fever in children

1. THE CHILD
WITH A FEVER
Dr Sayed Ismail
Professor of pediatrics

2. LEARNING
OBJECTIVES
• Recognise ‘red flags’ in the history or examination
that indicate serious bacterial infection (SBI)
•
• List the differential causes of acute, chronic and
recurrent fever
• The initial investigations required in child presenting
with fever
• Understand the management of common causes of
fever in childhood
• Recognise when referral and hospital admission

3. BACKGROUND
• Fever is by far the commonest presenting
complaint in childhood and a cause of parental
anxiety
• Practitioners need the ability to distinguish the
acutely unwell child with a potential SBI from the
well child with a common viral illness.
• SBIs include
• Meningitis , sepsis,
• Osteomyelitis ,septic arthritis,
• Cellulitis,
• Urinary tract infections
• Pneumonia
• Enteritis.

4. Patients at high
risk of SBI
• Infants under 2 months of age
• Transplant recipients
• Immunosuppressed children
• Asplenic patients

5. ACUTE PHARYNGITIS
• Children with viral pharyngitis are non- toxic and may
present with a fever, sore throat and refusal to feed.
• Examination reveals an erythematous pharynx with
cervical lymphadenopathy.
• The commonest causative agent is a common virus.
• Viral infection may be associated coryzal symptoms,
diarrhoea or non- specifi c generalised rash.
• Splenomegaly, palatal petechiae and generalised
lymphadenopathy suggest Epstein–Barr virus
infection.

6. Group A beta- haemolytic
streptococcus
• accounts for 15%–30% of cases.
• It has a rapid onset. No coryzal signs . There
may be associated headache, abdominal pain,
palatal petechiae, swollen and erythematous
uvula and tonsillar exudates with tender cervical
lymphadenopathy.
• Complications of GABS
• Suppurative :
• otitis media
• sinusitis
• peritonsillar and retropharyngeal abscesses
• suppurative cervical lymphadenitis.
• Non- suppurative complications :
• acute rheumatic fever
• acute glomerulonephritis.

7. ACUTE OTITIS MEDIA
• Children may present with fever, ear pain (non- verbal
infant may pull at his or her ears), anorexia and irritability.
There may be associated coryzal symptoms or vomiting or
diarrhoea.
• With AOM, examination reveals a bulging, diffusely
erythematous eardrum with loss of the light reflex and
anatomical landmark.
• AOM is often over diagnosed. A red tympanic membrane
is a common finding in children with viral upper
respiratory tract infections (URTIs) and in the crying child

8. • Younger age, because of an immature, short and horizontal
eustachian tube
• Immunodeficiency
• Recurrent URTIS
• Trisomy 21
• Craniofacial abnormalities including cleft palate
• Attendance at day care or smoking in the home.
• Viral agents are implicated in up to 50% of cases.
• Common bacterial causes include Streptococcus pneumoniae,
Haemophilus infl uenzae and Moraxella catarrhalis.
• If associated with pharyngotonsillitis it is likely to be secondary to
S. pneumoniae and if associated with purulent conjunctivitis it is likely to be
secondary to H. influenzae
Risk factors for otitis media include

9. Complications of otitis media include
• Following an episode of AOM, 70% of patients will still have
an effusion at 2 weeks, 40% at 1 month, 20% at 2 months
and 5%–10% at 3 months.
• Perforation resulting in ear discharge, which
often relieves the pain
• Conductive hearing loss
• Acute suppurative labyrinthitis
• Facial nerve palsies
• Acute mastoiditis
• Intracranial spread of infection: venous sinus
thrombosis, meningitis, subdural or extradural
abscess.

10. PNEUMONIA • Viruses are the most common causes of pneumonia in children
< 2 years of age.
• In school- age children S. pneumoniae and Mycoplasma
pneumoniae are most common, but in 50% of children no clear
aetiology can be discerned.
• Typically, the child presents with fever (sometimes rigors) that
is associated with a new- onset cough, which may not be
productive in the early stages.
• Chest pain reflects the pleural involvement and abdominal pain
may reflect lower lobe disease.
• The typical child has difficulty in breathing and systemic
symptoms of anorexia, lethargy and headache.
• Physical examination reveals fever, tachypnoea and chest
retractions
• The presence of consolidation is suggested if auscultation
reveals diminished air entry, localised crackles, bronchial
breathing and occasionally a pleural rub.
• The finding of wheeze is suggestive of mycoplasma infections

11. • Pulse oximetry is recommended for those children with an
elevated respiratory rate, to assess the need for supplemental
oxygen.
• Pneumonia is assessed as mild to moderate in infants if:
• temperature is <38.5°C
• respiratory rate is <50
• recession is mild , the infant is taking full feeds.
• Pneumonia is assessed as severe in infants if the following are
present:
• temperature is >38.5°C
• respiratory rate >70 breaths/min
• moderate to severe recession ● nasal flaring ● cyanosis ●
intermittent apnoea ● grunting respiration ● not feeding ●
tachycardia
• capillary refill time ≥2 seconds.

