Ika-kelompok-Acute Fever in Children

7/27/2019 Ika-kelompok-Acute Fever in Children

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ACUTE

FEVER IN

CHILDREN

FACULTY OF MEDICINE

BRAWIJAYA UNIVERSITY

MALANG

2010


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What is

FEVER? Fever is a rise in the body temperature to 101

Fahrenheit or greater

Fever is the body's natural response to a viral

or bacterial infection.

Fever is considered beneficial to help the

body fight infection and usually not dangerous

but if the fever is too high then in can cause

further complications.2

common

symptom


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20% of paediatric visits.

- How sick a child looks is more important than

the level of fever.

Any ill child with a high fever should be

examined carefully to exclude serious infections

such as meningitis, UTI or pneumonia.

Any fever in a baby less than 8weeks old should be taken

seriously.3


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Pathophysiology

Fever is the hallmark of immune systemactivation resulting in increase body temperature.

It is accomplished by two endogenous(cytokinesTN alpha and IL-1,IL-6) and exogenous pyrogens(LPS , toxins and tumor). This endogenousproinflammatory substance induce enzymecyclooxygenase (COX-2) and production of

prostaglandin E2. Prostaglandin E activatate thermoregulatory

systems in anteriorhypothalamus(thermoregulator) to elevate body temperature

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Classification of Fever

A. Fever with Localized Signs

B. Fever without localized Signs (Bacteremia)

C. Persistent Pyrexia of Unknown Origin (PUO)D. Drug Fever

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Patterns of FeverPattern Diseases

Continuous Thypoid, malignant falciparum malaria

Remmitent Most viral or bacteria disease

Intermittent Malaria, lymphoma, endocarditis

Hectic or septic Kawasaki disease, pyogenic infection

Quotidian Malaria (P. vivax)

Double quotidian Kala azar, gonococcal arthiritis, juvenile

rheumatoid arthiritis, drug fever(carbamazepine)

Relapsing periodic

Recurrent fever

Tertian or quartan malaria, brucellosis

Familial medeterranean fever


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Periodic

fever (PF)

Episodes of fever recurring at

regular or irregular intervals.

Each episode is followed by

several days weeks or months

of normal temperature

Examples:

Malaria

(Termed tertian when febrile

spike occurs every third day

and quartan when spike

occurs every fourth day)

Brucellosis

Relapsing

fever (RF)

Recurrent fever caused by

numerous Borrelia sptransmitted via lice or ticks

Recurrent fever is an illness

involving the same organ (e.g.Urinary tract) or multiple

organ systems in which fever

recurs at irregular intervals.

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The following degree of temperature

are accepted as fever : -

Rectal temperature : 38.0C

Oral temperature : 37.6 C

Axillary temperature : 37.4 C

Tympanic temperature : 37.6C

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Clinical changes during fever

Manifestations Clinical findings

Symptoms Chills (rigor), myalgia, headaches,

anorexia, excessive sleep, fatigue, thirst,

delirium, scanty urine (oliguria)

Signs Drowsiness, irritability, tachycardia,

tachypnoea, increased BP, flushed face,

grunting, decrease in GFR, proteinuria.

Appearance of an innocent (functional)murmur and third heart sound

ECG changes Shortening QT-intervals, increase in

supraventricular ectopic beats.


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Metabolic changes during fever

energy expenditure

O2 consumption

insensible waterloss

glucose production

amino acids release

C-reactive protein,haptoglobin,

ceruloplasmin,

fibrinogen, triglyceride hormones: cortisol,ACTH, growth

hormone, arginine

vasopressin

copper

liver albumin

nitrogen balance sodium

iron, zinc


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GENERAL Complications of fever

Dehydration

Febrile seizure

Deliriumin association with a high degree of body

temperature.

Hyperpyrexia significant association between such a

degree of temperature elevation and serious bacterial

infections, such as bacterial meningitis. Apart from infection,

hyperpyrexia up to 41.8C has been reported in newborn

infants presenting with intraventricular haemorrhage.

Herpes labialis (less often) results from activation of alatent herpes simplex infection in association with febrile

illnesses.


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As children < 36 months experiencethe highest rate of febrile illnesses

with localizing signs. There are

separated into 4 age groups :


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Fever in children


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Symptoms and signs of a child with

serious bacterial infection

General Reduced activity, weak cry, poor eyecontact, absent smile.

Body temperature Instability, fever

Signs of shockClammy, mottled skin, reduced CRT

Respiratory apnoea, tachypnoea, shallow

respiration, grunting

Gastrointestinal Poor feeding, vomiting, abdominal

distension, diarrheaCNS Drowsiness, sometimes althernating

with irritability

CRT= Capillary refill time


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The most common organisms causing SBI in

children younger and older than 3 months of age

Children 3months S.pneumonia, N.meningitidis, Salmonella

GBS= group B streptococcus ; CONS = coagulase negative

staphylococci; S. streptococcus: N,Neisseria; H. Haemophilus


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Management of a child aged 0-


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Management of a child 3-36months of age

without Localized Signs (SBI)

Ill-looking child Admit & administer antibiotic

Not ill-looking & body temperature < 39 degree Celsius

Urine dipsticks, review if condition worsens

Body temperature > 39 degree Celsius

Option 1

Urine dipstickFBC

Blood culture

Chest x-ray

Consider anatibiotic

Option 2

UrineNo blood test

Review if

condition worsens

Option 3

FBC: if WBC > 15000,Blood culture

consider antibiotic


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Fever in children > than 36

months

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Causes of fever

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DiagnosisHistory

The parents have normally noticed the fever and may have checkedthe child's temperature

Ask about the duration and pattern of the feverdoes it occur atparticular times of the day?

