In the name of God
Fever In Children
Fever
Fever
Fever is a common symptom with various diseases in
children
Fever Definition
A centrally mediated elevation of body temperature
in response to stress or insult
Rectal temperature is over 100.4°F (38°C)
Oral temperature above 37.5°C
Auxiliary temperature above 37.2°C
Fever in children
Fever is a controlled in body T over the
normal values for an individual
Body T is regulated by thermosensitive
neurons located in the preoptic of anterior
hypothalamomus
Termoregulatory responses include;
increased or decreased sweating
extracellular fluid volume regulation
behavioral responses
Pathogenesis
Endogenous pyrogens including the :
1-cytokines interleukin 1and 6
2-TNF
3-INTERFERON
Exogenous pyrogens including the
Microbes and microbial toxins which
stimulate macrophages to produce
endogenous pyrogens
Endotoxin can directly affec
thermoregulation
Pathogenesis)con)
Increase T is associated with decrease
microbial reproduction and increase
inflammatory response
Fever may exacerbate ;
cardiac insufficiency in heart disease or
chronic anemia
Pulmonary insufficiency in chronic lung
disease
Metabolic instability in diabetes mellitus or
inborn error of metabolism
Prostaglandins and
the role of NSAIDs
Pyrogens and Fever
Actions of endogenous pyrogens in
fever regulation
Heat illness
Situation in witch either environmental stress
impair
the
ability
of
the
central
thermoregulatory mechanism to maintain
normal body temperature or internal factors
produce excessive heat or impair the body’s
ability to dissipate metabolism heat
Body temperature is elevated despite a normal
set-point in POAH
Example of Heat illness
Hyperthyroidism
Malignant hyperthermia
Anhidrotic ectodermal dysplasia
Pharmacologic agent
Medical drug (anticholinergics and phenothiazines)
Street drug
Fever is s friend or enemy?
Fever is a beneficial response in favor the host
Fever may directly impair reproduction or even
the survival of an invading microorganism
Moderate fever may enhance the immunologic
response
Fever is friend or enemy?
High fever can impair the immunologic response
Fever increase the basal metabolic rater by
10-12 % for 1 °C
Increase oxygen consumption
Carbon dioxide production
Increase Fluid and caloric requirements
can precipitate febrile seizures
May
be
associated
with
neurological
manifestation irritability,delirium,disorientation
and hallucinations
Treatment of Fever
Anti pyretic drugs should not proscribed
routinely to febrile children
WHO recommend the use anti pyretic for
children with fever of ≥ 39 C°
The decision to treat
when the patient is uncomfortable
susceptible To febrile seizure
Critically ill-sepsis or septic shock
Cardiac or respiratory failure
Neurological diseases or injury
Disturbed fluid ,electrolyte status
Acetaminophen
Is the first line therapy for childhood
fever
Rapidly and almost completely absorb
from GI
half-life in plasma about 2 hour
Dose 10-15 mg/kg/dose PO/PR Q 4-6 hr
Maximum 5 dose/24 hr
Acetaminophen Side affect
Skin rash and allergic reaction occasionally
Neuttropenia ,thrombocytopenia and pancytopenia
rarely
Toxic Effect
Hepatotoxicity
Renal tubular necrosis
Hypoglycemia coma
Acetaminophen
AAP recommend that rectal Acetaminophen
therapy should be avoided unless specifically
discussed with the health care provider and that
direction be followed
Ibuprophen
Inhibit prostaglandin synthetase.
Dose 8-10 mg/kg Q 6-8hr
Side affect
Gastiris
Gastrointestinal apset
Platelets aggregation
Acetaminophen versus Ibubrophen
Acetaminophen:
provided greater initial temperature
reduction
Ibubrophen:
Provided more significant antipyretic effect
at 4 hr
Temperature decrement lasted longer
The two drug have equal tolerability
Prostaglandins and
the role of NSAIDs
Nimesulide
A new NSAID is useful in treatment of
fever
Was more effective than Acetaminophen
for treatment of fever
Appear to be safe as Acetaminophen
Dose 1.5 mg/kg/Dose TID
Fever
Fever is a common manifestation of
infectious disease but is not predictive of
severity
Many infections are usually benign in
normal hosts
Sepsis ,meningitis pneumonia
,osteoarticular infections , pyelonephritis
may have significant morbidity or
mortality
Most febrile episodes can be diagnosed
by careful history and physical
examination and few lab tests
The causes of fever
Infection
vaccines ,
endocrine disorders, genetic disorders , metabolic
disorders , immunologic and rheumatologic
disorders
tissue injury, malignancy , drugs
granulomatous diseases , inflammatory diseases
factitious fever
Clinical Manifestation
Causes of very high T) >41) include :
central fever , malignant hyperthermia
drug fever , heatstroke
T lower than (<36) can be sepsis and
more commonly with cold exposure ,
hypothyroidism , or overuse of antipyretic
Intermittent fever , sustained fever ,
Remittent fever , Relapsing fever , periodic
fever
Type of fever
Intermittent fever - Fever that touches normal for
a few hours during the day. It is seen in malaria,
acute pyelonephritis, local boils and furuncles.
tuberculosis, lymphoma, and juvenile rheumatoid
arthritis (JRA)
Remittent fever - Fever that fluctuates between 1.5
degree F in 24 hours without touching normal.
viral infections but also may occur with bacterial
infections (especially endocarditis), sarcoid,
lymphoma, and atrial myxoma.