12. The commonest causative organism is Escherichia coli.
Infants present with non- specific symptoms including fever,
irritability, lethargy, poor feeding or febrile convulsions.
Children present with more classical symptoms of cystitis with
dysuria, and urgency and frequency or a reluctance to void.
There may be a return of enuresis. Fever is often absent or low
grade.
Children with pyelonephritis present with systemic symptoms
including fever, vomiting and abdominal or fl ank pain.
Predisposing factors include:
● congenital structural abnormalities
● incomplete bladder emptying or infrequent voiding
● constipation.

13. • In 30% of children with UTI,
vesicoureteric refl ux (VUR) is present.
VUR is a developmental anomaly of the
vesicoureteric junction.
• There is often a positive family history. There are five
described grades of VUR.
• Grade I: reflux without dilatation into distal ureter
• Grade II: reflux with dilatation into proximal ureter
• Grade III: reflux into renal pelvis with dilatation
• Grade IV: further dilatation and distortion of calyces
Grade
• V: hydronephrosis

14. MENINGOCOCCAL DISEASE
• Meningococcal disease has two main clinical presentations:
meningitis and septicaemia, which often occur together.
• Septicaemia is more common and more dangerous. It is
more likely to be fatal when it occurs without meningitis.
• Not all children with meningococcal disease present with a
fever.
• The presentation of early meningococcal disease can be
difficult to differentiate from common viral illnesses.
• 50% of children presenting to their primary care physician
with meningococcal disease are sent home on their first
visit. These children are more likely to die

15. • Meningitis can present with severe
headache, neck stiffness, photophobia,
decreased level of consciousness or
seizures.
• Positive Kernig and Brudziniski signs
• Septicaemia can present with a rash,
tachycardia, tachypnoea, cool
peripheries, prolonged capillary refi ll
time, hypovolaemia, limb or joint pain,
abdominal pain or decreased level of
consciousness.

16. • The presentation in infants is very non- specific
• There may be a history of poor feeding, irritability, a high-
pitched cry, abnormal tone, lethargy, a tense and bulging
fontanelle and/or cyanosis. Some children may complain of
painful feet and be reluctant to walk
• The onset of the rash in meningococcal disease occurs at a
median of 8 hours after the start of the illness in infants.
• The presence of purpura is highly predictive of
meningococcal disease and should be considered an
emergency requiring prompt evaluation and treatment.
• Purpura fulminans is a severe complication of meningococcal
disease occurring in approximately 15%–25% of those with
meningococcemia. It is characterised by the acute onset of
cutaneous haemorrhage and necrosis due to vascular
thrombosis and disseminated intravascular coagulopathy.

17. Long- term complications of
meningococcal disease include:
● Hearing loss
● Neurological impairment
including learning, motor and
neurodevelopment defi - cits
and epilepsy
● orthopaedic damage
including amputation, growth
plate damage and arthritis
● post- necrotic tissue/skin loss
● renal impairment
● psychiatric and behavioural
problems.

18. • EXAMINATION
• Assess the overall appearance of child by
observation: toxic or well looking?
• Assess for signs of meningism
• Vital signs including temperature should be
recorded
• Expose the child fully and perform a head-
to- toe examination
• Ear, nose and throat: otitis media,
pharyngitis, stomatitis, cervical
lymphadenopathy
• Joint exam: swelling, erythema, paresis
• Skin exam: rash, erythema, tenderness
• Respiratory exam: signs of respiratory
distress, wheeze, crepitations
• Gastrointestinal exam: abdominal
tenderness, masses

19. Recognising the sick child (Toxicity)
• The ABCD can also be used to assess toxicity where
• ‘A’ is for arousal, alertness or decreased activity,
• ‘B’ is for breathing difficulties (tachypnoea, increased work of
breathing),
• ‘C’ is for poor colour (pale or mottled), poor circulation (cold
peripheries, increased capilliary refill time) or cry (weak or
high pitched),
• ‘D’ is for decreased fluid intake (less than half normal) and/or decreased
urine output (fewer than four wet nappies per day).
• The presence of any of these signs places the child at high risk for serious
illness

