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APPROACH TO FEVER IN CHILDREN

Kaustubh Kamat
Consultant Paediatrician, Vakola, Mumbai 400 098.

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Commonest symptom for which parents consult a family physician or a paediatrician is fever. This may mean different things in different age groups - right from a new-born to an adolescent. You must carefully review each case clinically to reach the cause of fever and avoid unnecessary use of antibiotics or diagnostic tools.

Causes - Common causes of fever in different age groups are as follows:

Newborn - Neonatal Septicemia (Hospital Nosocomial Infection)

1 mth to 1 yr - Septicaemia

GI infection
Respiratory infection - tonsillitis, diphtheria
Skin infection - impetigo, pyodermas
Viral fevers - influenza, mumps, hepatitis, polio
Malaria, Dengue
Urinary Tract Infection
Infectious diseases - measles, chicken-pox, mumps

1yr to 5 yr - Respiratory infection

GI infection - Typhoid, viral hepatitis
Viral fevers
Helminthiasis
Dehydration fever
Immunological disorders - systemic lupus
Rheumatic fever/ Rheumatoid arthritis

Approach to Fever - In a brief history, you must ask for

1. Duration of fever
2. Degree of fever
3. Associated symptoms
4.Treatment given before the patient approached you

On Examination

The following signs must be carefully looked for:

1.Look of the child - sick looking, toxic, playful
2.Extent of temperature - temp. charting
3.Pulse, resp. rate, cyanosis, icterus, lymphadenopathy, petechiae, purpuric spots
4.Focus of infection -

ENT infections - ear infection
Throat infection - tonsillitis, diphtheria, pharyngitis
Chest infection - pneumonia, pleural effusion
Skin infection - impetigo, pyoderma, folliculitis
CNS infection - meningitis

5. Associated symptoms like
Hepatomegaly - malaria, enteric fever, dengue fever
Splenomegaly - malaria, enteric fever, infectious mononeuclosis
Meningeal signs - neck stiffness, Kernig’s neck sign, leg sign

Investigations

It is common practice to ask for a battery of

Commonest Antibiotics Used
DRUG	DOSAGE	INDICATIONS
Penicillin Group
Amoxycillin	40mg/kg/day in 3 divideddoses, after food 100mg/kg/day in 3 divideddoses, after food	Upper & Lower respiratory infections Enteric fever
Amoxycillin + Clavulinic acid	Dosage as above; Clavulinicacid is given to accentuate theeffect of Amoxy. Can be given even in BD doses for better compliance	Otitis media, Bronchitis,Pneumonia, Tonsillitis
Ampicillin	50mg/kg/day in 3 divided doses	...same as above...
Macrolides
Erythromycin	40mg/kg/day in 4 divided doses	Tonsillitis, Pharyngitis
Roxithromycin	** mg/kg/day in 2 divided doses,on empty stomach
Azithromycin	** mg/kg/day in a singledose for 3-6 days onempty stomach	Tonsillitis, Otitis media, Bronchitis
Clarithromycin
Cephalosporins
1st generation Cefazolin Cefalothin Cephalexin (sepexin, sporidex)	50mg/kg/day in 4 divided doses	Respiratory infections, Otitis media
2nd generation Cefuroxime Cefaclor (Keflor, Distaclor) Cefoxitin Cefotexan	100mg/kg/day in 3 divided doses 20-40mg/kg/day in 3divided doses	Otitis media, Resistant Respiratory infections
3rd generation Cefotaxime (clavoran, omnatax) Ceftriaxone (Monocef) Ceftazidine	50-100 mg/kg/day in 3 divided doses	Severe Respiratory inf. Enteric fever Enteric, CNS infection
4th generation Cefepime
Quinolones
Norfloxacin Ciprofloxacin	10-20 mg/kg/day in 2 divided doses - oral 2-4 mg/kg/day - IV	Resistant enteritis, UTI 1st line drug for enteric fever. Also for UTI, Lower resp tract inf.
Ofloxacin, Sparfloxacin, Lomefloxacin, Pefloxacin and Amifloxacin - not commonly used in paediatrics
OTHER DRUGS USED
Aminoglycosides
Streptomycin		Tuberculosis
Gentamycin, Amikacin,		UTI, GI, Respiratory and
Tobramycin, Netilmycin		CNS infections
Antikoch’s
Isoniazid Rifampicin Pyrazinamide	10 mg/kg/day X 9 mths 10-15 mg/kg/day X 9 mths 30-40 mg/kg/day X 2 mths	Primary complex, miliary,progressive pri. com., Pleuraleffusion, BCG lymphadenitis Fulminant disease
Ethambutol	25 mg/kg/day X 1st mth 15 mg/kg/day X 2nd mth onwards	Not commonly used in children
Streptomycin	40 mg/kg/day X 60-90 inj.	Especially in CNS Tuberculosis
Antimalarials
Chloroquine	10mg/kg stat followed by 5 mg/kg at 8 hrs and 5 mg/kg/day for 2 days	Vivax malaria
Pyrimethamine + Sulphadoxine	1 mg/kg single dose	Resistant Vivax malaria
Quinine	10 mg/kg dissolved in Normal saline over 12 hours.	Falciparum and Resistant Vivax
	Dilution - 1 mg/ml
Primaquine	0.3 mg/kg/day for 14 days	Radical cure for Vivax (G6P Deficiency must be ruled out before giving)
Mefloquine, Halofantrene, Quinhouse - newer drugs, not commonly used in children

