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Fever In Children

Fever In Children. In the name of God. Fever. Fever Fever is a common symptom with various diseases in children Fever Definition A centrally mediated elevation of body temperature in response to stress or insult Rectal temperature is over 100.4°F (38°C) Oral temperature above 37.5°C

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Fever In Children

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  1. Fever In Children In the name of God

  2. Fever Fever • Fever is a common symptom with various diseases in children Fever Definition • A centrally mediated elevation of body temperature in response to stress or insult • Rectal temperature is over 100.4°F (38°C) • Oral temperature above 37.5°C • Auxiliary temperature above 37.2°C

  3. Feverin children • Fever is a controlled in body T overthe normal values for an individual • Body T is regulated by thermosensitive neuronslocated in the preoptic of anterior hypothalamomus • Termoregulatory responses include; increased or decreased sweating extracellular fluid volume regulation behavioral responses

  4. Pathogenesis • Endogenous pyrogens including the : 1-cytokines interleukin 1and 6 2-TNF 3-INTERFERON • Exogenous pyrogens including the Microbes and microbial toxins which stimulate macrophages to produce endogenous pyrogens • Endotoxin can directly affec thermoregulation

  5. Pathogenesis)con) • IncreaseT is associated with decrease microbial reproduction and increase inflammatory response • Fever may exacerbate ; cardiac insufficiency in heart disease or chronic anemia Pulmonary insufficiency in chronic lung disease Metabolic instability in diabetes mellitus or inborn error of metabolism

  6. Prostaglandins and the role of NSAIDs

  7. Pyrogens and Fever

  8. Actions of endogenous pyrogens in fever regulation

  9. Heat illness • Situation in witch either environmental stress impair the ability of the central thermoregulatory mechanism to maintain normal body temperature or internal factors produce excessive heat or impair the body’s ability to dissipate metabolism heat • Body temperature is elevated despite a normal set-point in POAH

  10. Example of Heat illness • Hyperthyroidism • Malignant hyperthermia • Anhidrotic ectodermal dysplasia • Pharmacologic agent • Medical drug (anticholinergics and phenothiazines) • Street drug

  11. Fever is s friend or enemy? • Fever is a beneficial response in favor the host • Fever may directly impair reproduction or even the survival of an invading microorganism • Moderate fever may enhance the immunologic response

  12. Fever is friend or enemy? • High fever can impair the immunologic response • Fever increase the basal metabolic rater by 10-12 % for 1 °C • Increase oxygen consumption • Carbon dioxide production • Increase Fluid and caloric requirements • can precipitate febrile seizures • May be associated with neurological manifestation irritability,delirium,disorientation and hallucinations

  13. Treatment of Fever • Anti pyretic drugs should not proscribed routinely to febrile children • WHO recommend the use anti pyretic for children with fever of ≥ 39 C°

  14. The decision to treat • when the patient is uncomfortable • susceptible To febrile seizure • Critically ill-sepsis or septic shock • Cardiac or respiratory failure • Neurological diseases or injury • Disturbed fluid ,electrolyte status

  15. Acetaminophen • Is the first line therapy for childhood fever • Rapidly and almost completely absorb from GI • half-life in plasma about 2 hour • Dose 10-15 mg/kg/dose PO/PR Q 4-6 hr • Maximum 5 dose/24 hr

  16. Acetaminophen Side affect • Skin rash and allergic reaction occasionally • Neuttropenia ,thrombocytopenia and pancytopenia rarely Toxic Effect • Hepatotoxicity • Renal tubular necrosis • Hypoglycemia coma

  17. Acetaminophen • AAP recommend that rectal Acetaminophen therapy should be avoided unless specifically discussed with the health care provider and that direction be followed

  18. Ibuprophen • Inhibit prostaglandin synthetase. • Dose 8-10 mg/kg Q 6-8hr Side affect • Gastiris • Gastrointestinal apset • Platelets aggregation

  19. Acetaminophen versus Ibubrophen • Acetaminophen: • provided greater initial temperature reduction • Ibubrophen: • Provided more significant antipyretic effect at 4 hr • Temperature decrement lasted longer The two drug have equal tolerability

  20. Prostaglandins and the role of NSAIDs

  21. Nimesulide • A new NSAID is useful in treatment of fever • Was more effective than Acetaminophen for treatment of fever • Appear to be safe as Acetaminophen • Dose 1.5 mg/kg/Dose TID

  22. Fever • Fever is a common manifestation of infectious disease but is not predictive of severity • Many infections are usually benign in normal hosts • Sepsis ,meningitis pneumonia ,osteoarticular infections , pyelonephritis may have significant morbidity or mortality • Most febrile episodes can be diagnosed by careful history and physical examination and few lab tests

  23. Thecauses of fever • Infection • vaccines , • endocrine disorders, genetic disorders , metabolic disorders , immunologic and rheumatologic disorders • tissue injury, malignancy , drugs • granulomatous diseases , inflammatory diseases • factitious fever

  24. Clinical Manifestation • Causes of very high T)>41) include : central fever , malignant hyperthermia drug fever , heatstroke • T lower than (<36) can be sepsis and more commonly with cold exposure , hypothyroidism , or overuse of antipyretic • Intermittent fever , sustained fever , Remittent fever , Relapsing fever , periodic fever

  25. Type of fever • Intermittent fever - Fever that touches normal for a few hours during the day. It is seen in malaria, acute pyelonephritis, local boils and furuncles. tuberculosis, lymphoma, and juvenile rheumatoid arthritis (JRA) • Remittent fever - Fever that fluctuates between 1.5 degree F in 24 hours without touching normal. viral infections but also may occur with bacterial infections (especially endocarditis), sarcoid, lymphoma, and atrial myxoma. • Continuous fever - Fever that does not touch normal and fluctuates less than 1.5 degree F in a day. It is seen in enteric fever, Bacterial endocarditis, viral pneumonia. Typhoid fever, typhus, brucellosis, and many other infections

