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Dr.

Mulya Rahma Karyanti, SpA(K)


Courtesy of Dr. Alan R. Tumbelaka, SpA(K)
Child Heath Department
University of Indonesia

Fever
The most frequent complaint, usually

alarms parents
The clinical manifestations varies
Age : neonatal to adolescent
Problems if fever with no apparent
source

Mc Cartey PL.Fever. Pediatric in Rieviev 1998


Poerwo Soedarmo S,dkk: Buku Ajar Infeksi & Pediatri Tropis;2008
Avner JR.Acute Fever.Pediatric in Rieview 2009
Graneto JW.Pediatrics,Fever. http://www.medscape.com. 2009
Tolan RW :Fever Without a Focus . http://www.medscape.com, 2009

Fever definiton
Pathophysiological and Clinical term
Pathophysiological term
Body temperature increase above normal as
the result of a coordinated response to a
pathological insult in the thermoregulation
centre

Clinical term
Rectal temperature 38.0 C

Axillary temperature

37.4C
Tympanic membrane

Oral temperature 37.6C


37.6C
El-Radhi AS :Pathogenesis of Fever;Clinical Manual of Fever in Children. 2009
Ward MA: Fever Pathogenesis and Treatment . Pediatric Infectious Diseases; 2009

Hueter SE ,Defriez CB: Pathophysiology The Basis for Disease in Adults and Children;2006

Guideline Fever Without Source until 3 years of age

Beatriz et al. 2009

The Pathogenesis of Fever

Avner JR, MD. Acute Fever, Pediatrics In Review. 2009

Class

Commones Usual
t Cause
Fever
Duration

Fever with
Localizing Signs
(FWLS)

URTI

< 1 week

Fever without
Localizing Signs
(FWOLS)

Viral
Infection, UTI

< 1 week

Fever of Unkown
Origin
(FUO/PUO)

Infection,JIA

> 1 week

FWLS

El-Radhi AS :Fever;Clinical Manual of Fever in Children. 2009

of cases , FWOLS/FUO of cases

Fever with Localizing Sign


Group
Diseases
Upper airway infections

Viral UTI, AOM, Tonsillitis,


Laryngitis

Pulmonary

Pnemonia, Bronchiolitis

Gastrointestinal

Gastroenteritis, Hepatitis,
Appendicitis

CNS

Meningitis, Encephalitis

Exantems

Measles, Chickenpox

Collagen

Rheumatoid arthritis, Kawasaki


disease

Neoplasma

Leukemia, lymphoma

Tropics

Kala
azar Manual of Fever in Children. 2009
El-Radhi AS
:Fever;Clinical

Fever without Localizing Sign


Causes
Diseases
Infection

Bacteriemia / Sepsis
Most viruses (HH-6,EBV)
UTI, Malaria

PUO (Persistent /Pyrexia of


Unknown Origin)

Infection, Collagen ,
Neoplasma

Neoplasma

Leukemia, Lymphoma

Post Vaccination
Drug Fever

DPT,measles
Antibiotics, Cytotoxic,
Antiepileptics
El-Radhi AS :Fever;Clinical Manual of Fever in Children. 2009

Principal Causes of Pyrexia Unknown Origin


(PUO)

Causes
Infection
Localized
Systemic
Collagen Diseases
Neoplasma
Miscellaneous

Diseases
( 60-70 %)
Sinusitis ,Endocarditis ,Occult
abscess
EBV Viral, TBC, Brucellosis
(20%)
(5%)
( 5-10%)

JIA,SLE
Leukaemia, Lymphoma.
Neuroblastoma
Drug Fever

El-Radhi AS :Fever;Clinical Manual of Fever in Children. 2009

Fever
Most are beneficial : enhancing infection

host response, inhibiting the infectious


agents
Some are harmful : Neuro, cardiorespiratory diseases
Morbidity/mortality due to the underlying
disease

Antipyretic s
External Cooling
Parents Fever Phobia
Lorin MI.Fever and Its Treatment;Oskis Essential Pediatrics.2004
El-Radhi AS :Management of Fever ;Clinical Manual of Fever in Children. 2009
Poerwo Soedarmo S dkk :Buku Ajar Infeksi & Pediatri Tropis;2008
Ward MA : Patient information: Fever in children ; UpToDate CD-ROM 17.2 .2009

Most commonly used


Ideal antipyretics:
Rapid ,Effective in reducing fever
Available in liquid & suppository form
Low side effects , low toxicity when

overdoses
Low interaction with other medications, rare
contraindications
Safe and cost effective

Choices : Paracetamol
and Ibuprofen
El-Radhi AS :Management of .Fever ;Clinical Manual of Fever in Children. 2009
Isaacs D. Fever. Evidence Based Pediatric Infectious Diseases. 2007
Aronoff SC:Fever in Infant andtoddler:;http://emedicine.com.Updated Agustus 2009

