Fever resident survival guide (pediatrics)

| Resident
Survival
Guide

|
|
|

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:  Marufa Marium, M.B.B.S[2]

Synonyms and keywords:

Fever resident survival guide (pediatrics) Microchapters

Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

## Overview

[edit | edit source]

Fever in Children is exceptionally recurrent presenting complaints in pediatric department or emergency department or primary care comprising of 15-25%. Most of the parents has immense concern regarding this complaints. Physiologic thermoregulatory elevation of body core temperature above the standard quotidian temperature may termed as fever. As an ancient presenting complaints fever is thought to be an evil spirits by most of the ancient civilizations for example Egyptian, Greek, Mesopotamian etc. There were various ideology regarding fever as the Roman used to worship a God of fever, whereas in the middle age, by Persian famous scholar Avicenna, fever was explained as increased temperature produced by heart diffusing throughout the whole body. 'The Medical renaissance' removed the confusion by describing fever as a physiologic response of an infection in eighteenth century. A number of factor influences fever for instances Chronological age, stage of activity, durational variations(lower body temperature in morning, and higher in late afternoon), food intake etc. The body core temperature is estimated from different parts of body. American Academy of pediatrics has provided information on the accuracy of rectal temperature in infants under four years. But due to its uneasiness of patients oral temperature is the most preferred method in usual population whereas in children under 5 years axillary temperature is sensitive in clinical settings. The mechanism of fever comprises of several components, it includes-Toxic insult/ Infection / inflammatory mediatiors → Macrophage/endothelial cells → Pyrogens(Exogenous: LPS from Gm- organism/ Toxin from Microorganism and EndogenousIL-6/IL-1/IFN-a/TNF-a/Ciliary neurotropic factor/Muramyl Dipeptidase/Enterotoxins) and Cryogens(IL-10, Hormones like MSH, CRH, Neuropeptide Y, Bombesisn, Thyroliberin) → endothelial cells of Hypothalamus → PGE2 → Cyclic AMP → Elevation of Thermoregulatory set point → Heat conservation and production by → fever. The most common cause of fever is infection of any variety like bacterial, viral, fungal, parasitic, other causes are due to malignancy, autoimmune, medications etc.

## Causes

[edit | edit source]

### Life Threatening Causes

[edit | edit source]

Life-threatening causes of fever includes red flag symptoms or signs (Impaired intake of food, Fussiness, Irritability, Inconsolable crying, Lethargy, Poor moto stimuli response, pallor or cyanosis or or ruddiness mottling of skin, tachycardia, tachypnea, Delayed CRT/ Hypovolemia with reduction in urine output, Bulging fontanelle, Petechial or purpuric or blanching rash, Nuchal rigidity, Rigors, Drooling, tripod position, Vomiting) along with high body core temperature that may result in death or permanent disability within 24 hours if left untreated.[1][2][3][4][5]

* Sepsis
* Toxic Shock Syndrome
* Scalded Skin Syndrome
* Meningitis
* Pneumonia
* Influenza
* Stevens-Johnson syndrome/ Toxic Epidermal Necrolysis
* Acute Rheumatic Fever
* Typhoid Fever
* Malaria, Dengue, West Nile Fever
* Encephalitis
* Osteomyelitis
* Septic Arthritis
* Mastoiditis
* Retropharyngeal Abscess
* Kawasaki Disease
* UTI
* Orbital Cellulitis
* Central line associated fever

### Common Causes

[edit | edit source]

