Detail explanation about fever and common reasons for fever in paediatric patients for MBBS students

2. DR. RASHMIN CECIL
APPROACH TO
PEDIATRIC PATIENT
WITH
FEVER

3. • WHAT IS FEVER ?
• “Fever is controlled increase
in the body temperature over
normal value for an
individual.”

4. • DEFINITION OF FEVER :
• Fever is defined as a core temperature of > 38c.
• Temperatures in infants and children should be
measured rectally as axillary and tympanic
membrane temperatures are unreliable.
• An infant or child with a recent history of
documented fever but afebrile at the time of
presentation should be considered a febrile child.

5. • Range of normal body temperature:
(36 - 38º C) or (97 - 99 º F)
• PUO : [Pyrexia Unknown Origin]
• Children with a fever documented by
healthcare provider & for which cause could
not be identified after 3 weeks of evaluation
in O.P.D or in hospital admitted cases after
1 week of evaluation are known as PUO.

6. FEVER WITHOUT FOCUS :
A child with fever of recent onset
with no obvious historical or
physical explanation for the fever is
said to have fever without source
(FWS).

7. • Mercury thermometer is the best.
• Others are :
1. Digital
2. Ear
3. Rectal Thermometer
4. Low - reading Thermometer
5. Strip Technique
How to measure temprature ?

8. Where (part of the body)
to be measured?
• Ideally : Rectal
• Theoretically : Oral
• Practically : Axilla (Skin)
• Time : measure for at least 2 minutes
0.4º C (0.7 ºF) < ORAL 0.4 º C (0.7 ºF) > ORAL
Skin Temperature : Rectal (Ear drum ) :

9. GRADES OF FEVER
(TEMPERATURE)
TEMP: Cº TEMP: Fº
HYPOTHERMIA < 35º < 95º
SUBNORMAL 35º – 36.7º 95º - 97º
NORMAL 36.7º - 37.2º 98º - 99º
MILD FEVER 37.2º - 37.8º 99º - 100º
MODERATE
FEVER
37.8º - 39.4º 100º - 103º
HIGH FEVER 39.4º - 40.5º 103º - 105º
HYPERPYREXIA > 40.5º > 105º

10. : TYPES OF FEVER :
TYPES FEATURES
• Continuous
Fever
• Temperature never touching
normal
• Daily fluctuations are less
than 1 ºC.
• Remittent /
Hectic Fever
• Temperature never touches
Normal & fluctuations are >
2 ºC/ day

11. • INTERMITTENT
FEVER
• Temperature touches the
normal level.
• *Daily : Quotidian
• *Every alternate day:
Tertian
• *After every 2 days:
Quartan
• Others: Pel ebstein
• Step ladder Pattern
: TYPES OF FEVER :

12. STAGES OF FEVER
• [1] The PRODROMAL Stage : (may be Absent)
• [2] The Stage of ONSET or INVASION : (Initial
or pyrogenetic phase)
• [3] The Stage of Fever DEVELOPMENT :
(Fastigium)
• [4] The Stage of DECLINE : ( Defervescence or
Termination)

13. Infection, microbial toxins
Mediators of Inflammation,
Immune reaction
Pyrogenic cytokines
IL-1, IL-6, TNF, IFN
Microbial Toxins
FEVER
Heat Conservation
Heat Production
Elevated
Thermoregulatory
Set point
Hypothalamic
Endothelium
PGE2 Cyclic AMP
PATHO-
PHYSIO-
LOGY
Monocytes/Macrophages,
Endothelial Cells
& others

14. • Fever is one of the most common
symptom faced by practitioner.
• Fever is a common diagnostic
and therapeutic challenge.
Clinical Importance of fever :

15. • Parents expect correct diagnosis and
prompt control of fever.
• As against this, for the treating doctor,
it is almost impossible to diagnose the
cause of fever for the first 2-3 days.

16. • In this common scenario,
irrational antibiotic use and
unnecessary laboratory tests are
rules in routine office practice,
triggered by the fear of missing
serious illness.

17. • Identifying the cause of fever
depends on localization, which
takes 2-5 days

18. Inquire about
1. Behavior
2. Urine output
3. Convulsions
4. Profuse vomiting
5. Severe Abdominal pain
:: Assessment of Seriousness ::

19. • Specially Look For
1. Disproportionate HR and RR
2. Capillary Refill time
3. Differential Body Temperature
4. Chest retraction
5. Meningeal signs
6. Faucial Membrane
:: Assessment of Seriousness ::

20. :: Analysis in office practice ::
Nature of fever at onset
Response to PCM
Rhythm of fever
Trends of fever
Inter-febrile period
Localization
1
2
3
4
5
6

21. • [1] High fever :
• Viral Fever
• Bacterial infection
• Acute tonsillitis, Acute Bacillary Dysentery,
UTI
• Malaria
• [2] Moderate Fever :
• Pneumonia, Meningitis, Typhoid
1. Nauure of fever at onset :

22. • Fair to poor : Bacterial Infection
• Fair to good : viral Infection
• Erratic : Malaria
• Good : Non infective
inflammation
2. Response to PCM :

23. • Rhythmic fever : Acute Bacterial,
Acute Viral
• Erratic : Malaria
• Two spikes per day : Non infective
inflammation
3. Rhythm of fever :

24. • Settles down : Viral
• Static or get worse : Bacterial Infection
• Erratic : Malaria
• No change : Non infective
inflammation
4. Trend of fever on 3-4th day :

25. 1. Appear Well and playful :
Viral
2. Sick look and lethargic :
Bacterial
5. Inter-febrile period :

26. 1. Generalized involvement of system :
Viral
2. Some part of the system affected :
Bacterial
6. Localization :

27. • Four different 5 year old patients
present with fever for 3 days, no
other symptoms; assessed to have no
risk;
• each one ended up with a different
diagnosis.
:: Case Scenario ::

28. • How would you separate them out
clinically?
1. Onset of fever;
2. Response to paracetamol;
3. Behavior during inter febrile period;
4. Rhythm, trend, accompanying
symptoms if any.

