Fever in Children

Blok 27 – Agustus 2018

 Fever
§ One of most common clinical symptoms
managed by pediatricians and other HCPs
o Unscheduled physician visits
o Telephone calls
§ Causes heightened anxiety in parents and
caregivers
§ Pediatricians and nurses are the primary
resource for information on fever management
for parents and caregivers
 Objectives
• To know about fever: definition, classification,
etiology and patophysiology
• To assess patient with fever.
• To determine which patients are at high risk of
developing serious bacterial infection.
• To initiate empiric therapy.
• To know about antipyretics use in fever
management
 Objectives
• To know about fever: definition, classification,
etiology and patophysiology
• To assess patient with fever.
• To determine which patients are at high risk of
developing serious bacterial infection.
• To initiate empiric therapy.
• To know about antipyretics use in fever
management
 Definition of Fever
• Fever: an abnormal elevation of body temperature
that occurs as part of a specific biologic response that
is mediated and controlled by the central nervous
system
– 0 to 28 to 30 days of age: rectal temperature ≥38.0ºC
– Healthy one- to three-month-old: rectal temperature ≥38.0
– Children 3 to 36 months: rectal temperatures ≥38.0
– Older children and adults: oral temperatures ≥37.8
 Classification of Fever
• Duration of fever:
– Acute (≤ 7days ),
– Acute recurrent or periodic (episodic fever
separated by afebrile periods)
– Chronic/ demam lama (> 7 days), which is more
commonly referred to as fever of unknown origin
(FUO)
 Classification of Fever
Fever
without
localizing
signs
Fever with Fever of
localizing unknown
signs origin

Fever
 Classification of Fever
Classification Definition Most frequent Duration
etiology of fever
Fever with Acute febrile illness with focus Upper <1
localizing infection which could be respiratory week
signs diagnosed by anamnesis & tract infection
physical examination (URTI)
Fever without Acute febrile illness without Viral infection, <1
localizing focus infection diagnosed after urinary tract week
signs anamnesis & physical infection (UTI)
examination
Prolonged A single illness in which duration of fever exceeds that
fever expected for the clinical diagnosis (e.g., >10 days for
viral upper respiratory tract infections; >3 weeks for
mononucleosis)
Or
A single illness in which fever was an initial major
symptom and subsequently is low-grade or only a
perceived problem
 Classification of Fever
Classification Definition Most Duration
frequent of fever
etiology
Fever of • Criteria for FUO in Petersdorf and Infection, > 1 week
unknown Beeson’s landmark study in adults in juvenile
origin 1961: A single illness of at least 3 idiopathic
weeks’ duration in which fever arthritis
>38.3°C is present on most days,
and diagnosis remains uncertain
after 1 week of intense evaluation
• Nowadays: Children with fever
>101oF (38.3oC) of at least eight
days' duration, in whom no diagnosis
is apparent after initial outpatient
or hospital evaluation that includes
a careful history and physical
examination and initial laboratory
assessment
 Fever with Localized Signs
Common Causes
Organ system Diseases
Upper airway infections Viral URTI, otitis media, tonsillitis, laryngitis,
herpetic stomatitis
Pulmonary Bronkhiolitis, pneumonia
Gastrointestinal Gastroenteritis, hepatitis, appendicitis
CNS Meningitis, encephalitis
Exanthems Campak, chicken pox
Collagen Rheumathoid arthritis, Kawasaki disease
Neoplasma Leukemia, lymphoma
Tropics Kala azar, cickle cell anemia

Acute febrile illness with focus of infection, which can be

diagnosed after history & physical examination
Fever without localizing signs
About 20% all febrile episodes demonstrate no
localizing signs
Most common cause is a viral infection
Most occuring during the first few years of life

Serious infections occured in 1% cases:

serious bacteriemic infections (SBIs)
Children 3-24 months have the highest incidence (3-4%),
aged 7-12 months demonstrating twice incidence
association with high fever >39.50C
 Fever without localized signs
Common causes
Etiology Causes Diagnostic tools

Infections Bacteremia/sepsis Ill looking, high CRP, leukocytosis

Most virus (HH-6) Well appearing, nomal CRP, WBC
UTI Urine dipsticks
Malaria In malarial area

