Fever in children: Difference between revisions

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{{SK}} Fever in kids
{{SK}} Fever in kids


==Overview==
==Overview==
[[Fever]] can be defined as any elevation of body [[temperature]] above 38°C, it is a normal [[physiological]] response as a result of the encounter of an [[infectious]] agent producing [[exogenous]] and [[endogenous]] pyrogenes affecting the central set point of body temperature. It is mostly caused by a [[benign]] [[viral infection]], but it can be an indicator of a serious [[sickness]] such as [[meningitis]], [[septicaemia]], [[pneumonia]]. The risk for severe change depends on the clinical condition and the age of the infant. Most predictive for serious sickness are situations in which infants are younger than 3 months with body temperature > or = 38°C, infants between 3 and 6 months with body temperature > or = 39°C, and children of any ages with critical clinical signs. Uncomplicated [[fever]] is [[benign]] and should not be treated.


==Historical Perspective==
==Historical Perspective==


*[Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
*The history of [[fever]] are briefly reviewed by the Greeks as well as the views brought up in the Bible and widespread throughout the Middle Ages where [[fever]] and [[disease]] were interpreted as punishment for misbehavior.
*In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
*Later views are introduced, based on the rise of science and Harvey's discovery of the [[circulation]] of the [[blood]] which produced two rival camps, [[iatrochemists]] and [[iatrophysicists]].
*In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].
*Next are brought up as the contributions of [[tissue]] [[pathology]], experiments defining the role of the [[CNS]] in regulating [[body]] [[temperature]], the old correlation of fever with [[inflammation]] and the discovery of [[microbial]] agents of disease and [[bacterial]] [[pyrogens]] in the late nineteenth and early twentieth century
*Finally, work in the last 30 years is summarized, starting with the discovery of [[endogenous]] [[pyrogen]] ([[EP]]) and the recent finding that [[EP]] is probably similar to [[lymphocyte activating factor]] ([[LAF]]) and [[leukocytic endogenous mediator]] ([[LEM]]) which collectively as [[interleukin-1]] ([[IL-1]]) play a major role in both [[inflammation]] and [[immunity]].<ref name="pmid2029820">{{cite journal| author=Stein MT| title=Historical perspective on fever and thermometry. | journal=Clin Pediatr (Phila) | year= 1991 | volume= 30 | issue= 4 Suppl | pages= 5-7 | pmid=2029820 | doi=10.1177/0009922891030004S02 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2029820  }} </ref>
 
==Classification==
==Classification==


*Fevers may be classified based on duration into:<ref name="pmid21843857">{{cite journal| author=Ogoina D| title=Fever, fever patterns and diseases called 'fever'--a review. | journal=J Infect Public Health | year= 2011 | volume= 4 | issue= 3 | pages= 108-24 | pmid=21843857 | doi=10.1016/j.jiph.2011.05.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21843857  }} </ref>
*'''Fever''' may be classified based on duration into:<ref name="pmid21843857">{{cite journal| author=Ogoina D| title=Fever, fever patterns and diseases called 'fever'--a review. | journal=J Infect Public Health | year= 2011 | volume= 4 | issue= 3 | pages= 108-24 | pmid=21843857 | doi=10.1016/j.jiph.2011.05.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21843857  }} </ref>
**Acute fevers: <7 days duration, if untreated it can become persistent or chronic, attributes to infectious disease such as upper respiratory tract infection and malaria.
**'''Acute fever''': (<7 days duration), if untreated it can become [[persistent]] or [[chronic]], attributes to [[infectious]] disease such as [[upper respiratory tract infection]] (URTI) and [[malaria]].
**Sub-acute fevers: <2 weeks, seen in typhoid fever and intra-abdominal abscess.
**'''Sub-acute fever''':(<2 weeks), seen in [[typhoid fever]] and [[intra-abdominal abscess]].
**Chronic fevers: >2 weeks, typical of chronic bacterial infections like tuberculosis, viral infections like HIV, cancers and connective tissue diseases.
**'''Chronic fever''': (>2 weeks), typical of [[chronic]] [[bacterial infections]] ([[tuberculosis]] [[TB]]), [[viral infections]] ([[HIV]]), [[cancers]] and [[connective tissue diseases]].
 