29. 1. High fever at onset, fair/variable
2. Response to paracetamol,
3. Inter febrile period normal,
4. Fever comes up every 5-6 hours
5. On day-2 : cold and cough appears,
6. On Day - 3 : fever seems to be abating
:: Patient : 1

30. • What do we infer from the
onset of fever?
• High fever at the onset could
be viral, bacterial, or malaria.

31. • What does the response to antipyretic and
the inter febrile behavior tell us?
• Fair response to antipyretic : Less likely
to be a severe bacterial infection.
• Normal behavior in the inter febrile phase
: Suggests that it is less likely to be a
bacterial infection.

32. • So then, is it viral fever or malaria?
• Since the fever is rhythmic, coming up
every 5-6 hours, once antipyretic
effect wears off, it is equivalent to
continuous fever.
• This would make malaria less likely.

33. • Any other points to favor a diagnosis
of viral fever?
• Appearance of mild cold and cough on
day 2 : Suggesting generalized
involvement of respiratory system.
• Downward trend of fever on day - 3
Suggests a self-limiting disease.

34. 1. High fever at onset,
2. Poor response to paracetamol,
3. Interfebrile period sick,
4. Fever rises every 4 hrs,
5. On Day – 3, fever trend worsening -
look for…
:: Patient : 2

35. • Like the previous child, even in
this child the fever is high at
onset,
• Suggesting viral, bacterial or
malarial fever.

36. • What else can we infer?
• Poor response to paracetamol & child
sick in inter febrile phase : Suggests a
bacterial infection.
• High at onset, bacterial infection at
the site of entry of germs.

37. • So what should we be looking for?
• Localization in the form of
tonsillitis, lymphadenitis, UTI
• We need to ask for relevant
symptoms

38. • High fever at onset,
• Erratic fever irrespective of
Paracetamol,
• Inter febrile period normal,
• Same trend continues on Day -3
:: Patient : 3

39. • Once again, high fever at onset and
inter febrile period normal suggests
viral fever or malaria,
• but in this child the fever is erratic,
with no downward trend visible so
far, suggesting malaria.

40. • Mild to moderate fever at onset,
• Initially fair response but not on
Day - 3,
• Trend of fever rising by Day - 3,
• Inter febrile period sick
:: Patient : 4

41. How do we analyze this child’s fever?
• Mild to moderate fever at onset
• Suggest viral fever or
bacteremic bacterial infection
• Fever responded to antipyretic
initially but not subsequently

42. • Suggestive of progression or worsening
• Child is sick in interfebrile period
• Suggestive of bacterial infection
• No localized symptoms of lung and
CNS
• This all together suggestive of typhoid

43. • Patient 1:
• High fever at onset,
• Fair/variable response to paracetamol,
• Inter-febrile period normal,
• Fever comes up every 5-6 hours,
• On day-2, cold and cough appears,
• And on day-3, fever seems to be abating
• Acute viral infection
:: Case Scenario contd . . . .

44. • Patient 2: high fever at onset,
• Poor response to paracetamol,
• Inter febrile period sick, fever rises every
4 hrs,
• On Day- 3 fever trend worsening- look
for…
• Bacterial tonsillopharyngitis

45. • Patient 3: high fever at onset,
• Erratic fever irrespective of
paracetamsol,
• Inter febrile period normal,
• Same trend continues even on Day-3.
• Malaria

46. • Patient 4 : mild to moderate fever at
onset,
• Initially fair response but not on Day-3
• Trend of fever rising by Day-3
• Inter febrile period sick
• likely be Typhoid fever

47. • Provisional diagnosis possible even without
physical signs; analyses fever pattern &
document it
• No fever = no acute bacterial infection = no
antibiotics
• No Antibiotics for first 3 – 4 days of fever
till disease localizes
:: FEVER RULES ::

48. • If empirical Antiboitics has to be
started, send relevant
investigations before starting
• Drug resistance is rare in
common community infections

49. • If rationally selected antibiotic fails,
look for alternate diagnosis while
trying second antibiotic
• If two antibiotics fail, acute bacterial
infection is ruled out – do not try third
antibiotic

50. Approach to fever as it evolves
• Day 1 - 2 : Rule out seriousness,
observe and paracetamol only
• Day 3 - 4 : Look for localization,
clinically or by relevant tests,
consider pneumonia, meningitis,
UTI, consider antibiotic therapy
after tests

51. • Day 5 – 7 : Assess progress of
fever, review, repeat tests,
observe and paracetamol only
• Day 8 – 10 : Reassess
periodically

52. • Additional relevant tests
consider change of Ab therapy
• Beyond 2 weeks
• Search for non infective cause /
chronic infection by relevant
tests TB at any age, SOJIA,
neuroblastoma