Fever in the first few years of life can be the initial manifestation of benign as well as life threatening illness. Fever is the most common reason for which children are brought to the emergency department. In order to avoid missing serious conditions associated with fever, the physician must determine which children need further diagnostic evaluation or in-hospital stay and which patients may be discharged for outpatient treatment and follow-up.


Definition of fever
In general, fever is considered to be present if the rectal temperature is above 38.3oC, oral temperature is above 37.8oC or axillary temperature is above 37oC.

FEVER SYNDROMES

Fever with focus
The majority of febrile episodes in children are associated with infections. The diagnosis is made by identifying the focus: e.g. otitis media, upper respiratory infection, septic arthritis etc.

Fever without localising signs
This term refers to the presence of fever in a child in whom a careful history and physical examination fail to reveal a cause. The physician may wait up to one week, before certain investigations are made. However, fever without localising signs also may be due to conditions like urinary tract infections, or prodromal phase of conditions like infectious mononucleosis and Kawasaki disease.

Fever with non-specific signs
When the duration of fever is less than two weeks at presentation, and there is a possibility of hepatomegaly, splenomegaly, rash, jaundice or lymphadenopathy, specific investigations for icteric hepatitis, enteric fever and infectious mononucleosis may provide the diagnosis. Other diseases that should be ruled out include; malaria, TB, meningitis, septicemia etc. The physician must assess epidemiological data for dengue fever; leptospirosis and other locally present diseases.

Recurrent fever
This term refers to children presenting with episodes of documented fever separated by days or even weeks of normal temperature. The physician must carefully differentiate recurrent episodes of fever due to one specific disease from frequent respiratory infections or recurrence of separate illnesses.

Fever complicating chronic illness
A child, who has fever persisting for over two weeks may have a chronic disease and must be actively investigated for childhood tuberculosis, leukaemia or lymphoma.

Fever of unknown origin (FUO)
     Generally the term FUO is reserved for children with:
a. History of fever of more than one week duration (more than 2 weeks in an adolescent)
b. Documentation of fever by a physician
c. No apparent diagnosis, inspite of investigations including a blood culture


DIAGNOSTIC CLUES IN THE FEBRILE CHILD

History and physical assessment
A thorough history and physical examination remain the cornerstones of diagnosis.

Physical examination
   Careful and meticulous physical examination is mandatory in all children who have fever. Repetitive    examination (preferably daily) is also important to pick up subtle or new signs, which may appear    during the course of the illness.

Some important pointers to the diagnosis are;

• The presence of toxic and sick appearance may suggest bacterial aetiology
• A child who otherwise looks well in spite of fever, may have a non-infective cause
• Hyperaemic throat exudates may suggest infectious mononucleosis, or enteroviral infections
• Continuous absence of sweat in the presence of significant fever suggests dehydration due to    associated G.I. symptoms or diabetes insipidus.
• Red watering eyes, uveitis may point towards connective tissue disease like SLE, or rheumatoid    arthritis
• Fever blisters (herpes) are a common finding in patients with pneumococcal, streptococcal,    malarial disease or salmonella infection
• Bone tenderness may suggest occult osteomyelitis or bone marrow invasion by neoplastic cells.

 MANAGEMENT OF FEBRILE CHILDREN
An expert panel paediatric emergency physicians, infectious disease specialists and paediatricians in the US, have published recommendations primarily for children up to three years of age. Admission is recommended for all patients up to 28 days of age with a rectal temperature of 38oC. For those who are 28 to 90 days old and appearing well, adherence to the Rochester criteria is recommended to pick outpatients.

These criteria are:

• Reliable parents and 24-hour follow up
• Non-toxic appearing, born full term
• Previously healthy, no current antibiotic use
• WBC of 5,000-15,000 cells/mm3 with less than 1500 bands
• Normal chest x-ray, urine test

METHODS OF FEVER REDUCTION

There are several approaches to fever reduction in the paediatric patient, many of them tailored to specific clinical situations. For example, children who are suffering from heat stroke or any other serious disorder that compromises thermoregulation require rapid and aggressive cooling measures (e.g. a fan with continuous cool mist or gastric lavage). A simple, time-honoured technique, sponging with tepid water, is widely used for cooling febrile children.


INDICATIONS FOR ANTIPYRETIC TREATMENT
The decision to administer antipyretic therapy should be based on balancing the likely benefits (improved comfort and behaviour) and risks (medication side-effects) of treatment. The WHO ARI Programme recommends that antipyretic treatment should generally be restricted to young children with high fever (that is, rectal temperatures of 390C or more).

Children under the age of 5 years and specially those between 6 months and 3 years are at risk of febrile convulsions, particularly at rectal temperatures of 400C or above. These febrile convulsions resolve spontaneously and are not associated with long term neurological complications.
The commonly used antipyretics are paracetamol and ibuprofen. Aspirin is contraindicated because of its link with reyes syndrome. Nimesulide, which is a popular antipyretic, has been banned in a number of European countries (it is not approved in the US) recently. This is due to reports of liver toxicity & Reyes syndrome with usage of this drug.

For children 0-3 months old; Admission is recommended for all patients 0-28 days old with a rectal temperature of 38o C. Empiric antibiotic therapy should be administered to those infants who have undergone a lumbar puncture and blood culture to help distinguish partially treated meningitis and bacteraemia from a viral syndrome.

For children 3 months to 36 months of age: Non-toxic appearing children (males less than 6 months and females less than 2 years) with a temperature of 39o C or more should undergo a urine culture. Blood cultures and empiric antibiotic therapy (parenteral ceftriaxone 50 mg/kg IM or oral amoxicillin 60 mg/kg/d orally for 3 days) are recommended for all children or only those with WBC counts greater than 15,000 cells/mm3.

CONCLUSION
Management of fever in young
children, especially those up to
3 years of age, needs to be structured to minimise unfavourable outcomes.


REFERENCE
1. Pediatrics 1993; 92:1-12.