1. APPROACH TO FEBRILE ILLNESSES IN CHILDREN Adebola E. Orimadegun Institute of Child Health College of Medicine University of Ibadan

2. Definition of fever Temperature -Rectal>38 º c -Oral >37.6 -Axillary >37.3 Acute fever - fever with source - fever without source

3. Introduction Fever is most common presenting complaint in paediatrics: 20 – 40% f all visits Majority of children presenting with fever < 3 years old Both minor and life-threatening infectious diseases common in this age group respiratory infections occult bacteremia meningitis

4. Introduction Distinguishing viral illness from occult bacteraemia can be difficult Children with occult bacteraemia treated as outpatients without antibiotics can develop bacterial meningitis or other focal bacterial infections Management of young febrile children must minimize unfavourable outcomes

5. Common causes of acute fever Malaria Upper Respiratory Tract Disease – Viral respiratory tract disease – Otitis media – Sinusitis Lower Respiratory Tract Disease – Bronchiolitis – Pneumonia Gastrointestinal Disorders – Bacterial gastroenteritis – Viral gastroenteritis

6. Common causes of acute fever Musculoskeletal Infections Cellulitis Septic arthritis Osteomyelitis Urinary Tract Infections Bacteremia Meningitis

7. Diagnostic classifications for which the integrated management of childhood illness (IMCI) guidelines Malaria The child has: – fever (temperature =>37.5 o C or =>99.5 o F), and – a positive blood smear. None of the following is present, on examination: altered consciousness severe anaemia (haematocrit <18% or haemoglobin <6 g/dl) hypoglycaemia (blood glucose <2.5 mmol/litre or <45 mg/dl) respiratory distress jaundice. Note: If a child has fever, but it is not possible to confirm with a blood film, treat the child as for malaria.

8. Diagnostic classifications for which the integrated management of childhood illness (IMCI) guidelines General danger signs present – Not able to drink or breastfeed, vomits everything or convulsions (all by history), or abnormally sleepy or difficult to wake up Very severe febrile disease – Fever (by history, feels hot, or axillary temperature >37.5 o C) and any general danger sign, or stiff neck

9. Diagnostic classifications for which the integrated management of childhood illness (IMCI) guidelines Severe pneumonia – Cough or difficult breathing (by history) and 50 breaths per minute or more in a child aged 2–11 months or 40 breaths per minute or more in a child aged 12–59 months

10. Diagnostic classifications for which the integrated management of childhood illness (IMCI) guidelines Acute ear infection Ear problem (by history) and ear pain (by history) or ear discharge for less than 14 days (by history) or pus seen draining from the ear

11. Diagnostic classifications for which the integrated management of childhood illness (IMCI) guidelines Severe complicated measles Fever (by history, feels hot, or axillary temperature 37.5 o C) and generalized rash and cough, runny nose, or red eyes, and any general danger sign, clouding of cornea, or deep or extensive mouth ulcers

12. Fever without a source: definition Acute febrile illness in which the aetiology of the fever is not apparent after a careful history and physical exam

13. Serious bacterial infection: definition Serious bacterial infections include meningitis, sepsis, bone and joint infections, urinary tract infections, pneumonia, and enteritis

14. History taking Fever : character, pattern, duration Associate organ/systemic symptom - RS : cough, rhinorrhea, dyspnoea - GI : nausea, vomiting, diarrhea, - GU : abnormal urine - NS : alteration of consciousness, seizure, severe headache

15. History taking Behavior activity e.g. drowsy, food/milk intolerance Sick contact Previous treatment, past medication Underlying disease, recent immunization

16. Physical Examination Vital signs : GA : irritability, sign of dehydration, pale, jaundice HEENT : TM, nasal discharge, tonsils & pharynx Skin rash, sign of soft tissue infection CVS : new onset of murmur, embolic phenomenon

17. Physical Examination RS : breath sound, adventitious sound, percussion Abdomen : BS, hepatosplenomegaly CNS : level of consciousness, fontanelle, motor system, meningeal irritation sign Bone and joint system

18. Fever: Treatment Antipyretics: lower the central set point inhibit cyclo-oxygenase enzyme, prevent synthesis of prostaglandin do not interfere with immune response to infection Doses: Acetaminophen: 15 mg/kg every 4 hours Ibuprofen: 10 mg/kg every 6-8 hours

19. Fever: Treatment Adequate hydration – fever can cause excessive heat loss – better heat disipation with adequate intravascular volume – careful not to overhydrate and cause hyponatremia comfortable surroundings: temperature 22 o C Not bundled in extra clothing or blankets Sponging with tepid water – temperature around 27 o C – ice baths or alcohol should be avoided: lead to shivering which may increase body temperature and is uncomfortable

20. Conclusion Appropriate care for fever with or without a source in infants and children is essential to minimizing risks of serious bacterial infection. Guidelines presented do not eliminate all risks. Health workers need to individualize therapy based on clinical circumstances

21. How to position the unconscious child Turn the child on the side to reduce risk of aspiration. Keep the neck slightly extended and stabilize by placing cheek on one hand Bend one leg to stabilize the body position