TUGAS PAPER

BAHASA INGGRIS
FAVER

DOSEN FASILITATOR
Ns. Stephanie Dwi Guna,S.Kep.M.Nurs

Diva Shabrina Salsabila (22031048)

PROGRAM STUDI S1 KEPERAWATAN

FAKULTAS KESEHATAN

UNIVERSITAS HANG TUAH PEKANBARU

2024
Machine Translated by Google

Sari
Practical
Pediatrics,
Instructions
Vol. 2, no. 2, August 2000 Sari Pediatrics, Vol. 2, no. 2, August 2000: 103 - 108

Fever in Children
Ismoedijanto

Fever in children is a problem that is still relevant for pediatric practitioners.

Fever is a sign of an increase in the set-point in the hypothalamus due to infection
or an imbalance between heat production and expenditure.
On the other hand, not all children infected will show symptoms of fever, the
younger the age, the less clear the clinical picture. Actions for children with fever
begin with considering whether there is an emergency, what the cause is and
whether the fever needs to be brought down immediately. In order for this action
to be precise and targeted, a grouping/classification of patients is needed so that
a general algorithm can be used. In each group there are still emergency criteria,
criteria for the type of infection that lead to the action taken, especially empirical
treatment and administration of antibiotics. The action taken should not be a
momentary action, but a continuous action, until the patient is free from the
problem. The decision to be treated must be followed by laboratory examination
and administration of empirical antibiotics. Follow-up actions will be adjusted to
the results of supporting examinations, the patient's response to treatment until
the problem is completely resolved.

Key words: Fever - hypothalamic set point - algorithm - empirical antibiotics

A
Children who suffer from fever constitute some of the seriousness suffered by the child with fever, whether the
the patients who go to pediatricians (19-30%)1 fever is a sign of a serious illness that must be treated
and in general no pediatrician feels comfortable seriously or not.
dealing with children with fever. Fever can be an early sign This article mainly focuses on the actions that need to
of infection, but fever can also be caused by metabolic be taken in patients with fever, according to their classification.
abnormalities and other causes . The problem of fever in
children is open, there are many unexpected possibilities.
There is no fixed procedure that is certain to work, the
existing instructions are only a kind of outline that must be Fever
translated with the depth of knowledge, creativity and art of
the doctor who handles it according to the patient's condition. The definition of fever is a condition where the body temperature is

above normal temperature, namely body temperature above 38º Celsius.

Every pediatrician should try to find
Correspondence
address: Dr. Ismoedijanto Sp.A (K)
Division of Infectious Diseases and Tropical Pediatrics, Child Health Sciences
Section FK-UNAIR/RS Dr. Soetomo, Jl. Prof. Dr. Moestopo no. 6-8. Surabaya,
Indonesia Telephone 031-5501748/5501680, Fax. 031-5938735.
Body temperature is the temperature of the viscera, liver and
brain, which can be measured orally, rectally and axillary.
1,2,3 How to measure temperature determines high and low
body temperature. Measuring temperature through the mouth
is done by taking the temperature in the mouth (sucking a
thermometer is done on cooperative children), the results are
almost the same as rectal temperature, but can be lower if
the breathing frequency is fast.
Temperature measurement through the rectum is carried out