*[[Fever]] also can be classified based on height of body [[temperature]] into:
**[[Low grade fever]]
**[[Moderate grade fever]]
**[[High grade fever]] (attributes to Serious [[bacterial infections]] in [[infants]])
**[[Hyperpyrexia]]


*fevers also can be classified based on height of body temperature into:
*The height of [[fever]] may correlate with [[severity]] of [[illness]], such as in [[dengue fever]], [[shigellosis]], and [[acute]] [[falciparum malaria]].
**Low grade fever
*There are three major [[fever]] type: [[Sustained]]/[[continuous]] [[fever]], [[intermittent]] fever and [[remittent]] fever.
**Moderate grade fever
**[[Continuous]] or [[sustained]] [[fever]] does not [[fluctuate]] more than about 1°C (1.5°F) during 24hours, but never touches normal, characteristics of [[lobar]] and [[gram negative]] [[pneumonia]], [[typhoid]], [[acute]] [[bacterial]] [[meningitis]], and [[urinary tract infection]].
**High grade fever (attributes to Serious bacterial infections in infants)  
**[[Fever]] with [[bradycardia]] ([[Faget’s sign]] or [[sphygmothermic dissociation]])is characteristic of untreated [[typhoid]], [[leishmaniasis]], [[brucellosis]], [[Legionnaire]]’s disease and [[psittacosis]], and [[Yellow Fever]].
**Hyperpyrexia
**[[Intermittent]] [[fever]] is defined as fever present only for several hours during the day. It can be seen in [[malaria]], [[pyogenic infections]], [[tuberculosis (TB)]], [[schistosomiasis]], [[lymphomas]], [[leptospira]], [[borrelia]], [[kala-azar]], or [[septicemia]].
**Sources of [[continuous]], [[intermittent]] or [[transient]] [[bacteraemia]] may lead to [[continuous]], [[intermittent]] or  [[transient]] fevers respectively. In [[malaria]], depending on the specie of [[parasite]], fever can occur with a periodicity of 24h (quotidian-due to plasmodium falciparum), 48h (tertian plasmodium ovale and vivax), or 72h (quartan Plasmodium malaria). The [[Pel-Epstein’s fever]] is an [[intermittent]] [[low grade fever]] characterised by 3—10 days of [[fever]] with subsequent a [[febrile periods]] of 3—10 days. It is thought to be a typical but rare manifestation of [[Hodgkin’s lymphoma]].
**[[Remittent]]  [[fever]]  is  defined  as  fever  with  daily fluctuations exceeding 2◦C but at no time touches normal. [[Remittent]]  [[fevers]]  are  often  associated  with  [[infectious  diseases]] such as [[infective endocarditis]], [[rickettsiae]] infections, and [[brucellosis]]. Relapsing fevers refer to those that are recurring  and  separated  by  periods  with [[low grade fever]] or no fever. [[Periodic]] or [[relapsing]] fevers are seen in [[malaria]], [[lymphoma]], [[borrelia]], cyclic  [[neutropenia]], and [[rat-bite fever]]. [[Fever]]  associated  with  [[night  sweats]]  has been described in [[infectious diseases]] such as [[TB]], [[Nocardia]], [[brucellosis]], [[liver]] or [[lung]] [[abscess]] and [[sub-acute]] [[infective endocarditis]], as well as in [[non-infectious]] [[diseases]] such as [[polyarteritis nodosa]] and [[cancers]] such as [[lymphomas]].


