [2] Moderate Fever :
• Pneumonia, Meningitis, Typhoid
1. Nauure of fever at onset :

22. • Fair to poor : Bacterial Infection
• Fair to good : viral Infection
• Erratic : Malaria
• Good : Non infective
inflammation
2. Response to PCM :

23. • Rhythmic fever : Acute Bacterial,
Acute Viral
• Erratic : Malaria
• Two spikes per day : Non infective
inflammation
3. Rhythm of fever :

24. • Settles down : Viral
• Static or get worse : Bacterial Infection
• Erratic : Malaria
• No change : Non infective
inflammation
4. Trend of fever on 3-4th day :

25. 1. Appear Well and playful :
Viral
2. Sick look and lethargic :
Bacterial
5. Inter-febrile period :

26. 1. Generalized involvement of system :
Viral
2. Some part of the system affected :
Bacterial
6. Localization :

27. • Four different 5 year old patients
present with fever for 3 days, no
other symptoms; assessed to have no
risk;
• each one ended up with a different
diagnosis.
:: Case Scenario ::

28. • How would you separate them out
clinically?
1. Onset of fever;
2. Response to paracetamol;
3. Behavior during inter febrile period;
4. Rhythm, trend, accompanying
symptoms if any.

29. 1. High fever at onset, fair/variable
2. Response to paracetamol,
3. Inter febrile period normal,
4. Fever comes up every 5-6 hours
5. On day-2 : cold and cough appears,
6. On Day - 3 : fever seems to be abating
:: Patient : 1

30. • What do we infer from the
onset of fever?
• High fever at the onset could
be viral, bacterial, or malaria.

31. • What does the response to antipyretic and
the inter febrile behavior tell us?
• Fair response to antipyretic : Less likely
to be a severe bacterial infection.
• Normal behavior in the inter febrile phase
: Suggests that it is less likely to be a
bacterial infection.

32. • So then, is it viral fever or malaria?
• Since the fever is rhythmic, coming up
every 5-6 hours, once antipyretic
effect wears off, it is equivalent to
continuous fever.
• This would make malaria less likely.

33. • Any other points to favor a diagnosis
of viral fever?
• Appearance of mild cold and cough on
day 2 : Suggesting generalized
involvement of respiratory system.
• Downward trend of fever on day - 3
Suggests a self-limiting disease.

34. 1. High fever at onset,
2. Poor response to paracetamol,
3. Interfebrile period sick,
4. Fever rises every 4 hrs,
5. On Day – 3, fever trend worsening -
look for…
:: Patient : 2

35. • Like the previous child, even in
this child the fever is high at
onset,
• Suggesting viral, bacterial or
malarial fever.

36. • What else can we infer?
• Poor response to paracetamol & child
sick in inter febrile phase : Suggests a
bacterial infection.
• High at onset, bacterial infection at
the site of entry of germs.

37. • So what should we be looking for?
• Localization in the form of
tonsillitis, lymphadenitis, UTI
• We need to ask for relevant
symptoms

38. • High fever at onset,
• Erratic fever irrespective of
Paracetamol,
• Inter febrile period normal,
• Same trend continues on Day -3
:: Patient : 3

39. • Once again, high fever at onset and
inter febrile period normal suggests
viral fever or malaria,
• but in this child the fever is erratic,
with no downward trend visible so
far, suggesting malaria.

40. • Mild to moderate fever at onset,
• Initially fair response but not on
Day - 3,
• Trend of fever rising by Day - 3,
• Inter febrile period sick
:: Patient : 4

41. How do we analyze this child’s fever?
• Mild to moderate fever at onset
• Suggest viral fever or
bacteremic bacterial infection
• Fever responded to antipyretic
initially but not subsequently

42. • Suggestive of progression or worsening
• Child is sick in interfebrile period
• Suggestive of bacterial infection
• No localized symptoms of lung and
CNS
• This all together suggestive of typhoid

43. • Patient 1:
• High fever at onset,
• Fair/variable response to paracetamol,
• Inter-febrile period normal,
• Fever comes up every 5-6 hours,
• On day-2, cold and cough appears,
• And on day-3, fever seems to be abating
• Acute viral infection
:: Case Scenario contd . . . .

44. • Patient 2: high fever at onset,
• Poor response to paracetamol,
• Inter febrile period sick, fever rises every
4 hrs,
• On Day- 3 fever trend worsening- look
for…
• Bacterial tonsillopharyngitis

45. • Patient 3: high fever at onset,
• Erratic fever irrespective of
paracetamsol,
• Inter febrile period normal,
• Same trend continues even on Day-3.
• Malaria

46. • Patient 4 : mild to moderate fever at
onset,
• Initially fair response but not on Day-3
• Trend of fever rising by Day-3
• Inter febrile period sick
• likely be Typhoid fever

47. • Provisional diagnosis possible even without
physical signs; analyses fever pattern &
document it
• No fever = no acute bacterial infection = no
antibiotics
• No Antibiotics for first 3 – 4 days of fever
till disease localizes
:: FEVER RULES ::

48. • If empirical Antiboitics has to be
started, send relevant
investigations before starting
• Drug resistance is rare in
common community infections

49. • If rationally selected antibiotic fails,
look for alternate diagnosis while
trying second antibiotic
• If two antibiotics fail, acute bacterial
infection is ruled out – do not try third
antibiotic

50. Approach to fever as it evolves
• Day 1 - 2 : Rule out seriousness,
observe and paracetamol only
• Day 3 - 4 : Look for localization,
clinically or by relevant tests,
consider pneumonia, meningitis,
UTI, consider antibiotic therapy
after tests

51. • Day 5 – 7 : Assess progress of
fever, review, repeat tests,
observe and paracetamol only
• Day 8 – 10 : Reassess
periodically

52. • Additional relevant tests
consider change of Ab therapy
• Beyond 2 weeks
• Search for non infective cause /
chronic infection by relevant
tests TB at any age, SOJIA,
neuroblastoma