Fever in children Dr.dr.Irene Ratridewi,SpA(K) dr. Savitri Laksmi Winaputri,SpA(K) Outline • Definition n classification • Differential diagnosis • Work up • Treatment Definition • Fever increase of body temperature > 10C above daily body temperature as response to endogenous pyrogens • Most common symptom clinic or ER • Mostly caused by infection • Hyperthermia increase of body temperature > 10C above daily body temperature NOT as response to endogenous pyrogens • Less common compare to fever • As a response to surrounding/environmental temperature changes (conduction, radiation, convection) • Ex: heatstroke, dehydration, incubator, phototherapy procedure, metabolic syndrome (hyperthyroidism), malignancy Classification Sepsis, UTI, pneumonia, Malignancy, meningitis Sepsis, UTI, pneumonia, Malignancy Pharyngitis Malaria, malignancy Typhoid fever 6 Differential diagnosis • It is very important to differentiate the cause of fever • Bacterial vs non bacterial (viral) • Needs hospitalization or not • Specific treatment or supportive/symptomatic treatment DEMAM SEBAGAI ALARM SIGN Skor Diagnostik Faktor-faktor yang dinilai • Warna kulit (color) • Aktifitas (activity) • Respirasi (respiration) • Hidrasi (hydration) • Lain-lain (others) Derajat keparahan • Ringan (mild) • Sedang (intermediate) • Berat (severe) PENYEBAB DEMAM Tiga kelompok utama demam yang dijumpai pada praktek pediatrik Klasifikasi Penyebab tersering Lama demam Demam dengan localizing signs Infeksi saluran nafas atas <1 minggu Demam tanpa localizing signs (no local sources) Infeksi virus, infeksi saluran kemih <1minggu Fever of unknown origin (FUO) Infeksi, juvenile idiopathic arthritis >1 minggu Demam dengan localizing signs • Demam akut dengan fokus infeksi yang dapat didiagnosis melalui anamnesis & pemeriksaan fisik • Paling sering ditemukan pada praktek pediatrik • Demam berlangsung singkat, baik mereda spontan atau karena pengobatan • Diagnosis dipastikan dengan pemeriksaan sederhana seperti pemeriksaan foto thoraks Demam dengan localized signs Kelompok Penyakit (diagnosis banding) Infeksi saluran nafas akut ISPA virus, otitis media, tonsillitis, laringitis, stomatitis herpetika Pulmonal Bronkiolitis, pneumonia Gastrointestinal Gastroenteritis, hepatitis, appendisitis Sistem saraf pusat Meningitis, ensefalitis Eksantema akut Kolagen Campak, cacar air Rheumathoid arthritis, penyakit Kawasaki Neoplasma Leukemia, lymphoma Tropis Kala azar, sickle cell anemia Demam tanpa localizing signs • Sekitar 20% episode demam tidak ditemukan sumber infeksinya • Penyebab tersering adalah infeksi virus, terutama terjadi pada beberapa pertama kehidupan – Namun harus dipikirkan setelah menyingkirkan infeksi saluran kemih dan bakteremia (penyebab paling sering) Umumnya memiliki awitan akut, berlangsung kurang dari 1 minggu, dan merupakan masalah diagnostik yang sering dihadapi oleh dokter anak dalam merawat anak berusia kurang dari 36 bulan (3 tahun) Penyebab umum demam tanpa localizing signs (fever without sources) Penyebab Infeksi Contoh Bakteremia/sepsis Sebagian besar virus Hypersensitivitas sistem imun Infeksi saluran kemih Malaria Juvenile idiopathic arthritis Petunjuk diagnosis Tampak sakit, CRP tinggi, leukositosis Tampak baik, CRP normal, leukosit normal Dipstik urine Di daerah malaria Pre-articular, ruam, splenomegali, antinuclear factor tinggi, CRP tinggi Pasca vaksinasi Vaksinasi DPwT, campak, PCV Waktu demam terjadi berhubungan dengan waktu vaksinasi Drug fever Sebagian besar obat Riwayat minum obat Pemeriksaan penunjang/laboratorium Laboratorium rutin : - pemeriksaan darah lengkap (CBC) + hitung jenis leukosit dan morfologi darah tepi Pemeriksaan tanda atau marker infeksi : C-reactive protein (CRP) atau procalcitonin (PCT) Diagnosis etiologi diperlukan pemeriksaan spesifik: - pemeriksaan serologis - kultur atau biakan dari bahan pemeriksaan yang tepat - pemeriksaan antigen atau materi genetik (PCR) Demam tanpa localizing signs Evaluasi klinis Evaluasi pemeriksaan laboratorium • • • • • • DPL* Urin analisis Biakan darah Biakan urin Lumbal pungsi Foto toraks +/- • • • • • • DPL Urin analisis Biakan darah Biakan urin Lumbal pungsi +/Foto toraks +/- Rawat Rawat • antibiotik +/- • antibiotik +/atau Pulang *DPL=darah perifer lengkap 3-36 bulan 1-3 bulan 0-1 bulan • antbiotik +/- • • • • • • DPL+/Urin analisis +/Biakan darah +/Biakan urin +/Lumbal pungsi +/Foto toraks +/- Pulang • antibiotik +/atau Rawat • antibiotik +/- Work up FUO Fever > 7 days with normal preliminary investigation Differential Diagnosis Treatment • Surface cooling with warm water • Put wet warm towel on armpit, groin, back of neck, fossa poplitea, forehead • Give antipyretic paracetamol 10-20 mg/kgBW/dose, every 4-6 hours • Precautions for Ibuprofen and metamizole • Supportive treatment: fluid maintenance (oral or intravenous), oxygen when needed, avoid thick blanket • Find the definitive cause of the fever • Afebrile with good clinical appearance good outcome Notes • Neonates with serious bacterial infection (SBI) may present afebrile/hypothermia + history of fever with unwell appearances • Fever is only ONE signs of clinical conditions • Fever and hyperthermia might be classified as Pyrexia Early screening to find the cause of the fever: • Complete blood examination, includes LED and blood smear when necessary • CRP (inflammation) or procalcitonin (suggested serious bacterial infection) Clinical symptoms Viral infection Bacterial infection • Doing well (relative) • Low grade fever (< 38,50C), or sudden high grade fever (>380C) • Unwell/toxic appearance • Low to high grade fever; or hypothermia (sepsis); continues fever • Maculopapular rash (scarlet fever) or bullae or petechial (toxic shock syndrome, meningococcemia) • May present rash (vesicular, maculopapular rash) • Myalgia arthralgia Laboratory examination Viral infection Bacterial infection • Leukopenia • Early stage neutrophils > then lymphocytes >> • Atypical lymphocytes • Platelet normal or slightly decrease (except dengue) • CRP low or slightly increase • Procalcitonin < • Leukocytosis or leukopenia • Neutrophils > (depend on the type of bacteria GPB or GNB) • Severe infection Hb < • Platelet increase; but may decrease in sepsis • CRP > • Procalcitonin > Take home messages • Basically, Fever is different from hyperthermia • Beware of hyperpyrexia • Infection is the most common cause of fever beware of serious bacterial infection • Warnings: leucopenia or leukocytosis, high grade fever/hypothermia, main the general appearance (use the yale or Philadelphia or boston criteria based on age) • Surface cooling is number 1, antipyretic later Referrences • Barbi E, et.al. Fever in children: Pearls and pitfalls. Children. 2017;4(81):1-20 • Ramgopal S, et.al. Serious bacterial infection in neonates presenting afebrile with history of fever. Pediatrics. 2019:144(2)