{| style="border: 2px solid #4479BA; align="left"
{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Body temperature}}
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Body temperature}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|C}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|°C}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|F}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|°F}}
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Normal
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |'''Normal'''
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |37-38
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |37-38°C
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |98.6-100.4
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |98.6-100.4°F
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Mild/low grade fever
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |'''Mild/low grade fever'''
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |38.1-39
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |38.1-39°C
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |100.5-102.2
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |100.5-102.2°F
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Moderate grade fever
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |'''Moderate grade fever'''
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |39.1-40
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |39.1-40°C
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |102.2-104.0
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |102.2-104.0°F
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |High grade fever
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |'''High grade fever'''
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |40.1-41.1
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |40.1-41.1°C
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |104.1-106
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |104.1-106°F
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Hyperpyrexia
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |'''Hyperpyrexia'''
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |>41.1
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |>41.1°C
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |>106.0
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |>106.0°F
|-
|-
|}
|}
{{clear}}
*Hyperpyrexia in severe malaria is defined as rectal tem-perature above 40◦C
*The height of fever may correlate with severity of illness, such as in dengue fever, shigellosis, and acute falciparum malaria.
*There are three major fever type: Sustained/continuous fever, intermittent fever and remittent fever.
**Continuous or sustained fever does not fluctuate more than about 1◦C (1.5◦F) during 24hours, but never touches normal, characteristics of lobar and gram negative pneumonia, typhoid, acute bacterial meningitis, and urinary tract infection.


==Pathophysiology==
==Pathophysiology==


The pathophysiological mechanisms for the injurious effects of a fever, classified as follows:<ref name="pmid27411542">{{cite journal| author=Walter EJ, Hanna-Jumma S, Carraretto M, Forni L| title=The pathophysiological basis and consequences of fever. | journal=Crit Care | year= 2016 | volume= 20 | issue= 1 | pages= 200 | pmid=27411542 | doi=10.1186/s13054-016-1375-5 | pmc=4944485 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27411542  }} </ref>
*The development of the [[pyrexia]] is similar to the normal [[thermoregulatory]] processes that follow exposure to [[cold]] [[temperatures]].<ref name="pmid21843857">{{cite journal| author=Ogoina D| title=Fever, fever patterns and diseases called 'fever'--a review. | journal=J Infect Public Health | year= 2011 | volume= 4 | issue= 3 | pages= 108-24 | pmid=21843857 | doi=10.1016/j.jiph.2011.05.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21843857  }} </ref>
*Direct cellular damage:
*The [[thermal]] balance point in [[fever]] is reset to a higher level such that normal [[peripheral]] and [[central]] [[body]] [[temperatures]] are now sensed as cold temperature signals by the thermoregulatory circuitry.
**Membrane, mitochondrial and DNA damage
*Fever is different from [[heat stroke]] and [[hyperthermia]] where body [[temperature]] is increased without an equivalent increase of the [[thermal]] [[balance]] point.
**Stimulation of excitotoxic mechanisms  
 
**Protein denaturation
'''The role of pyrogens and cryogens'''
**Cell death
*The initiation, manifestations and regulation of [[pyrexia]] are dependent on the [[pyrogenic]] and [[anti-pyretic]] properties of numerous [[exogenous]] and [[endogenous]] [[substances]].
*[[Pyrogens]] directly or indirectly lead to [[pyrexia]] and [[cryogens]] prevent [[extortionate]] [[temperature]] elevation.
*The [[balance][] in the [[interactivity]] between [[pyrogens]] and [[cryogens]] is control the [[height]] and [[duration]] of the [[pyrexia]].
 
'''Pryogens'''
*[[Pyrogens]] are classified into [[exogenous]] and [[endogenous]] [[pyrogens]] based on their site of production.
*Exogenous pyrogens are part or whole [[micro]] [[organisms]] ([[lipopolysaccharide]] ([[LPS]]) in [[gram negative]] [[cell wall]]) or products of [[micro]] [[organisms]] as [[toxins]].
*[[Endogenous]] [[pyrogens]] include [[muramyl dipeptidase]] and [[enterotoxins]] of [[Staphylococcus aureus]] and group A and B [[Streptococcus]] (superantigens).
*[[Endogenous]] [[pyrogens]] are mainly [[pyrogenic]] [[cytokines]] including [[interleukins]] ([[IL-6]], [[IL-1]]), [[interferon gamma]] ([[INF-a]]) and [[ciliary neurotropic factor]] ([[CNTF]]) and [[tumor necrosis factor]] ([[TNFa]]).
 