FUO Juvenile idiopathic Pre-articular, rash, splenomegaly,

arthritis high antinuclear factor, CRP
Post DTwP, measles Time of fever onset in relation to the
vaccination time of vaccination
Drug fever Most drug History of drug intake, diagnosis of
exclusion
 What etiologies cause fever?
• Infectious
• Inflammatory
• Oncologic
• Other: CNS dysfunction, drug fever
• Life-threatening conditions
 Infectious
• Systemic
– Bacteremia, sepsis, meningitis, endocarditis
• Respiratory
– URI, sinusitis, otitis media, pharyngitis, pneumonia,
bronchiolitis
• Abdominal
– Urinary tract infection, abscess (liver, kidney, pelvis)
• Bone/joint infection
• Hardware infection
– Central line, VP shunt, G-tube
 Inflammatory
• Kawasaki disease
• Juvenile inflammatory arthritis
• Lupus
• Inflammatory bowel disease
• Henoch-Schonlein purpura
 Others
• CNS dysfunction
• Drug fever
 Pathophysiology of Fever
§ Fever: normal physiologic response
o Results in an increase in the hypothalamic set
point
• Response to endogenous and exogenous pyrogens
 Objectives
• To know about fever: definition, classification,
etiology and patophysiology
• To assess patient with fever.
• To determine which patients are at high risk of
developing serious bacterial infection.
• To initiate empiric therapy.
• To know about antipyretics use in fever
management
 EVALUATION - History
• History of present illness
– degree and duration of fever, method of measurement,
and the dose and frequency of antipyretics (if any).
– Important associated symptoms that suggest serious illness
include poor appetite, irritability, lethargy, and change in
crying (eg, duration, character).
– Associated symptoms that may suggest the cause: vomiting,
diarrhea (including presence of blood or mucus), cough,
difficulty breathing, favoring of an extremity or joint, and
strong or foul-smelling urine.
– Drug history should be reviewed for indications of drug-
induced fever.
 EVALUATION - History
• Factors that predispose to infection are identified.
– In neonates:
• prematurity, prolonged rupture of membranes, maternal
fever, and positive prenatal tests (usually for group B
streptococcal infections, cytomegalovirus infections, or
sexuallytransmitted diseases).
– For all children:
• recent exposures to infection (including family and caregiver
infection), indwelling medical devices (eg, catheters,
ventriculoperitoneal shunts), recent surgery, travel and
environmental exposures (eg, to endemic areas, to ticks,
mosquitoes, cats, farm animals, or reptiles), and known or
suspected immune deficiencies.
 EVALUATION - History
• Review of systems:
– symptoms suggesting possible causes, including
• runny nose and congestion (viral URI),
• headache (sinusitis, Lyme disease, meningitis),
• ear pain or waking in the night with signs of discomfort (otitis
media),
• cough or wheezing (pneumonia, bronchiolitis),
• abdominal pain (pneumonia, strep pharyngitis, gastroenteritis,
UTI, abdominal abscess),
• back pain (pyelonephritis), and
• any history of joint swelling or redness (Lyme disease,
osteomyelitis).
 EVALUATION - History
– A history of repeated infections (immunodeficiency)
or symptoms that suggest a chronic illness, such as
poor weight gain or weight loss (TB, cancer), is
identified.
– Certain symptoms can help direct the evaluation
toward noninfectious causes; they include
• heart palpitations, sweating, and heat intolerance
(hyperthyroidism) and
• recurrent or cyclic symptoms (a rheumatoid,
inflammatory, or hereditary disorder).
 EVALUATION - History
• Past medical history should note
– previous fevers or infections and known conditions
predisposing to infection (eg, congenital heart disease,
sickle cell anemia, cancer, immunodeficiency).
– A family history of an autoimmune disorder or other
hereditary conditions (eg, familial dysautonomia,
familial Mediterranean fever) is sought.
– Vaccination history is reviewed to identify patients at
risk of infections that can be prevented by a vaccine.
 EVALUATION – Physical Examination

• Vital signs:
– abnormalities in temperature and respiratory rate.
– In ill-appearing children, BP should also be
measured.
– Temperature should be measured rectally in infants
for accuracy.
– Any child with cough, tachypnea, or labored
breathing requires pulse oximetry.
 EVALUATION – Physical Examination
• Child's overall appearance and response to the
examination are important.
– A febrile child who is overly compliant or listless is of more
concern than one who is uncooperative.
– An irritable infant or child who is inconsolable is also of
concern.
– The febrile child who looks quite ill, especially when the
temperature has come down, is of great concern and
requires in-depth evaluation and continued observation.
– Children who appear more comfortable after antipyretic
therapy do not always have a benign disorder.
 Age is important
• >10 % of well-appearing young infants with a
temperature >38 C has a serious bacterial
infection or meningitis
• Only <2 %of well-appearing older infants and
young children with a temperature >39 C
(manifest bacteremia}
 Serious Bacterial Infection (SBI) Syndromes
Pneumonia Meningitis
Bacteremia Osteomyelitis
Urinary tract infection Bacterial Gastroenteritis
Sepsis