Physical methods to reduce body


temperature
Bed rest and External cooling

External cooling
Warm water, Total body surface

cooling
Tepid water (30 C)

Temp > 40 C
One hour after antipyretic
Duration 30 minutes
Fisher RG : Fever and Shock Syndrome;Moffets Pediatric Infectious Diseases.2005
Ward MA: Fever Pathogenesis and Treatment . Pediatric Infectious Diseases; 2009

Advice /tell them :


Mild and moderate fever is beneficial ,

supports the immune system


To observe the childs interaction with
the environment
To prevent dehydration : small,
frequent drinks
To reduce discomfort with antipyretics
Dont overdress ,provide light blankets
when children are cold / shivering
El-Radhi AS :Management of Fever ;Clinical Manual of Fever in Children. 2009
Ward MA : Patient information: Fever in children ; UpToDate CD-ROM 17.2 .2009

Antipyretic only if necessary for

comfort (child/parent)
Try tepid sponging first
Use paracetamol or ibuprofen (not >
48 hrs/3 days)
Ibuprofen is not recommended for
babies < 6 mo old
Isaacs D. Fever. Evidence Based Pediatric Infectious Diseases. 2007

To predict a serious bacterial


infection (SBI)
The key factors :
The child age
The height of temperature
The presence or absence of

infection focus
The presence or absence of
toxicity
Isaacs D. Fever. Evidence Based Pediatric Infectious Diseases. 2007

SBI :
Meningitis,Bacteriemia

/Sepsis,Enteritis,
Pnemonia,Pericarditis,Osteomyelitis,Se
ptic arthritis,Cellulitis

Common bacteria cause of SBI :

S pneumoniae
N meningitidis
H influenzaetype b
L monocytogenes
E coli
Tolan RW :Fever Without a Focus . http://emedicine.com.Updated: Jan 22, 2009
Granetto JW:Pediatric Fever. http://emedicine.com.Updated: Jan 22, 2009

Neonate < 28 days

Young child suggestive UTI on urinalysis

Appear toxic

History FUO or Prolonged fever

Suspected SBI

Tachypnea, grunting, rash, headaches ,


vomiting

Skin petechiae

Infant with fever > 40C, without focus

First febrile seizure

Unreliable ,not assured follow up parent

WBC > 20.000,high


CRP

Bloody diarrhea, abdominal tenderness,


drowsiness

El-Radhi AS : Management of Fever ;Clinical Manual of Fever in Children. 2009

Sign of toxicity 0-36 months febrile

children (ABCD)

A
B
C
D

:
:
:
:

Arousal, Alertness, and Activity


Breathing difficulties
Color and/ or Circulation and/or Cry
Decreased fluid intake, urine output

More than one increased risk factor for


serious illness
(Toxic child : drowsy, lethargic, or irritable,
pale, mottled, and tachycardi)

Isaacs D. Fever. Evidence Based Pediatric Infectious Diseases. 2007

Antibiotic indications :

With focus of infection suggesting

bacterial disease
Neonates and ill looking children
Fever > 40 C ,< 36 months , without focus
infection
Without infection focus, screening test are
abnormal

Depend on :

Severity of illness, immunization status ,

epidemiology of local organism

Isaacs D. Fever. Evidence Based Pediatric Infectious Diseases. 2007


El-Radhi AS :Management of .Fever ;Clinical Manual of Fever in Children. 2009

AGE

ANTIBIOTICS

DOSE mg/kg
BW

0-3 mos

Amox/Ampicillin
Plus
Gentamicin

50

IV/6 hourly

7,5

IV /daily

Benzylpenicillin
OR
Ceftriaxone

30/50.000U

IV/6 hourly

50

IV/IM daily

4 mos 4
yrs
Over 4 yrs

The COMBINATION
OF
30/50.000U
IV/6 hourly
Benzylpenicilin
50
IV/6 houly
PLUS
Di/Flucl/Nafcillin
50
IV/8 hourly
OR as A SINGLE
50
IV/IM daily
AGENT
Cefotaxim OR
Isaacs D. Fever. Evidence Based Pediatric Infectious Diseases. 2007
Ceftriaxon

Algorithm for management of the febrile child <3


years old

Isaacs D. Fever. Evidence Based Pediatric Infectious Diseases. 2007

Fever is most common complaint, not dangerous and


may be protective.
The most common cause are Infections
Fever is caused by the increase of the temperature set
point in the thermoregulatory centre as the result of
PGE2 stimulation.
There are 3 classifications of fever
Antipyretics, External cooling, and feverphobia have
to be managed properly
Paracetamol and Ibuprofen are commonly used
antipyretic
Under certain conditions,febrile children should be
hospitalized and the administration of antibiotic
considered .