'''Cryogens'''
*[[Cyrogens]] include [[cytokines]]([[IL-10]]), [[hormones]] ([[a-melanocyte stimulating hormone]], [[corticotrophin]] and [[corticotrophin releasing hormone]]) and [[neuroendocrine]] products ([[neuropeptide Y]], [[bombesin]], and [[thyroliberin]]), and [[cytochrome P-450]].
*The [[antipyretic]] effect induced by [[inhibiting]] [[synthesis]] of [[pyrogenic]] [[cytokines]] ([[glucocorticoids]]), [[cytokine]] [[receptors]] [[blockade]] ([[IL-1]] [[receptor]] [[antagonist]]), and increasing [[heat]] loss by enhancing [[sensitivity]] of warm [[sensitive]] [[neurons]] ([[bombesin]]).
 
 
 
The [[pathophysiological]] [[mechanisms]] for the [[injurious]] effects of a [[fever]], classified as follows:<ref name="pmid27411542">{{cite journal| author=Walter EJ, Hanna-Jumma S, Carraretto M, Forni L| title=The pathophysiological basis and consequences of fever. | journal=Crit Care | year= 2016 | volume= 20 | issue= 1 | pages= 200 | pmid=27411542 | doi=10.1186/s13054-016-1375-5 | pmc=4944485 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27411542  }} </ref>
*Direct [[cellular]] [[damage]]:
**[[Membrane]], [[mitochondrial]] and [[DNA]] [[damage]]
**[[Stimulation]] of [[excitotoxic]] [[mechanisms]]
**[[Protein]] [[denaturation]]
**[[Cell death]]
*Local effects:
*Local effects:
**Cytokine stimulation
**[[Cytokine]] [[stimulation]]
**Inflammatory response
**[[Inflammatory]] response
**Vascular stasis
**[[Vascular]] [[stasis]]
**Extravasation
**[[Extravasation]]
**Oedema
**[[Oedema]]
*Systemic effects:
*Systemic effects:
**Endotoxaemia
**[[Endotoxaemia]]
**Gut bacterial translocation
**[[Gut]] [[bacterial]] [[translocation]]


==Causes==
==Causes==
Line 102: Line 128:
Causes of undiagnosed [[fever]] in children include:<ref name="pmid14218464">{{cite journal| author=BREWIS EG| title=CHILD CARE IN GENERAL PRACTICE. UNDIAGNOSED FEVER. | journal=Br Med J | year= 1965 | volume= 1 | issue= 5427 | pages= 107-9 | pmid=14218464 | doi= | pmc=2165027 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14218464  }} </ref>
Causes of undiagnosed [[fever]] in children include:<ref name="pmid14218464">{{cite journal| author=BREWIS EG| title=CHILD CARE IN GENERAL PRACTICE. UNDIAGNOSED FEVER. | journal=Br Med J | year= 1965 | volume= 1 | issue= 5427 | pages= 107-9 | pmid=14218464 | doi= | pmc=2165027 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14218464  }} </ref>
*'''Infection'''
*'''Infection'''
**Viruses
**[[Viruses]]
**Pyogenic Inection
**[[Pyogenic]] [[Infection]]
**Salmonella Infection
**[[Salmonella]] [[Infection]]
**Brucellosis
**[[Brucellosis]]
**Tuberculosis
**[[Tuberculosis]]
*'''Collagen Vascular Diseases'''
*'''Collagen Vascular Diseases'''
*'''Neoplasm'''
*'''Neoplasm'''


==Differentiating [disease name] from other Diseases==
==Differential diagnoses for fever in children==