103
Machine Translated by Google
in children under 2 years. The thermometer is inserted into the
rectum to a depth of 2-3 cm and the two buttocks are pressed
together, measurements are taken for 3 minutes.
The measured temperature is the body temperature that is close
to the actual temperature (core temperature). It is said to have a
fever if the temperature is above 380 C.
Measuring temperature through the armpit (axillary) can only
be done in large children who have a fairly wide axillary area, in
small children the armpits are narrow so they are affected by
outside temperature. Make sure the tip of the thermometer is right
in the middle of the axilla and measurements are taken for 5
minutes. The results of axillary measurements will be 0.5-1.00 C
lower than the results of measurements through the rectum.
Temperature is measured by feeling the skin, the areas touched
are areas with lots of blood vessels, such as the cheeks, forehead
and nape. Even though this method is less accurate (depending
on the condition of the mother's hands), the mother's touch is
quite reliable and is used as a sign of fever in the MTBS (Integrated
Management of Sick Toddlers ) program.
Body Temperature Regulation
Temperature is the result of the body's metabolic production
which is needed for smooth blood flow and to ensure that the
body's chemical reactions can run well (enzymes only work at
certain temperatures). As homeothermic creatures, children
always try to regulate their body temperature. Body temperature
is regulated by a mechanism involving the nervous system,
biochemistry and hormones. The hypothalamus receives internal
body temperature information from the temperature of blood
entering the brain and external body temperature information from
heat receptors in the skin. The thermostat in the hypothalamus is
set at a set-point of around 370 C with a range of about 10 C, and
the temperature is maintained by maintaining a balance of heat
generation or release. The efferent nerves from the hypothalamus
consist of somatic nerves and autonomic nerves, so that the
hypothalamus can regulate muscle activity, sweat glands, blood
circulation and lung ventilation.
The posterior hypothalamus is a regulatory center whose job is to
increase heat production and reduce heat expenditure. If the
outside temperature is lower, heat generation will be carried out
by increasing metabolism, with the muscle contraction/shivering
mechanism, heat output will be reduced by vasoconstriction of
blood vessels
104
Sari Pediatrics, Vol. 2, no. 2, August 2000
skin and reduced sweat production. The anterior hypothalamus is
the center for regulating heat production. If the temperature
outside the body is higher then heat output is increased by means
of vasodilation, evaporation (sweating), radiation (emitted), contact
(touch/compress), flow (from hot to cold areas), and
convection.2,3, 4 Children's body surface is relatively wider than
adults, so the evaporation and radiation processes are very
important, especially in tropical areas.
Causes of Fever
Fever is the result of an increase in the set point (due to infection)
or due to an imbalance between heat production and expenditure.
Fever in infection occurs due to microorganisms stimulating
macrophages or PMN to form PE (endogenic pyrogen factors)
such as IL-1, IL-6, TNF (tumor necrosis factor), and IFN
(interferon). This substance works on the hypothalamus with the
help of the prostaglandin-forming enzyme cyclooxygenase . It is
prostaglandins that increase the hypothalamic set point . In other
conditions, for example in tumors, blood diseases and
malignancies, collagen diseases, metabolic diseases, the source
of PE release is not from PMN but from other places. on age. The
younger the baby, the less ability it has to change set-point and
produce heat. Small babies often suffer from severe infections
without symptoms of fever.
Pathophysiology of Fever
Theoretically, an increase in temperature during infection is
considered beneficial, because blood flow is faster so that food
and oxygenation run more smoothly. However, if the temperature
is too high (above 38.5ºC) the patient begins to feel uncomfortable,
the blood flow is fast, the amount of blood to supply vital organs
(brain, heart, lungs) increases, so the blood volume to the
extremities is reduced, as a result the tips of the feet/hands
become palpable cold.
A high fever stimulates a very fast metabolism, the heart pumps
stronger and faster, and the breathing frequency is faster.
Dehydration occurs due to evaporation of the skin and lungs and
is accompanied by an imbalance
Machine Translated by Google
Sari Pediatrics, Vol. 2, no. 2, August 2000
electrolyte, which drives the temperature higher.
Tissue damage will occur if the body temperature is
higher than 410 C, especially in brain and muscle
tissue, which is permanent. This damage can cause
brain stem damage, seizures, coma and even paralysis.
Muscle damage occurs in the form of rhabdomyolysis
resulting in myoglobinemia.3,4,7
Fever Classification to Determine
Action
Fever can be the only symptom present in infected
patients. Heat can be produced excessively in
hyperthyroidism, aspirin intoxication or heat dissipation
disorders, for example heatstroke. Classification is
carried out based on the level of patient severity,
etiology of fever, and age. 5,6,8,9,10 Classification
based on patient age is divided into age groups
less than 2 months, 3-36 months and more than 36
months. Patients aged less than 2 months, with or
without signs of SBI (serious bacterial infection).
Infection often occurs without fever. Patients with fever
must be assessed whether they also show severe
symptoms. 11 According to the Yale Acute Illness
Observation Scale or Rochester Criteria, which
assesses whether there is an infection that is causing
an emergency. Blood examination (leukocyte and type
count) can be an indication of the need for treatment
and administration of empirical antibiotics.
Classification based on the duration of fever in children
is divided
into: 1. Fever less than 7 days (short fever) with clear
local signs, the etiological diagnosis can be made
by anamnestic, physical examination, with or
without laboratory assistance, for example acute
tonsillitis.
2. Fever for more than 7 days, without local signs, the
etiological diagnosis cannot be made by amannesis,
physical examination, but can be traced by laboratory
tests, for example typhoid fever.
3. Fever of unknown cause, most of which are viral
syndromes.
Apart from the classification mentioned above, there is
still another classification, namely the combination classification
using emergency signs and age as entry, followed by
clinical signs, duration of fever and area of exposure
as causal criteria, as shown in the algorithm below.
Management Approach
At certain stages, fever can benefit patients in the
sense that it can increase phagosity and reduce the
viability of germs, although existing research does not
yet support its clinical benefits.
However, parents' anxiety and doctors' doubts encourage
action to reduce fever, even though this action can obscure
the symptoms and the drugs used are not necessarily safe
from the risk of Reye's syndrome, salicylate intoxication and
liver disorders. The reduction in fever must be in accordance
with the classification of the cause, whether it is necessary to
lower the set-point or by other means.
Management of children with fever consists of
physical management and both symptomatic and
etiological treatment.
General Measures to Reduce Fever Symptomatically
Try to get the child to sleep or rest so that his
metabolism decreases. Sufficient fluids so that
electrolyte levels do not increase when evaporation
occurs. Good air flow, for example with a fan, forces
the body to sweat, channeling hot air to other places
so that the fever goes down. Do not use a stream that
is too strong, because the skin temperature may drop
suddenly. Ventilation/air flow regulation is important in
tropical areas. Remove thick clothing/blankets to
prevent radiation and evaporation. Dilate peripheral
blood vessels by wiping the skin with warm water (tepid-
sponging). Cooling with ice water or alcohol is less
useful (it actually causes vasoconstriction of blood
vessels), so it is difficult to distribute heat either through
evaporation or radiation mechanisms. In hyperthermia,
surface -cooling can help.
Another symptomatic measure is administering
fever medication. The way fever medicine works is by
lowering the set-point in the brain and making the
blood vessels in the skin dilate, resulting in excretion
105
Machine Translated by Google