  26. FeverProne to Relapse • Infectious causes • Noninfectious causes Behcet disease , crohn disease , SLE • Periodic fever syndromes: • familial Mediterranean fever • cyclic neutropenia • Hyper igD syndrome • (PFAPA) periodic fever aphthous stomatitis pharyngitis - adenopathy

  27. Febrile Patients at increased Risk for Serious Baterial infections • Immunocompetentpatient: Neonates(28 days) infants<3 mo Infants and children 3-36 mo Hyperpyrexia(>40) Fever with petechiae Immunocompromised patients: Sickle cell disease -Asplenia Complement / properdin deficiency- Agammaglobulinemia AIDS – Malignancy Congenital heart disease Central venous line

  28. Treatment • fever<39 in healthy children do not require treatment • Antipyretic therapy dose not change the course of infection • Antipyretic therapy is beneficial in high-risk patients • Hyperpyrxia indicates risk of; severe infection ,hypothalamic disorders ,CNS hemorrhage

  29. Fever without localizing signs • usually acute onset present for< 1 wk. • Young infants limited signs of infection and difficult to distinguish between bacterial and viral infection.

  30. Fever without localizing signs • Infants< 4 wk are at risk for; • late-onset bacterial diseases • Perinatally acquired herpes simplex virus • Acquire community pathogens

  31. Infants<3mo with fever • Fever in this age should always suggest the possibility of serious bacterial disease • Pyelonephritis is more common in uncircumcised boys ,neonate and infants with UT anomalies and young girls • Other bacterial diseases include: • , pneumonia , omphalitis ,mastitis skin and soft tissue infection. otitis media

  32. Infants<3mo with fever • Viral infection is identified in 70% • Bacteremia is present in 5% • Serious bacterial infection are present in 10-15% in T > 38

  33. Approach to febrile infants <3 mo • Careful history and physical examination • Toxic infants must prompt hospitalizatIion and immediate parenteral antimicrobial therapy after B /C , U/C ,LP • Ceftriaxone 50- 80mg/day or cefotaxim 50mg/kg/dose and ampicillin 50/kg/dose. • If CSF IS abnormal vancomycin 15/kg/ dose should be given

  34. Approach to febrile infant<3mo (con) 2-Infants with fever unlikely to have a serious bacterial infection if; • appear generally well and previously healthy • No evidence of skin, soft tissue, bone , joint and ear infection • Who have WBC5000-15000 and band <1500 * and U/A normal

  35. Occult Bacteremia in children 3-36 m0 ¤* Occurs in 1.5% well appearing in this age with fever • Bacteremia is present in 11% pneumonia and • 1.5% otitis media or pharyngitis • S,pneumoniae , N,menigitidis and salmonella . • S,Pneumonia account for 90% of cases.

  36. Occult Bacteremia in children 3-36 m0 • Risk factors include : T>39 or greater ,WBC 15000 an elevated band count ESR + and CRP +

  37. Occult bacteremia(con) • Without therapy occult bacteremia may; ■ Resolve spontaneously ■ May persist ■ May lead to localized infection • pnemococcal bacteremia spontaneous resolution occur in 30-40% in all patients

  38. Occult bacteremia(con) • H ,influenza type b bacteremia is with a higher risk of localized serious infection. • Fewer than 5% of these bacteremia can be transient.

  39. Fever with petechiae • Independent of age , with or without localizing signs indicates high risk for bacterial infections . serious bacteria infection 8-20% meningococcal sepsis or meningitis 7-10% • Managemen t includes ; prompt hospitalization ,B/C ,CSF/C, and administration parenteral antimicrobial agent

  40. Fever with sickle cell disease • Children should be hospitalized; ifseriously ill , T>40, WBC<5000 0r>30000or pulmonary infiltration ,or severe pain • The increased risk is due to: functional asplenia, defect in the properdin pathway • S,pneumoniae H, influenzae type b,Salmonella • sepsis, meningitis, pneumonia, osteomylitis. • Prevention of pneumococcal sepsis is ; long term penicillin therapy and pneumococcal and H,inflenza vaccine.

  41. Treatment of occult bacteremia • Toxic-appearing infants without focal signs: • must hospitalization and prompt antimicrobial therapy after B/C ,U/C, CSF/C

  42. Treatment of occult bacteremia • for Non toxic-appearing infants with T>39: • B/C and give ceftriaxon a single dose 50mg/kg • if the WBC is 15000 or greater obtain B/C and ceftrixon • If the child,s condition deteriorate or new symptoms develop the infants must return immediately .

  43. Treatment occult bacteremia) con) • If the child develops a localized infection therapy is directed toward the specific pathogen and site • If the child appears well ,afebrile ,and physical findings is normal with B/C+ , should receive 7-10 days of oral antibiotic

  44. Treatment occult bacteremia) con) • If the child appears ill and continues fever with no identifiable focus of infection.or • IF B/C is H,influenzae or N, meningitidis • The child should have a repeat B/C ,LP, and treatment in hospital with appropriateantimicrobial agents

  45. Fever of unknown origin“FUO” • Fever of 101F for longer than three weeks or • Fever of uncertain diagnosis for more than one week in a hospitalized patient

  46. Etiology of FUO • “A fever of unknown origin is more likely to be the unusual presentation of a common disorder than the common presentation of a rare disorder”

  47. Etiology of FUO • Infections • Autoimmune • Malignancy • Others (incl.. factitious fever, drug fever, sarcoid) • Never determined:

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