* Infectious causes are bacterial, viral, parasitic, fungal whereas noninfectious causes include autoimmune disease, malignancy, drug fever, congenital cause.[6]
* Infectious:
* Bacterial: Tonsillitis, abscess, sinusitis, tuberculosis, cellulitis/erysepelas, endocarditis, pyelonephritis, Shigellosis/bacilary dysentry, staphylococcal food poisoning, V.Parahemolyticus/ V.vulnificus/V.Cholerea infection, mycoplasma, listeriosis, brucellosis, bartonella, leptospirosis etc.
* Viral: Adenovirus, RSV, CMV, EBV, HIV, HSV, Hepatitis virus, Parvo Virus, Enterovirus, Measles Virus, Mump Virus, Parainfluenza, Noro virus etc.
* Fungal: Cryptosporidium, Candia, Blastomycosis, Histoplasmosis, Pneumocystis Jiroveci.
* Parasitic: Malaria, Toxoplasmosis, Amebiasis, Ehrlichiosis, Q fever, Leishmaniasis, Helminthiasis, Lyme disease, Rocky Mountain spotted fever.

Non-infectious:

*     * Malignancy / Hematologic: Leukemia, Lymphoma, Sickle cell anemia, hemophilia, cyclic neutropenia, Langerhans cell histiocytosis.
* Genetic / Congenital: Familial Mediterranean fever, TNF associated periodic fever syndrome, Neonatal Onset multisystem inflammatory disorder (NOMD), Familial cold autoinflammatory syndrome, familial dysautonomia.
* Autoimmune: Systemis juvenile idiopathic arthritis/still disease, granulomatosis with polyangitis, behcet disease, polyarteritis nodosa, henoch-scholen purpura, antiphospholipid antibody syndrome, SLE, sarcoidosis, hyperthyroidism, benogn giant cell lymhnode hyperplasia/castleman disease, , juvenile dermatomyositis.
* Other: Diabetes incipidus, pancreatitis, serum sickness, drug fever etc IG4 related disease, factious fever, hypothalamic dysfunction.[7][8]

## FIRE: Focused Initial Rapid Evaluation

[edit | edit source]

Focused Initial Rapid Evaluation is done following several criteria or guideline to identify and quantify the risk in febrile infants/children and clinically manage patients according to risk.[9][10][11][12][13][14] The criteria or guidelines are:

* Rochester criteria (Infants up to 60 days of age)
* Philadelphia criteria (Infants from 29-60 days of age)
* Boston criteria(Infants of 28-89 days of age)
* The 2007 NICE traffic light system
* 'Red features' of 2013 NICE traffic light system
* The Dutch college of general practitioner guidelines
* Yale observation scale
* A pneumonia rule
* A meningitis rule

After evaluation with these criteria and guidelines, extensive clinical examination, Continuous monitoring, laboratory findings, parental reassurance and guidance, safety measurements aids adjunctive diagnostic approach in evaluation febrile infants/children.

## Complete Diagnostic Approach

[edit | edit source]

Shown below is an algorithm summarizing the diagnosis of fever in infants and young children according the the American Academy of Family Physician guidelines.[15][16][17]

## Diagnosis

[edit | edit source]

Shown below is an algorithm summarizing the diagnosis of Fever in children.

{{familytree | | | | | | | | | | | | B01 | | | | | |B01=Physical Examination: •General appearance: Restlessness/ Irritable/lethargic/Inconsolable crying/fussiness?
• Skin: decreased or normal turgor/ pallor/cyanosis/Mottling/ruddiness/rash?
• HEENT: Headache/Dizziness/Bulging fontanelle/nuchal rigidity/rigors/rhinorrhea]]/otorrhoea/earche/erythematous tympanic membrane/orbital cellulitis/tender sinus point?
• CVS: Dysrhythmia/Tachycardia?
• Respiratory: Tachypnea/ Hypoxemia, Compensatory hypoventilation, Wheezing, stridor, rhonchi, crackles, [[increased or decreased fremitus Pulmonary microatelactasis, Increased V/Q mismatch
• GI: Nausea/vomiting/diarrhea?
• GU: Urine output, frequency?
• CNS: Confusion, loss of consciousness/Mental obtundation, Neuromuscular excitability/Muscle cramps, Poor motor stimuli response, Tremor, tingling and numbness in extremities, Weakness? }}