Continuous fever - Fever that does not touch
normal and fluctuates less than 1.5 degree F in a
day. It is seen in enteric fever, Bacterial
endocarditis, viral pneumonia. Typhoid fever,
typhus, brucellosis, and many other infections
Fever Prone to Relapse
1. Infectious causes
2. Noninfectious causes
Behcet disease , crohn disease , SLE
3. Periodic fever syndromes:
familial Mediterranean fever
cyclic neutropenia
Hyper igD syndrome
(PFAPA)
periodic fever aphthous stomatitis
pharyngitis - adenopathy
Febrile Patients at increased Risk for
Serious Baterial infections
Immunocompetent patient:
Neonates(28 days)
infants<3 mo
Infants and children 3-36 mo
Hyperpyrexia(>40)
Fever with petechiae
Immunocompromised patients:
Sickle cell disease -Asplenia
Complement / properdin deficiencyAgammaglobulinemia
AIDS – Malignancy
Congenital heart disease
Treatment
fever<39 in healthy children do not require
treatment
Antipyretic therapy dose not change the
course of infection
Antipyretic therapy is beneficial in high-risk
patients
Hyperpyrxia indicates risk of;
severe infection ,hypothalamic disorders
,CNS hemorrhage
Fever without localizing signs
usually acute onset present for< 1 wk.
Young infants limited signs of infection and
difficult to distinguish between bacterial
and viral infection.
Fever without localizing signs
Infants< 4 wk are at risk for;
late-onset bacterial diseases
Perinatally acquired herpes simplex
virus
Acquire community pathogens
Infants
<3mo with fever
 Fever in this age should always suggest the
possibility of serious bacterial disease
 Pyelonephritis is more common in
uncircumcised boys ,neonate and infants with
UT anomalies and young girls
 Other bacterial diseases include:
 , pneumonia , omphalitis ,mastitis
soft tissue infection. otitis media
skin and
Infants
<3mo with fever
Viral infection is identified in 70%
Bacteremia is present in 5%
Serious bacterial infection are
present in 10-15% in T > 38
Approach to febrile infants <3 mo
Careful history and physical examination
 Toxic infants must prompt
hospitalizatIion and immediate parenteral
antimicrobial therapy
after B /C , U/C ,LP
 Ceftriaxone 50- 80mg/day or cefotaxim
50mg/kg/dose and ampicillin 50/kg/dose.
 If CSF IS abnormal vancomycin 15/kg/
dose should be given
Approach to febrile infant< 3mo (con)
2-Infants with fever unlikely to have a serious
bacterial infection if;
 appear generally well and previously
healthy
 No evidence of skin, soft tissue, bone
, joint and ear infection
 Who have WBC 5000-15000 and band
<1500 * and U/A normal
Occult Bacteremia in children 3-36 m0
¤
*
Occurs in 1.5% well appearing in this age with
fever
Bacteremia is present in 11% pneumonia and
1.5%
otitis media or pharyngitis
S,pneumoniae , N,menigitidis and salmonella .
S,Pneumonia account for 90% of cases.
Occult Bacteremia in children 3-36
m0
Risk factors include :
T>39 or greater ,WBC 15000
an elevated band count ESR +
and CRP +
Occult bacteremia
(con)
Without therapy occult bacteremia
may;
■
Resolve spontaneously
■
May persist
■
May lead to localized infection
pnemococcal bacteremia spontaneous
resolution occur in 30-40% in all patients
Occult bacteremia
(con)
H ,influenza type b bacteremia is with
a higher risk of localized serious
infection.
Fewer than 5% of these bacteremia
can be transient.
Fever with petechiae
Independent of age , with or without localizing
signs indicates high risk for bacterial
infections .
serious bacteria infection 8-20%
meningococcal sepsis or meningitis 7-10%
Managemen t includes ;
prompt hospitalization ,B/C ,CSF/C, and
administration parenteral antimicrobial agent
Fever with sickle cell disease
Children should be hospitalized;
if seriously ill , T>40, WBC<5000 0r>30000 or pulmonary
infiltration ,or severe pain
The increased risk is due to:
functional asplenia , defect in the properdin
pathway
S,pneumoniae H, influenzae type b , Salmonella
sepsis, meningitis, pneumonia, osteomylitis.
