CLINICAL APPROACH

IN CHILDREN WITH FEVER

Ida Safitri Laksono

Infectious Disease sub division –
Pediatric Dept
 Structure of presentation

• Introduction
• What is fever
• Type of fever
• Child presenting with fever
• Differential diagnosis of fever
• Key points on making diagnosis a child
presenting with fever
 Fever in childhood
• among the most likely reason to seek for medical
help
• may be infectious / non-infectious;
• viral origin is the majority; serious bacterial
infection may ensue
• Differentiation between viral and bacterial disease
may be difficult, especially in neonates and young
infants
• Evaluation and management is evolving at a rapid
pace (1. amount of research conducted, 2.
introduct of HIB vaccine, 3. Streptococus
pneumoniae vaccine, 4. ever-evolving diagnostic
technologies and therapies)
 What is fever
• A rise in the temperature set point at
hypothalamus by a variety of physiological
mechanism

• Fever usually occurs as a result of the body’s

exposure to infecting micro organism, immune
complexes or other sources of inflammation
• Pathophysiologically : is an IL-1 mediated
elevation of the thermoregulatory set point of
the hypothalamic center
• Clinically: fever is body temperature of 1° C
(1.8 F) or greater above the mean at the site
of temperature recording.

El Radhi et al 2009
 How to define fever
• Need to know what is normal body
temperature
• How we can assess fever ( by history? Touch?
Use termometer?)
DEFINITION

Normal variation in body temperature
no

single value defined as fever
Generally accepted values:

rectal temperature above 100.4 F (38 C)

oral temperature above 99.5 F (38.5 C)

axillary (armpit) temperature above 99 F
(37.4 C)

ear temperature above 100.4 F (38 C) in
rectal mode or above 99.5 F (38.5 C) in oral
mode
Arch Dis Child Educ Pract Ed 2008;93:26–29.
Type of febrile pattern
• Continuous (sustained ) fever :
persistent elevation of body temperature with a
max fluctuation of 0.4 C during a 24-h period
• Remitten : the fluctuation of body temperature is
wide (> 1 C), a fall in temp each day but not to a
normal level. The fever usually low in the morning
and higher in the late evening.
• Intermitten : temp returns to normal each day,
usually in the morning and peaks in the afternoon
(4.00 – 8.00 pm)
• Hectic (septic) : when remitten or intermittent
fever shows a very large difference between the
peak and the nadir
Recurrent : describes a single illness involving
the same organ or multiple organ system in
which fever recurs at regular
 Child presenting with fever
When fever is present, assess the child
further for signs related to it

Classify fever according to the signs

which are present or absent
In respect to fever, helpful clues come from
the type of onset (abrupt or slow), the
duration, the pattern of fever and the febrile
curve following institution of specific
treatment.
Even not absolutely correct, a specific
infection tends to associate with the
characteristic pattern of fever
 Special attention should be paid to the
following in children presenting with fever

HISTORY
Duration of fever ( < 7 days or > 7 days)
Residence in or recent travel to an area with
malaria/ dengue transmission
Skin rash
Stiff neck
Headache
Pain on passing urine
Ear pain


 Examination

Stiff neck
Skin rash : haemorrhagic (petechiae),
maculopapular ( morbiliform)
Skin sepsis
Discharge from ear
Severe palmar pallor
Local tenderness
Fast breathing
Local tenderness
Severe malnutrition
Laboratory examinations

• Blood smear
• Lumbar puncture if signs
suggest meningitis
• Urine microscopy
 Differential diagnosis of fever without
localizing signs
• Malaria ( anemia, blood smear +, enlarged spleen)
• Septicemia (seriously ill with no apparent cause,
shock)
• Typhoid (seriously ill with no apparent cause,
abdominal tenderness, confusion, shock)
• Urinary tract infection (crying on passing urine,
incontinence, frequent on passing urine)
• Fever associated with HIV infection (severe
malnutrition)
 Differential diagnosis of fever with
localized signs
• Meningitis ( neck stiffness, bulging fontanelle)
• Otitis media ( pus draining from ear)
• Mastoiditis ( tender swelling above or behind ear)
• Osteomyelitis ( local tenderness)
• Septic arthritis ( tender, hot, swelling of joint)
• Pneumonia ( fast breathing, lower chest indrawing)
• Throat abscess ( sore throat, tender cervical nodes)
• Dengue (joint and muscle pains, liver tenderness)
• Sinusitis ( facial tenderness, nasal discharge)
What possible
diseases the child
suffered from
What specific
signs
 Differential diagnosis of fever with rash

• Measles ( typical rash, runny nose, red eyes)

• Viral infection ( transient non specific rash)
• Meningococcal infection (purpuric rash)
• Dengue hemorrhagic fever ( bleeding,
petechiae, liver enlargement)
• Some causes of fever are only found in certain
regions ( tropical infectious diseases)
• Other fever are mainly seasonal
• Or can occur in epidemics (dengue)
 Fever lasting longer than 7 days
• There are many causes of prolonged fever
• It is important to know the most common causes in a
given area
• Investigation for the most likely cause can then be
started and treatment decided
• There could be a “ trial of treatment”
• Take a history for any possible chronic illness or
malignancy which may cause persistent fever
• Some persistent fever may presenting with or
without localizing signs
 Differential diagnosis of fever lasting
than 7 days
• Infective endocarditis
• Rheumatic fever
• Miliary Tuberculosis
• Malaria
• Abscess
• Salmonella infection
• HIV
• Meningitis
 Laboratory examinations to confirm
diagnosis
• Blood film for malaria parasite
• Complete blood count
• Urinalysis
• Mantoux test
• Chest X-ray
• Blood culture
• HIV testing
• Lumbar puncture
Key points on making diagnosis in child
presenting with fever
• History taking
• Physical examinations
• Considered the signs which are present or
absent ( localizing signs, rash etc)
• Considered the local setting ( epidemiological
data)
• Laboratory investigations
Thank you
•