| History: • H/O Familial Mediterranean fever/TNF associated periodic fever syndrome/Neonatal Onset multisystem inflammatory disorder (NOMD)/Familial cold autoinflammatory syndrome/familial dysautonomia?
• Recent or current Antibiotics/Sulfa containing drug/diuretics/antiepileptic medication/antidepressant/digoxin/steroid]] use?|

|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|

| Younger than 29 days?|

| yes: • Blood Test (CBC with differential count, blood culture)
• Urine test (Urine analysis, urine culture)
• Lumber punture
• Stool test (stool analysis, fecal WBC count)
• Chest radiography|

| NO Red flags present and more than 29days of age then • Blood Test (CBC with differential count, blood culture)
• Urine test (Urine analysis, urine culture)
• Lumber punture
• Stool test (stool analysis, fecal WBC count)
• Chest radiography|

| more than 29 days and Red flags present? yes, then inpatient management • Blood Test (CBC with differential count, blood culture)
• Urine test (Urine analysis, urine culture)
• Lumber punture
• Stool test (stool analysis, fecal WBC count)
• Chest radiography

| Broad spectrum antibiotic for generalized cause|

| Broad spectrum antibioticfor UTI

| • Ceftriaxone
• Cefotaxime|

| • Cefotaxime

| 'Empiric antibiotic (Ceftriaxone, cefixime, azythromycin, amoxicillin) and if No good outpatient follow up|

| Empiric antibiotic (Ceftriaxone, cefixime, azythromycin, amoxicillin) and if Yes good outpatient follow up

| • Inpatient monitoring|

| • Close outpatient monitoring

Ampicillin|

| Gentamicin|

| Cefotaxime|

## Treatment

[edit | edit source]

Shown below is an algorithm summarizing the treatment of Fever in children.[10][15][16]

| Fever in children

|
|
|
|
|
|
|

| symptomatic management|

| Antimicrobial management|

| • Hydration
•IV fluid
•Tepid sponge
• Airway, breathing, circulation maintenance|

Acetaminophen, NSAIDs|

| Steroid, Immunoglobulins, antiepileptic medications for other inflammatory or immunologic cause or seizure|

| According to blood, urine, stool culture

Aspirin in Kawasaki disease|

| Broad spectrum antibiotic and then narrowed down according to culture and sensitivity|

| Rule out bacterial cause

| Bacterial: Ampicillin, gentamicin, cefotaxime, cefixime, vancomycin|

| Antiviral, anti fungal, Anti parasitic medications according to causal agent

## Do's

[edit | edit source]

* Monitoring and Maintenance of hydration by physicians, nurses, parents.
* Careful evaluation for identifying the 'red flags'.
* Stress factors of catabolism triggers fever, so these should be evaluated and avoidance of it will prevent recurrence of fever.
* Dosage and concentration of medications should be measured with the greatest care according to pediatric dose.
* Using a standardized delivery device for application of medication on children.

## Don'ts

[edit | edit source]

* Bath with cold water, inappropriate dressing (over or under) are not recommended.
* Don't use aspirin except for Kawasaki disease.
* Higher Acetaminophen and NSAIDs dosage is not are not recommended.
* Combination therapy with acetaminophen and Ibuprofen are not encouraged.

## References

[edit | edit source]