Prevention of pneumococcal sepsis is ;
long term penicillin therapy and pneumococcal
and H,inflenza vaccine.
Treatment of occult bacteremia
Toxic-appearing infants without focal
signs:
 must hospitalization and prompt
antimicrobial therapy after B/C ,U/C,
CSF/C
Treatment of occult bacteremia
for Non toxic-appearing infants with
T>39:
1. B/C and give ceftriaxon a single dose 50mg/kg
2. if the WBC is 15000 or greater obtain B/C and
ceftrixon
If the child,s condition deteriorate or new
symptoms develop the infants must return
immediately .
Treatment occult bacteremia )con)
If the child develops a localized infection
therapy is directed toward the specific
pathogen and site
If the child appears well ,afebrile ,and
physical findings is normal with B/C+ ,
should receive 7-10 days of oral antibiotic
Treatment occult bacteremia )con)
1. If the child appears ill and continues fever
with no identifiable focus of infection.or
2. IF B/C is H,influenzae or N,
meningitidis
The child should have a repeat B/C ,LP,
and treatment in hospital with
appropriate antimicrobial agents
Fever of unknown origin
“FUO”
Fever of 101F for longer than three
weeks or
Fever of uncertain diagnosis for more
than one week in a hospitalized patient
Etiology of FUO
“A fever of unknown origin is more
likely to be the unusual presentation
of a common disorder than the
common presentation of a rare
disorder”
Etiology of FUO
Infections
Autoimmune
Malignancy
Others (incl.. factitious fever, drug
fever, sarcoid)
Never determined:
Causes of bacteraemia and Meningitis
in
young
children
Under 1 month old
Group B streptococcus
Escherichia coli (and other enteric Gram negative
bacilli)
Listeria monocytogenes
Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcus aureus
Neisseria meningitides
Salmonella spp
1-3 months old
Streptococcus pneumoniae
Group B streptococcus
Neisseria meningitides
Salmonella spp
Haemophilus influenzae
Listeria monocytogenes
Over 3 months old
Streptococcus pneumoniae
Haemophilus influenzae
Neisseria meningitides
Salmonella spp
Clinical and laboratory “low risk”criteria for
children younger than 3 months with fever and no
focus of infection
Clinical criteria
Born at term (gestational age ≥ 37 weeks) with uncomplicated nursery stay
Previously healthy infants
No toxic manifestations
No focal bacterial infection (except otitis media)
Laboratory criteria
White blood cell count 5-15 × 109/l, < 1.5 × 109 band cells/l, or band/neutrophil
ratio < 2
Normal urine analysis results (negative Gram stain of unspun urine, negative
leucocyte esterase and nitrite, fewer than five white blood cells per high power
field)
When diarrhoea is present, no haem and fewer than five white blood cells per
high power field
Fewer than 8 × 106 white blood cells/l in cerebrospinal fluid, if lumbar
puncture is performed, and negative Gram stain findings in cerebrospinal fluid
No infiltrate on chest radiograph
Parenteral antimicrobials used to treat
children with fever and no focus of infection
Children younger than 3 months
Ampicillin 100-200 mg/kg/day intravenously in divided
doses every 6 hours plus gentamicin 7.5 mg/kg/day in
divided doses every 8 hours Or ceftriaxone, 50
mg/kg/day in a single dose Or cefotaxime, 150
mg/kg/day in divided doses every 8 hours
Children older than 3 months
Ceftriaxone, 50 mg/kg/day in a single dose Or
cefuroxime, 150-200 mg/kg/day in divided doses
every 6-8 hours
Pointers to referral and dmission to
hospital
Febrile infants 7 days of age or less
High risk (see box 2) febrile infants 28-90
days of age
Toxic looking febrile children up to 36
months of age
Summary points
The main bacterial causes of infections in children aged under 1 month are group B
streptococcus, Escherichia coli (and other enteric Gram negative bacilli), Listeria
monocytogenes ,Streptococcus pneumoniae , Haemophilus influenzae,Staphylococcus
aureus, Neisseria meningitides, andSalmonella spp
Most bacterial infections in children over 3 months are caused by S pneumoniae
(in non-immunised children), N meningitidis, or Salmonella spp
All febrile children under 3 years old who have toxic manifestations should be admitted
to
hospital, be fully investigated for sepsis and meningitis, and receive antimicrobial
treatment
The risk of bacterial infection is very low in children over 24 months old who seem well,
and
follow up without laboratory tests or treatment with antimicrobials is generally
adequate
In 3-24 month old children antimicrobial treatment is initiated if foci are found; if no
identifiable source is found and the child seems well, no diagnostic tests or antibiotics
are generally needed
Most febrile infants under 1 month old and all those under 7 days should be admitted to
hospital and treated with antimicrobials; however ,observation in hospital without
antimicrobials or outpatient management is an option in selected low risk cases