20. • Red flags ABCDE
• A Alerness
• B Respiratory distress
• C Signs of impending shock
• D Seizures , Altered level of consciousness ,
Meningism
• E Petechiae rash

21. DIFFERENTIAL DIAGNOSIS
• Common causes
• Viral URTIs: Cough, runny nose
• Pharyngitis : Sore throat, refusal to feed, erythematous pharynx, cervical
lymphadenopathy
• Otitis media : Irritable, vomiting or diarrhoea, pulling at ear, may present without
fever, otorrhoea, associated coryzal symptoms
• Viral exanthems : Coryzal symptoms, rash, lymphadenopathy
• Viral pneumonia : Temperature usually <38 Gradual onset ,bilateral crepitation ,
wheezing
• Viral gastroenteritis: Vomiting, watery diarrhoea, dehydration, absence of blood per
rectum

22. • Serious bacterial infections
• UTIs Very non- specifi c presentations, may present without fever, failure to thrive, malodorous urine,
poor feeding, vomiting, jaundice, family history of VUR
• Bacterial pneumonia :Tachypnoea, signs of respiratory distress, localised crepitations
• Meningococcal disease :Toxic, poor perfusion, lethargy, apnoea, bulging fontanelle, high- pitched cry,
hypotonia, listlessness, poor feeding, seizures, fever or hypothermia, vomiting, cool peripheries
• Encephalitis :Altered level of consciousness, seizures, headaches, irritability Septic arthritis and
osteomyelitis Paresis, abnormal position of limb, pain elicited on passive movement, swelling
• Cellulitis Localised erythema, increased temperature
• Bacterial gastroenteritis Vomiting, bloody diarrhoea Septicaemia Toxic, poor perfusion, hypotension,
altered level of consciousness
• Orbital cellulitis Erythema of eyelids, pain on eye movement, reduction in visual acuity, proptosis

23. Prolonged fever
• Infections Epstein–Barr virus, malaria, Lyme disease, Rocky Mountain spotted fever,
bacterial endocarditis, tuberculosis, rheumatic fever, cat scratch disease, HIV,
abscesses, systemic fungal infection
• Inflammation Systemic juvenile idiopathic arthritis, systemic lupus erythematosus,
Kawasaki’s disease
• Neoplasia Leukaemias, lymphomas, metastases, solid organ tumours

24. Recurrent fever (occurring at regular intervals)
• PFAPA syndrome (periodic fever, aphthous ulcers, pharyngitis, cervical lymphadenopathy)
Fevers occur every 21–28 days
• Cyclic neutropenia Fevers occur every 21–28 days
• Relapsing fever Fevers occur every 14–21 days
• Familial Mediterranean fever Fevers occur every 7–21 days
• Hyperimmunoglobulinaemia D syndrome Fevers occur every 14–28 days
• Epstein–Barr virus Fevers occur every 6–8 weeks

25. INVESTIGATIONS
In an unwell infant under 2 months of age with a fever, A full septic
workup should be performed.
Decisions to treat for presumed sepsis should not be based on
laboratory investigations alone. Decisions should be based on the
clinical picture, i.e. a child who is clinically unwell and toxic should be
commenced on antibiotics for presumed SBI, irrespective of whether
the white cells or inflammatory markers are raised.

26. Sepsis work up
FBC: a child with a WCC of less than 15 × 109 is
considered to have a lower risk of SBI
A neutrophil count of >10 000 is considered high- risk
for SBI
Urea and electrolytes: may show signs of dehydration
C- reactive protein: may be raised
Blood cultures may show growth of bacteria
Lumbar puncture
Clean- catch urinalysis and culture
Chest X- ray: may show signs of consolidation or
collapse
Notes :
• Automated blood culture systems can now
identify most bacterial pathogens in <24
hours.
• Most recently, nested multiplex polymerase
chain reaction (PCR) testing of positive blood
cultures can identify bacterial pathogens and
antimicrobial resistance genes in
approximately 1 hour
• Similarly, multiplex meningoencephalitis
panels can provide results on CSF for 14
potential CSF pathogens in 1 hour,
• rapid viral PCR and multiplex respiratory viral
testing