Allen C: Fever without a source in children 3 to 36 months of age.UpToDate CDROM 18.2,2010

Smitherman HF,Macias CG : Evaluation and management of fever in the neonate and young infant (< 3mo of age),UpToDate
CDROM 18.2,2010
Tolan RW :Fever Without a Focus , http://www.medscape.com, 2009
 ETIOLOGY Serious Bacterial Infection (SBI)

Common Bacterial Etiology of SBI

Streptococcus pneumoniae Streptococcus agalactiae
Neisseria meningitidis Haemophilus influenzae type b
Listeria monocytogenes Eschericia coli

Allen C: Fever without a source in children 3 to 36 months of age.UpToDate CDROM 18.2,2010

Smitherman HF,Macias CG : Evaluation and management of fever in the neonate and young infant (< 3mo of age),UpToDate
CDROM 18.2,2010
Tolan RW :Fever Without a Focus , http://www.medscape.com, 2009
Source: Jornal de Pediatrica - Vol. 85, No. 5, 2009
 Yale Observation Scale (YOS) degree of Illness
Indications Assessment of febrile child ages 3-36 months
Predicts serious infection (Occult Bacteremia)
Quantifies "Toxic Appearance" in children

Observation Items 1 (Normal) 3 (Moderate 5 (Severe

Impairment) Impairment)
Quality of cry Strong with normal tone Whimpering or sobbing Weak cry, moaning, or
or contentment without high-pitched cry
crying
Reaction to parent Brief crying that stops or Intermittent crying Continual crying or limited
stimulation contentment without crying response

Color Pink Acrocyanotic or pale Pale or cyanotic or

extremities mottled or ashen
State variation If awake, stays awake; if Eyes closed briefly while Falls asleep or will not
asleep, wakes up quickly awake or awake with arouse
upon stimulation prolonged stimulation
Hydration Skin normal, eyes normal, Skin and eyes normal and Skin doughy or tented,
and mucous membranes mouth slightly dry dry mucous membranes,
moist and/or sunken eyes
Response (eg, talk, smile) Smiling or alert (<2 mo) Briefly smiling or alert Unsmiling anxious face or
to social overtures briefly (<2 mo) dull, expressionless, or not
alert (<2 mo)
Risk SBI : Score < 10 (2.7%) , Score > 16 (92%)
Yale Observation Scale (YOS) degree of Illness
Indications Assessment of febrile child ages 3-36 months
Predicts serious infection (Occult Bacteremia)
Quantifies "Toxic Appearance" in children
A total score of less than 11 signifies a less than 3% probability of serious illness.
A total score 11-15 signifies a 26% probability serious illness
A total score of greater than 15 signifies 92 % probability of serious illness
Laboratory
Evaluation
• WBC and ANC
counts
• Urine test
• Cultures
• Chest radiograph
• Inflammatory
mediators
– CRP
– Procalcitonin
 Laboratory evaluation
• What would you do if the patient has device
(VP shunt, tracheostomy, gastrostomy tube) or
central line?
– CBC with differential
– Blood culture
– CSF (tap VP shunt)
 Laboratory evaluation
• What would you do if the patient has a high
risk for sepsis?
– Immunocompromised
– Transplant recipient
– Oncology patient

– CBC with differential

– Blood culture
– Urinalysis and urine culture
 Laboratory evaluation
• What would you do for an infant ≤ 2 months of
age?
– CBC with differential
– Blood culture
– Urinalysis and urine culture
– Lumbar puncture
 Laboratory evaluation
• Who needs a urinalysis and urine culture?
– Circumcised males < 6 months
– Uncircumcised males < 1 year
– Females < 2 years
– Immunocompromised patients
– Patients with history of UTI/pyelonephritis
 Laboratory evaluation
• Who needs a lumbar puncture?
– Neonates ≤ 2 months
– Ill-appearing
– Altered mental status

• What tests do you send?