Sari Pediatrics, Vol. 2, no. 2, August 2000

FEVER

Clinical signs of emergency:

Toxic, sensorium disturbance, meningismus, airway
obstruction, inadequate ventilation, circulatory failure,
hemorrhagic rash, hyperpyrexia

Yes No

Meningitis
Immunocompromised
Sepsis Yes No

Epiglottitis
Pneumonia
Pericarditis Sepsis Patient's age

Heat Stroke

0-2 months 2-6 months 6-36 bl >36bl

Local infection or Local bacterial infection

Sepsis The fever is not high and/or looks
Viral syndrome
Meningitis healthy viral exanthem disease
Poisoning
Local bacterial infection
Malignancy
Yes No
Miscellaneous collagen-vascular
diseases

Local bacterial infection Sepsis

Viral syndrome Meningitis
Immunization reaction Local bacterial infection
Viral syndrome
Immunization reactions
Poisoning Yes No

ISPA
Appears healthy and/or temperature
Otitis <39º C
Sinusitis

Pharyngitis
Gastroenteritis
Urinary tract infection

Arthritis, septic No Yes

Osteomyelitis
Varicella Bacteremia Viral syndrome

Rubeola Immunization reactions

Poisoning, malignancy
Kawasaki disease
Miscellaneous
neoplasms
Quoted from Henretig, 1993.4

