Fever – Acute

Fever – Acute: Excerpt from In A Page: Pediatric Signs and Symptoms

Fever is an elevation of body temperature over the normal daily range for a specific individual in response to different insults. It occurs when the thermoregulatory center in the hypothalamus is reset to higher temperature because of exogenous and endogenous pyrogens. It should be distinguished from hyperthermia, which describes the inability of the body to maintain the temperature that is set centrally because of environmental or internal factors. Fever is the primary complaint for 30% of patients seen by a pediatrician.

Differential Diagnosis

• Viral infections
  –Account for the majority of febrile illnesses (FI) in infancy and childhood
  –Upper respiratory infections (e.g., parainfluenza virus)
  –Lower respiratory infections (e.g., RSV)
  –Non-bacterial gastroenteritis (e.g., rotavirus)
  –Aseptic meningitis (e.g., enterovirus)
• Bacterial infections
  –UTIs account for 1.7% of FI in children 5 years and 7.5% in infants <8 weeks
  –Pneumonia (e.g., group A streptococcus)
  –Bacteremia (2% of FI in all children, highest rates seen in younger infants)
  –Meningitis (0.8% of FI in all children)
  –In febrile neonates, the overall rate of serious bacterial infections (SBI) is ~13%
• Vaccine reaction
  • Collagen vascular diseases
    –Kawasaki disease: 3,000 cases per year in the U.S., rates higher in Asia, 80% of cases occur in children <5 years
    –Henoch-Schönlein purpura: Low-grade fever is present in 50% of cases
    –Juvenile rheumatoid arthritis: Incidence 1/10,000
    –SLE
    –Acute rheumatic fever
  • Malignancy
    –Leukemia: Most common childhood malignancy; early symptoms include fever, fatigue, pallor, anemia, bone pain
    –Lymphoma
    –Solid tumors (neuroblastoma, sarcoma)
  • Inflammatory bowel disease
    –Diarrhea, pain, fever, blood loss
    –Crohn disease, ulcerative colitis
  • Tissue injury (trauma, hematoma, burns)
  • Drug reaction
  • Biologic agents (blood products, gamma-globulin)
  • Endocrinologic disorders
    –Thyrotoxicosis
    –Pheochromocytoma
  • Genetic diseases
    –Familial Mediterranean fever
  • Factitious fever

  Workup and Diagnosis

  • History
    –Rash, vomiting, diarrhea
    –Cough, nasal or eye discharge
    –Myalgias, arthralgias, bone pain
    –Bleeding, weight loss
    –Sick contacts, daycare attendance
    –Birth history (prematurity, neonatal complications)
    –Travel, animal and insect exposure
    –Medications, recent antibiotic use; immunizations, last date received
    –Immunodeficiency, chronic illnesses
  • Physical exam
    –Temperature: Rectal preferred for infants <3 months
    –Vitals: Relative brady- or tachycardia, tachypnea
    –Growth parameters especially if frequent febrile episodes/infections (immunodeficiency)
    –Appearance, irritability, quality of cry, consolability
    –Skin (color, rash, desquamation), conjunctivitis, ocular or nasal discharge, mouth lesions, throat and ear exam
    –Lymphadenopathy, abdominal exam, neuro exam
    –Joint exam (arthritis), muscle tenderness
    • Labs
      –Febrile neonates (<28 days) should have sepsis evaluation (CBC; blood, urine, CSF culture)
      –Febrile young infants are evaluated according to general appearance and/or focus of fever by exam
    • Immunologic workup and/or bone marrow for prolonged fever and/or other clinical evidence

    Treatment

    • Treating febrile episodes is common despite substantial evidence that fever is more beneficial than harmful; exception is patient with history of febrile seizures
    • Antipyretics are relatively safe drugs that inhibit prostaglandin synthesis and reduce hypothalamic set point to normal
    • Acetaminophen is safest antipyretic for young children
    • Aspirin must be avoided (risk of Reye syndrome)
    • NSAIDs are potent antipyretics and have antiinflammatory effects
    • Physical methods (cooling blankets, lukewarm baths) may be counterproductive if not combined with an antipyretic; alcohol baths are not recommended
    • Most viral syndromes are self-limited, requiring only antipyretics and increased fluid intake for risk of dehydration
    • Empiric treatment with antibiotics and hospitalization recommended only in neonates and critically ill patients
    >>>>

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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