Is there pain? Earache, difficulty swallowing, dysuria or frequencymay point to the source

Are there associated features such as malaise, anorexia, vomiting,coryza, cough or rash?

Has there been contact with other children with infection such as

meningitis or chicken pox? Has the child just been vaccinated?

Is the child still drinking adequate amounts of fluid?

What anti-pyretics and cooling measures have been tried?

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Examination

Check the temperature: oral, axilla or rectal

Chest: are there signs ofrespiratory infection

tachypnoea,recession, crackles or grunting?

Throat: feel for cervical lymphadenopathy and look

at tonsils.

Ears: are the tympanic membranes red or bulging?

CNS: is the child orientated? Is there signs of

meningism?

Urine: check the urine with dipstick or microscopy 22


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Investigations and their significance

Full blood count : Leucocytosis with neutrophilia suggests

bacterial infection

Throat swab :Streptococcus requires treatment with penicillin

Blood culture: If positive, suggests septicaemia. Treatment

may have to commence before result known

Lumbar puncture: To exclude meningitis and encephalitis.

Should be performed in any seriously ill child when no focus

of infection can be found, especially in infants


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Therapy

Acetaminophen(Tylenol/Tempra/Liquiprin/Panadol) every 4hours If your health care provider orders

lbuprofen (Pediaprofen/Motrin /Advil), give itevery 6-8 hours

Antibiotics, Antivirals

Aspirin shouldnotbe used in children under 12years as it is associated with the developmentof severe liver failure (Reyes syndrome).

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Management

- Dress child in lightweight clothing or removeclothing to allow heat loss through the skin

- Use a lightweight blanket if he feels cold or is

shivering Try to keep the child quiet - activityincreases body temperature

- Give the child extra fluids to prevent

dehydration or extra loss of water Sponging the skin with tepid water can also

bring down the temperature by evaporation

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COMPLICATIONS

Dehydration is common in children withuntreated fever. Specific attention on thehydration should be addressed in febrile

children. Occult bacteremia in the unimmunized child

may progress to secondary sites of infectionsuch as meningitis or osteomyelitis. Localizedinfections may lead to hematogenous seedingand sepsis.

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PROGNOSIS

The prognosis for routine febrile children

treated as described is generally good but

ultimately depends on the etiology of the fever. Most illnesses that cause fever last three to

seven days.

Sometimes, treatment of bacterial infectionsfails at home, and the child will need to be

hospitalized.

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Prevention

The following prevention method prevents acutefever in children :

Wash your hands with soap and water.

Cover your mouth and nose when sneezing andcoughing.

Handle food with clean hands (child guardian).

Properly immunize your child (see the children's

immunization schedule). Eat a healthy diet including fruits and vegetables

(so that child have enough nutrients vitaminsand minerals.

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Pyrexia of Unknown

Origin

In 1961 was defined as a duration

offever of at least 3 weeks anduncertanity of diagnosis after 1

week investigation in the hospital

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Laboratory investigation based on childs

condition, while the extent of

investigation is based on clues from

history :

travel abroad

exposure to animals

Ingestion of raw milk

Exposure to infection

Consideration of ethnic group

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Initial investigations (chest X-ray, blood,

urine culture) may rapidly establish a

diagnosis of unexplained fever. If theinvestigations fail to reach diagnosis,

further investigations and invasive

techniques may be used.

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PYREXIA OF UNKNOWN


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PYREXIA OF UNKNOWN

ORIGIN (PUO)

Cause Reason for being a case of PUOInfection (60-70%)

Localized

Sinusitis Standard sinus ro not performed or negative

Endocarditis Previously unsuspected of having a cardiac

defect

Occult abscess (abdomen,

dental)

Absence of clinical signs

Systemic

Viral (eg : EBV) Fever as the only sign of the disease

Kawasaki disease Incomplete presentation, diagnostic not

considered

Brucellosis Diagnostic test for brucella not performed


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Juvenile Idiopathic Arthritis Prearthric manifestation

SLE Atypical manifestation

Neoplasm (5%)

Leukemia Atypical presentation, blood test negative

Lymphoma Unusual localization

Neuroblastoma DisseminatedMiscellaneous (5-10%)

Drug fever Dx not considered, suspected drug not

stopped

Factitious fever Dx not considered, thermometer left to px

Collagen (20%)


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DRUG

FEVER


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DEFINITION

Disorder characterised by

elevation of body temperature

with administration of a drug and

disappearance of the fever afterdiscontinuation of the drug, with

no other cause of the fever after

physical examination and

laboratory investigation.


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DIAGNOSTIC FEATURE

DF is a diagnostic of exclusion

Test to confirm the diagnosis are absent and

rechallenge is discouraged generally.

DF may develop immediately after initiation of

therapy but usually delayed for 7-10 days.

Diagnosis is suggested by prompt

defervescence (usually in 24 hours) after

discontinuation of offending drug


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Predispose condition:Atopic disorders

Severe infection (ex:meningitis)

SLE. Patients dont appear toxic and temperature is

moderate.

High temperature may occur if it includeshectic pattern and chills. The highesttemperature caused by cytotoxic drugs.


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Cutaneous manifestation:

Usually urticaria, along with eosinophiliaand unproportionate relation with low

pulse and high temperature (relative

bradycardia).


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MECHANISM OF DRUGS INDUCING

FEVER

IL-1 produced by Ag-Ab complex with

leucocytes, drug acting as antigen (penicillin)

Antibiotic and cytotoxic drugs (bleomycin and

aspraginase) from microorganism that

sometimes has endotoxin provoking fever.

Cytotoxic drugs may suppress immune with

subsequent infection may lead to DF.

THANK YOU


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THANK YOU

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Ika-kelompok-Acute Fever in Children