Algorithm Chart for Fever in Children

106
Machine Translated by Google
Sari Pediatrics, Vol. 2, no. 2, August 2000
increased heat. A simple drug is salicylic acid and its
derivatives. The range of action of this drug is quite long, safe
for general consumption.
Several classes of pure antipyretics can reduce the
temperature if the child has a fever but do not cause
hypothermia if there is no fever, such as: acetaminophen,
acetosal, ibuprofen. Other drugs are drugs that are antipyretic
at low doses and cause hypothermia at high doses, such as
metamizole and drugs that can directly suppress the
temperature center (chlorpromazine), reduce shivering but
can cause hypothermia and hypotension. 3,4,8,12
Management of Caused Fever
Infectious Diseases
Treatment is carried out according to the etiological
classification. The difficulty faced is the different disease
patterns both in terms of geographic aspects and the age of
the patient. The chart above cannot simply be applied to
malaria endemic areas or dengue fever endemic areas. Once
again, the nature of exposure and geographic location greatly
influence the etiology of fever in children. The administration
of first antibiotics and hospitalization are also greatly influenced
by treatment facilities and supporting examinations. Each
hospital should have its own diagnostic and therapeutic
guidelines, depending on the epidemiological pattern of the
disease. In the 1998 IMCI study, in Indonesia the etiology of
fever in children was mostly infection (more than 80%).
Management of Fever According to Age
Management of fever in small babies has undergone significant
changes. In the group of babies under 2 months of age, the
common approach is hospitalization to receive empirical
antimicrobial treatment. In 1993, infectious, emergency and
pediatric health experts agreed to take a more conservative,
outpatient approach to these cases, if the risk of SBI was low.
One approach that can be taken to reduce care is to use
filters: the Yale Acute Illness Observation Scale or criteria
Rochester. In this group, if laboratory results show signs of
infection (blood leukocytes <5,000 or >15,000, blood neutrophil
count>1500, urine leukocytes above 10/lpb, feces leukocytes
>5/lpb), the child is immediately admitted to the hospital and
immediately receives antimicrobial treatment. empirically. In
the group that does not meet these criteria, there are 2
options, namely: 1. do a urine culture, blood culture, cerebro
spinal fluid culture, give ceftriaxon and ask for control again
after 24 hours. 2. Do a urine culture and observe first.
In children under 28 days of age, the approach should be
more aggressive by immediately admitting them to the hospital
to receive empirical antimicrobial therapy. In the 3-36 month
age group, the risk of bacteremia in children with fever is
around 3-11%. Bacteremia does not occur in this group if:
leukocytes are <15,000 with a temperature of >390 C, while
the possibility of bacteremia will be 5 times greater if
leukocytes are >15,000. In this latter group, blood culture was
immediately carried out and ceftriaxon was administered. In
the group of children over 36 months, treatment can be carried
out etiologically, paying attention to emergencies.
In the end, whatever is recommended will still give rise
to debate. There is no one standard that must be adhered to
as a guide. All actions must still be carried out based on a
sharp and focused history, and a thorough physical
examination. Doctors' tendencies to act are greatly influenced
by the experience they have and the breadth of knowledge
they have. The choice between carrying out tests or not,
administering antibiotics or observing, really depends on the
doctor's stance and personality. • Children who appear toxic
must receive immediate action • The younger, the higher the
clinical uncertainty • Children who do not appear toxic can be
difficult,
therefore require very close observation
• There is no need to always carry out supporting examinations
and if supporting examinations are carried out, actions
must be in accordance with the results • Carefully record
what is done or not done • There are no standard rules that
must be
obeyed
107
Machine Translated by Google
Bibliography
1. Kliegman RM, Behrman RE. Fever. In: Behrman RE, Kliegman RM,
Nelson WE, Vaughn VC, editors.
Nelson textbook of pediatrics, 14th edition, Philadelphia: WB
Saunders, 1992;p.647-56.
2. Sinclair JC. The control of body temperature and the pathogenesis of
fever: developmental aspects. In: Nestle Annals: Fever in children.
Vevey, Switzerland: Nestle Nutrition SA, 1984;p.1-10.
3. Hardiono D Pusponegoro. Management of fever in
child.
4. Henretig FM. Fever. In: Fleisher GR, Ludwig S, editors. Textbook of pediatric
emergency medicine; 3rd ed. Baltimore: Williams and Wilkins, 1993;p.202-
10.
5. Dechovitz AB, Moffet HL. Classification of acute febrile illnesses in
childhood. Clin Pediatr 1968; 7:649.
6. Department of Health. Integrated management of sick toddlers.
108
Sari Pediatrics, Vol. 2, no. 2, August 2000
Classification and action determination module, 1999.
7. Mortimer JG. Fever of unknown origin in children: Investigation and
management. J Paed Obs and Gyn, 1981; 7:27-32.
8. Darwis D, Ismail S. Management of hyperpyrexia in children. In: Iwan
Darmansyah and Suharti KS, editors. Fever management,
pharmacology section of FKUI and IDI JAKPUS, Jakarta:
1982;p.63-70.
9. Schmitt BD. Fever phobia: Misconceptions of parents about fevers.
Am J Dis Child 1980; 134:176-81.
10. Finkelstein J, Christiansen CL, Platt R. Fever in pediatric primary
care: Occurrence, management and outcomes.
Pediatr 2000; 105:260-6.
11. Prober CG. Managing the febrile infant: No rules are golden. J Paed
Obs and Gyn 2000; 26:13-20.
12. Santoso SO. Mechanism of action and selection of antipyretic drugs.
In: Iwan Darmansyah and Suharti KS, editors. Management of
fever. Pharmacology Section of FKUI and IDI, Jakarta, 1982;p.1-8.