27. Notes
• Tepid sponging should be discouraged. Parents often use cool water and cause peripheral
vasoconstriction of the skin, thus preventing heat loss through the skin
• Anxious parents may present early to their family doctors with their febrile child. If no
cause is apparent, explain that symptoms may evolve over the following hours.
• Some children with sepsis will present with a normal or even low temperature therefore
do not assume that all septic children will be febrile.
• not all fever is reflective of infection. Clinical conditions such as Kawasaki’s disease and
collagen vascular disease present with fever and symptoms evolve over time

28. • Fever and rash
• Do not assume that all rashes are part of a viral syndrome.
• Doctors need to be familiar with specific rashes inclusive of erythema
multiforme, erythema nodosum and those that reflect bacterial infections

29. • Fever in the child with incidental neutropenia.
• Pitfall: the finding of neutropenia in the child with fever may reflect severe sepsis;
however, if the child is not clinically septic, careful follow- up is advised, as a
percentage of these children will present with leukaemia within a few months.
• Fever in the child diagnosed with a malignancy who is neutropenic.
• Treat this child with intravenous antibiotics promptly while awaiting culture reports
(follow clinical protocol for antibiotic regimens). Th is is a clinical emergency.

30. Treatment
of fever
• Parents often focus on fever reduction as the sole
goal of addressing the needs of the febrile child;
however, for the doctor, fever most often reflects
the presence of an illness, so the aetiology is the
primary focus, and subsequently the focus is on
fever treatment.
• The two most common medications used to
reduce fever are paracetamol and ibuprofen. Both
are effective in fever reduction, and combined
treatment or alternating treatment is more eff
ective than single treatment

31. Treatment of
specific
conditions
• Sick infant less than 2 months of age
• Full sepsis work up
• Low threshold for hospital admission
• See last slides

32. Pharyngitis
Viral pharyngitis requires adequate hydration
and temperature control.
Group A beta- haemolytic streptococcal
infection should be treated to minimise the
risk of complication, reduce the duration of
symptoms and shorten the infectious period.

33. Acute otitis
media
• Most cases of otitis media are viral in origin and will
resolve spontaneously in 10–14 days .
• Antibiotic is giver for infant less than 6 month and
severe cases
• watchful waiting is a more prudent approach for
older children (offer antibiotic treatment if no
improvement after 3 days).
• A percentage of children will develop persistent
otitis media with effusion, which may impair their
speech development because of associated hearing
deficit, and these children require referral to ENT
specialist.
• Ventilation tubes (VTs) offer a temporary solution
for these children
• Patients who have VTs inserted should not be
restricted from swimming.

34. Pneumonia
Confirmed by chest X- ray
Admission to hospital is determined by the clinical
state of the child.
Oral amoxicillin is effective for most children admitted
to hospital and is not inferior to intravenous
antibiotics
For those with suspected mycoplasma infection,
erythromycin should be administered.
Cough suppressant and decongestants are not
warranted, but analgesia should be provided for fever
and pain

35. Urinary
Tract
Infections
In a child with a UTI, ensure that there is a positive urine culture
to guide antibiotic treatment.
Ensure: high fluid intake
Avoidance of constipation
Regular voiding: at least five times a day
Complete bladder emptying
Recommend good perineal hygiene: girls should wipe from front
to back, avoid soap, bubble bath, and shampoo in the perineal
area and wear cotton panties.
Cranberry juice has been shown to have a modest effect in the
reduction of UTI frequency
.

36. If the child is toxic give intravenous antibiotics such as
cefotaxime or ceftriaxone for 2–4 days followed by oral
antibiotics for a total duration of 10 days
For infants and children 3 months or older with cystitis/lower
urinary tract infection:Treat with oral antibiotics for 3 days.
Trimethoprim, nitrofurantoin, cephalosporin or amoxicillin
may be suitable.
In children with VUR the aim is to reduce UTI occurrence
through the use of prophylactic antibiotics, to prevent further
damage of renal function
Antibiotics for UTI

37. FOLLOW- UP
Encourage parents to seek medical help
again if the illness gets worse, even if this
is shortly after the patient was seen.
It may be necessary to suggest follow- up
within a specified period (usually within
4–6 hours).
Ensure that the parents understand how
to get medical help after normal working
hour

38. • Under 2 months of age with a
fever, there should be a very low
threshold for referral to hospital
• Fever with petechiae
WHEN TO REFER?

39. Clinical Practice Guideline:
Evaluation and Management of Well-Appearing Febrile
Infants 8 to 60 Days Old

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