Fever

Definition of Fever
• Fever is an elevation of body temperature that exceeds
the normal daily variation, in conjunction with an
increase in hypothalamic set point.
• Fever is defined as a rise in axillary temperature of
more than 37.2°C or 99⁰F
• most common reason for children to be taken to the
doctor
• cause of concern for parents and care givers.
• occurs in response to infection, injury, or inflammation
and has many causes.
• can be a result of a simple self-limiting infection or a
life-threatening disorder
 Pathophysiology
• The normal body temperature is maintained by a
complex regulatory system in the anterior hypothalamus.
• Development of fever begins with the release of
endogenous pyrogens into the circulation as the result of
infection, inflammatory processes (rheumatic disease),
or malignancy
• Pyrogens
– Exogenous pyrogens: Bacteria, Virus, Fungus, Allergen
– Endogenous pyrogens: Immune complex, lymphokine
like IL1, TNF, IL6
 Benefits of fever
• Protective role in the immune system
– Inhibition of growth and replication of microorganisms
– Aids in body’s acute phase reaction
– Enhanced immunologic function of wbc’s
– Promotion of monocyte maturation into macrophages
– Promotion of lymphocyte activation and antibody
production
– Decreased availability of free iron for bacterial
replication
HOW TO TAKE A CHILD’S TEMPERATURE

• A child's temperature can be taken

– from the rectum, ear, mouth, forehead, or
armpit
– It can be taken with a glass or digital
thermometer.
 Pattern of fever
• Continuous fever: Fever that does not fluctuate more than 1°C in 24
hours is called continuous fever. Eg pneumonia, typhoid, urinary tract
infections and infective endocarditis.
• Remittent fever: Fever that fluctuates more than 1°C in 24 hours but
never touches baseline is referred to as remittent fever. Eg typhoid and
infectious mononucleosis.
• Intermittent fever: Fever that fluctuates and touches baseline in between
febrile phases is called intermittent fever. Eg Malaria caused by
Plasmodium vivax results in fever every third day(tertian) and that caused
by Plasmodium malariae results in fever every fourth day(Quartan).
• septic fever: Fever variation between the highest and lowest
temperatures is very large and more than 5°C. Eg septicemia.
• Pel Ebstein fever: The febrile and afebrile periods alternate and follow a
definite pattern. For example, in Hodgkin’s disease and other lymphomas,
fever for 3 to 10 days is followed by a fever-free period of 3 to 10 days,
with the same cycle repeating.
• Fever of unknown origin(FUO) is defined as a fever >
101⁰F (38.3⁰C) lasting for 3 wks or more for which no
cause is apparent after 1 week of outpatient
investigation. Most common cause includes: enteric
fevr, malaria, TB, UTI, leukemia, Juvenile rheumatoid
arthritis
 Causes of fever
Infectious causes Non infectious cause
• Malaria • Juvenile rheumatoid
• Dengue arthritis(JRA)
• HIV • Systemic lupus
• Typhoid erythematosis(SLE)
• Leptospirosis • Acute rheumatic fever(ARF)
• Brucelosis • Collagen vascular disease
• Q fever • Malignancy
• Liver abscess • Drug fever
• Histoplasmosis • Central thermoregulatory
disorder
• Endocarditis
• Munchausen syndrome by
• Dental infection
proxy
 Fever with rash
• Macular or maculopapular rash
– Measles, rubella, dengue, roseola infantum, erythema toxicum, drug
rash
• Diffuse erythema with peeling and desquamation
– Stevens-Johnson syndrome, toxic epidermolysis, Kawasaki disease,
scarlet fever
• Vesicular rash
– Chicken pox, hand-mouth-foot disease, herpes simplex, herpes zooster
• Petechial/ purpuric rash
– Meningococcemia, dengue hemorrhagic fever, Henoch-Schonlein
purpura
• Urticarial rash
– Scabies, insect bites, pediculosis
• Nodular rash
– Erythema nodosum due to tuberculosis, lepromatous leprosy,
molluscum contagiosum
Nemonics: Very Sick People Must Take Double Eggs

Days of appearance of rash after fever

• V(day 1)= Varicella
• S(day 2)= Scarlet fever
• P(day 3)= Pox
• M(day 4)= Measles
• T(day 5)= Typhus
• D(day 6)= Dengue
• E(day 7)= Enteric fever
 Approach to fever
• HOPI • Underlying Diseases
– Onset, grade, duration, – Splenectomy
pattern, timing,
– Surgical Implantation
associated symptoms,
aggravating and relieving of Prosthesis
factors, – Immunodeficiency
• Personal History – Chronic Diseases
– Age, sex • Cirrhosis
– Place of origin, Travel • Chronic Heart
History Diseases
– Habits: Consumption of
• Chronic Lung
Unpasteurized Dairy
Diseases
Products.
 Approach to fever

• Drug and allergy • Associated Symptoms

History – Shaking, chills
– Ear pain, Ear drainage,
– Antipyretics
Hearing loss
– Immunosuppresants – Visual and Eye Symptoms
– Antibiotics – Sore Throat
• Family History – Chest and Pulmonary
Symptoms
– TB in the Family
– Abdominal Symptoms
– Recent Infection in the – Back pain, Joint or Skeletal
Family pain
 Look for danger signs of fever
• Changes in behaviour • Stiff neck
• Severe headache • Stomach pain
• Constant vomiting or • High pitched cry
diarrhoea • Swelling on the soft spot
• Skin rash of head
• Dry mouth • Irritable
• Sore throat that doesn’t • Unresponsiveness or limp
improve • Not hungry
• Earache that doesn’t • Wheezing or problems
improve breathing
 Investigation Physical Examination
• CBC- TC,DC, Hb, PCV, – Vital Signs
Platelets – Neurological Exam
• Urine RE/ME, Urine C/S – Skin Lesions, Mucous
• ESR Membrane
• CRP – Eyes
• Blood C/S – ENT
• CSF culture – Lymphadenopathy
• Serological test – Lungs and Heart
• X ray – Abdominal region
• USG (Hepatomegaly, Splenomegaly)
– Musculoskeletal
 Management of fever
• General measures
– Drinking plenty of clear fluids to replace fluids lost by
sweating, vomiting or diarrhoea - either water, or an
oral rehydration solution which contains electrolytes
– Changing clothing and bed linen frequently.
– Tepid baths (but don't use cold water, as this can
increase core body temperature by cooling the skin
and causing shivering).
– Keeping clothes and blankets to a minimum.
– Avoiding hot water bottles or electric blankets
(which may raise body temperature further).
– Ventilating the room.
 Management of fever
• Drugs to lower fever
– Typically, the following drugs are used
• Acetaminophen(PCM), given by mouth or by
suppository. First line drug. Pediatric dose: 10-
15mg/kg q4-6h
• Ibuprofen, given by mouth. Pediatric dose: 5-10
mg/kg/dose orally every 6 to 8 hours as needed (for
greater than 6 months of age)
Assessment of fever acc to IMNCI
 Classification of fever acc to IMNCI

• High malaria risk

• Low malaria risk
• If measles now or within last 3 months
Approach and management of fever acc to IMNCI
Approach and management of fever acc to IMNCI
Approach and management of fever acc to IMNCI
• THANK YOU