1. ↑ Posfay-Barbe K, Hofer M (February 2018). "[Fever throughout the ages in children]". Rev Med Suisse (in French). 14 (594): 358–361. PMID 29461748.CS1 maint: Unrecognized language (link)
2. ↑ Huppertz HI (March 2021). "[Fever of unknown origin]". Monatsschr Kinderheilkd (in German): 1–8. doi:10.1007/s00112-021-01145-5. PMC 7950420 Check `|pmc=` value (help). PMID 33727731 Check `|pmid=` value (help).CS1 maint: Unrecognized language (link)
3. ↑ deVos-Kerkhof E, Roland D, de Bekker-Grob E, Oostenbrink R, Lakhanpaul M, Moll HA (April 2016). "Clinicians' overestimation of febrile child risk assessment". Eur J Pediatr. 175 (4): 563–72. doi:10.1007/s00431-015-2667-5. PMC 4799264. PMID 26634248.
4. ↑ Urbane UN, Likopa Z, Gardovska D, Pavare J (July 2019). "Beliefs, Practices and Health Care Seeking Behavior of Parents Regarding Fever in Children". Medicina (Kaunas). 55 (7). doi:10.3390/medicina55070398. PMC 6681325 Check `|pmc=` value (help). PMID 31336677.
5. ↑ de Vos-Kerkhof E, Geurts DH, Wiggers M, Moll HA, Oostenbrink R (February 2016). "Tools for 'safety netting' in common paediatric illnesses: a systematic review in emergency care". Arch Dis Child. 101 (2): 131–9. doi:10.1136/archdischild-2014-306953. PMID 26163122.
6. ↑ Barbi E, Marzuillo P, Neri E, Naviglio S, Krauss BS (September 2017). "Fever in Children: Pearls and Pitfalls". Children (Basel). 4 (9). doi:10.3390/children4090081. PMC 5615271. PMID 28862659.
7. ↑ Rigante D, Rossodivita A, Cantarini L (May 2014). "Unmasking an obstinate fever". Isr Med Assoc J. 16 (5): 326–8. PMID 24979845.
8. ↑ Flaherty EG, Macmillan HL (September 2013). "Caregiver-fabricated illness in a child: a manifestation of child maltreatment". Pediatrics. 132 (3): 590–7. doi:10.1542/peds.2013-2045. PMID 23979088.
9. ↑ Dagan R, Powell KR, Hall CB, Menegus MA (December 1985). "Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis". J Pediatr. 107 (6): 855–60. doi:10.1016/s0022-3476(85)80175-x. PMID 4067741.
10. ↑ 10.0 10.1 Richardson M, Lakhanpaul M (June 2007). "Assessment and initial management of feverish illness in children younger than 5 years: summary of NICE guidance". BMJ. 334 (7604): 1163–4. doi:10.1136/bmj.39218.495255.AE. PMC 1885352. PMID 17540946.
11. ↑ Baker MD, Bell LM, Avner JR (November 1993). "Outpatient management without antibiotics of fever in selected infants". N Engl J Med. 329 (20): 1437–41. doi:10.1056/NEJM199311113292001. PMID 8413453.
12. ↑ Baskin MN, O'Rourke EJ, Fleisher GR (January 1992). "Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone". J Pediatr. 120 (1): 22–7. doi:10.1016/s0022-3476(05)80591-8. PMID 1731019.
13. ↑ Verbakel JY, Van den Bruel A, Thompson M, Stevens R, Aertgeerts B, Oostenbrink R, Moll HA, Berger MY, Lakhanpaul M, Mant D, Buntinx F (January 2013). "How well do clinical prediction rules perform in identifying serious infections in acutely ill children across an international network of ambulatory care datasets?". BMC Med. 11: 10. doi:10.1186/1741-7015-11-10. PMC 3566974. PMID 23320738.
14. ↑ Kerkhof E, Lakhanpaul M, Ray S, Verbakel JY, Van den Bruel A, Thompson M, Berger MY, Moll HA, Oostenbrink R (2014). "The predictive value of the NICE "red traffic lights" in acutely ill children". PLoS One. 9 (3): e90847. doi:10.1371/journal.pone.0090847. PMC 3954615. PMID 24633015.
15. ↑ 15.0 15.1 "Management of Fever in Infants and Young Children - American Family Physician".
16. ↑ 16.0 16.1 Black RE, Laxminarayan R, Temmerman M, Walker N, Herlihy JM, D’Acremont V, Hay Burgess DC, Hamer DH. PMID 27227231. Vancouver style error: non-Latin character (help); Missing or empty `|title=` (help)
17. ↑ Soon GS, Laxer RM (October 2017). "Approach to recurrent fever in childhood". Can Fam Physician. 63 (10): 756–762. PMC 5638471. PMID 29025800.