– Gram stain and culture
– Cell count and differential
– Protein and glucose
– Extra tube for additional studies
• Enteroviral PCR, HSV PCR, CA encephalitis project
 Laboratory evaluation
• Consider CRP, ESR
• Consider PT/PTT, fibrinogen
• Consider chest x-ray
• Consider nasopharyngeal DFA
• For immunosuppressed patients consider:
– Viral PCR studies (ie CMV, EBV, HHV6)
– Additional imaging (ie ultrasound, CT scan)
 Objectives
• To know about fever: definition, classification,
etiology and patophysiology
• To assess patient with fever.
• To determine which patients are at high risk of
developing serious bacterial infection.
• To know about antipyretics use in fever
management
 Which patients are high-risk for serious
bacterial infection?
• Neonates
• Transplant recipients
– Bone marrow
– Solid organ
• Oncology patients
– Undergoing therapy, mucositis, central line
– Most chemotherapy: nadir ~ 10 days after rx
• Asplenic patients, including sickle cell
 Objectives
• To know about fever: definition, classification,
etiology and patophysiology
• To assess patient with fever.
• To determine which patients are at high risk of
developing serious bacterial infection.
• To initiate empiric therapy.
• To know about antipyretics use in fever
management
 Treatment for non-high risk patients
• May not need empiric antibiotics
• Consider the following issues:
– Is patient clinically stable?
– Are the screening laboratory studies suggestive of
infection?
 Yale Observation Scale

A total score of less than 11 signifies a less than 3% probability of serious illness.
A total score 11-15 signifies a 26% probability serious illness
A total score of greater than 15 signifies 92 % probability of serious illness
 Objectives
• To know about fever: definition, classification,
etiology and patophysiology
• To assess patient with fever.
• To determine which patients are at high risk of
developing serious bacterial infection.
• To initiate empiric therapy.
• To know about antipyretics use in fever
management
 Antipyretics Use
§ Benefits of fever
o Protective role in the immune system
• Inhibition of growth and replication of microorganisms
• Aids in body s acute phase reaction
• Enhanced immunologic function of wbc s
• ­ lymphocyte response to mitogens
• ­ bactericidal activity of neutrophils
• ­ production of interferon
• Promotion of monocyte maturation into macrophages
• Promotion of lymphocyte activation and antibody
production
• Decreased availability of free iron for bacterial replication
 Antipyretics Use
• Antipyretics may prolong course of illness
– Adults with rhinovirus shed the virus longer
– Children with varicella have delayed time for
lesions to crust (about 1 day)
– Children with malaria take longer to clear
parasites (75 vs 59 hours)
 Antipyretics Use
§ Antipyresis
§ Many parents aim for normal temperature
o Daycare, school & work can drive this
§ Antipyresis therapy DOES NOT
o Reduce morbidity or mortality from a febrile illness
o Decrease the recurrence of febrile seizures
§ Antipyresis DOES
o Relieve discomfort
o Decrease insensible fluid loss
 Antipyretics Use
• Arguments againsts antipyretics use
– Fever is not an illness
– Most fevers are short-lived and benign
– Fever may protect the host
– Degree of fever does not correlate with severity of
illness
– ¯ fever may obscure diagnostic or prognostic signs
– No evidence that children with fever are at ­risk
of adverse outcomes such as brain damage
– Adverse effects of antipyretics outweigh benefits
 Antipyretics Use
§ Treatment Goals
§ Determine therapeutic endpoints
o Child s comfort
o Early identification of signs of need for intervention or
serious illness
– Altered mental status
– Changes in activity level
– Skin rash
– Signs of dehydration
– Specific pain (ear, abdomen, neck, etc.)
§ Exception: child with acute or chronic illness that will
not tolerate increased metabolic demands
 Antipyretics Use
• Therapeutic interventions
– Single or combination therapy
• Acetaminophen
• Ibuprofen
• Single regimens (of either acetaminophen or ibuprofen)
should be adequate for discomforts due to fever
– Remember therapeutic endpoint!
• Most studies have evaluated antipyretic efficacy
• Very limited data related to discomfort
 Antipyretics Use
• Safety
– Drugs
• Formulations
• Dosage
– Amount
– Frequency
• Accurate measuring device
• Specific regimens
– Risks of combination therapy
• Storage of products
• Avoid cough/cold combination products
– Provide written instructions
– Educate at well-child visits
 Take home points
• Infections are the most common cause of fever in
children
• During assessment of a child with fever, pay close
attention to vital sign changes, overall appearance,
and potential sites of infection