investigations, which should be avoided unless -

- fever is for prolonged time and not responding to routine treatment

- chronic fevers which relapse frequently

Common investigations to be asked for are

1. Total and Differential WBC count (RBC count and indices are not indicated per say in fever).

2. Urine routine - culture and ABS only if UTI is strongly suspected (pus cells are moderate to high/HPF).

3. X-ray chest - if signs of pneumonia, empyema, pleural effusion or primary complex.

4. Mantoux test - This is not done to diagnose primary complex. It is significant under 5 yr. of age and has to be interpreted carefully. Usually 10 X 10 mm is considered normal, if the child has been given BCG.

Special Immunological tests like ANA (anti nuclear antibody), DsDNA (double stranded DNA) should be done if one suspects disorders like SLE, polyarteritis nodosa or other connective tissue disorders.

Nowadays advanced tests like IgM, IgG antibodies against tuberculosis and dengue are done to confirm the diagnosis.

Treatment should be divided into -

1. Treatment of the cause

2. Treatment of complications due to fever

1. Treatment of the Cause : includes treatment of various infections by variety of antibiotics available in present market. You should carefully choose an antibiotic and should not necessarily use the latest antibiotics to impress the patient.

After selecting the antibiotic, patient must be

* Given appropriate mg/kg/day course in divided doses or a single dose as indicated

* Explained the importance of completing the course of the antibiotic as directed by you

* Explained whether the antibiotic should be administered on empty stomach or after food.

* Told not to stop the course on his own even if the fever subsides unless it is advised by you because of reasons like drug allergy and drug interaction etc.

* Given the antibiotic parenterally if oral compliance is poor.

1. Treatment of Complications : Include that of febrile seizures - this is commonest complication between 6 mths to 6 yr and need not necessarily occur during high fever. It is associated with tonic and/or clonic seizures and are of two types:

Typical - single seizure, lasting for less than 1-2 minutes and is not followed by neurological deficit except Todd’s paralysis

Atypical - multiple episodes lasting for 4-5 minutes and followed by neurological deficit.

In 50% of patients seizures, don’t relapse while 50% of patients they may relapse hence precautions should be exercised during each episode of fever, till the age of 6 yr.

Management includes:

a. tepid sponging with tap water

b. administration of oral antipyretics (NSAIDs) -

i. Paracetamol 50 - 75 mg/kg/day

ii. Ibuprofen 20 - 50 mg/kg/day

iii. Mefenamic acid 50 - 75 mg/kg/day

iv. Nimesulide

c.rectal administration of diazepam as a suppository or through IV canula prevents a seizure

d. oral administration of sodium valproate during fever can prevent a febrile fit.

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