For further information about the differential diagnosis, click [[Disease_Name differential diagnosis|here]].
{| border="2" cellpadding="4" cellspacing="0" style="margin: 1em 1em 1em 0; background: #f9f9f9; border: 1px #aaa solid; border-collapse: collapse;" width="75%"
! Cause !! Differential Diagnosis
|-
|<nowiki>Infectious; Bacterial or mycobacterial</nowiki>
| [[Brucellosis]], [[dental abscess]], [[endocarditis]], non-[[tuberculous]] [[mycobacteria]] (eg, [[Mycobacterium chelonae]]), [[occult]] [[bacterial infection]], recurrent [[bacterial infections]], relapsing [[fever]] ([[Borrelia]] spp other than [[Borrelia burgdorferi]]), [[Yersinia enterocolitica]]
|-
|<nowiki>Parasitic</nowiki>
| [[Malaria]] (eg, [[Plasmodium vivax]], [[Plasmodium ovale]])
|-
|<nowiki>Inflammatory or Immunologic</nowiki>
| [[Behçet syndrome]], [[inflammatory bowel disease]] (eg, [[Crohn disease]]), [[hereditary]] [[fever]] [[syndromes]] (eg, [[FMF]]), [[juvenile]] [[dermatomyositis]], [[PFAPA]] [[syndrome]], [[sarcoidosis]], [[systemic lupus erythematous]], [[systemic]] [[juvenile idiopathic arthritis]] ([[Still disease]]), [[vasculitis]] (eg, [[polyarteritis nodosa]])
|-
|<nowiki>Malignant</nowiki>
|[[Leukemia]], [[lymphoma]]
|-
|<nowiki>Other</nowiki>
|[[Benign]] [[giant]] [[lymph node]] [[hyperplasia]] ([[Castleman disease]]), [[CNS]] [[abnormalities]] (eg, [[hypothalamic dysfunction]]), [[drug fever]], [[factitious fever]], [[IgG4-related disease]], [[immunodeficiency]] [[syndromes]] with [[recurrent]] [[infections]]
|}<br clear="left" />
 
*[[CNS]]—[[central nervous system]]; [[FMF]]—[[familial Mediterranean fever]]; [[IgG4]]—[[immunoglobulin G4]]; [[PFAPA]]—[[periodic fever]], [[aphthous stomatitis]], [[pharyngitis]], and [[adenitis]].<ref name="pmid29025800">{{cite journal| author=Soon GS, Laxer RM| title=Approach to recurrent fever in childhood. | journal=Can Fam Physician | year= 2017 | volume= 63 | issue= 10 | pages= 756-762 | pmid=29025800 | doi= | pmc=5638471 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29025800  }} </ref>


==Epidemiology and Demographics==
==Epidemiology and Demographics==


*The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
*Following the widespread use of [[immunizations]] against [[Streptococcus pneumoniae]] and [[Haemophilus influenzae]] b, incidence of fever caused by [[infection]] due to these [[organisms]] has been decreased.
*In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].
*Since 1990, rates of invasive [[Hib]] [[infection]] (including [[meningitis]]) in children 5 years and younger have declined by more than 99%.
*In 2005, the incidence of fever caused by [[invasive]] [[pneumococcal]] [[infection]] in children declined by 77% from 1998.
 
===Age===
===Age===


*Patients of all age groups may develop [disease name].
*[[Fever]] caused by [[urinary tract infections]] ([[UTI]]s) are the most common source of serious [[bacterial infection]] in children younger than 3 months, commonly from [[E.coli]] or [[Klebsiella]] species.
*According to a case series, [[fever]] caused by [[pneumonia]] is the most common serious [[bacterial infection]] in children 3 to 36 months of age, followed by [[UTI]].
*[Disease name] is more commonly observed among patients aged [age range] years old.
*[Disease name] is more commonly observed among [elderly patients/young patients/children].
===Gender===
 
*[Disease name] affects men and women equally.
*[Gender 1] are more commonly affected with [disease name] than [gender 2].
*The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.
===Race===
 
*There is no racial predilection for [disease name].
*[Disease name] usually affects individuals of the [race 1] race.
*[Race 2] individuals are less likely to develop [disease name].
 
==Risk Factors==


*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
==Prognosis==
 
*The prognosis of [[fever]] depends on the underlying cause.
==Natural History, Complications and Prognosis==
*There is an association with a greater likelihood of serious [[bacterial infection]] ([[SBI]]) for [[temperatures]] >39 °C.  
 
*In a prospective cohort study on more than 12,800 children presenting with [[febrile illness]], [[fever]] >39 °C was associated with an increased risk of SBI, especially in [[infants]] under 6 months.  
*The majority of patients with [disease name] remain asymptomatic for [duration/years].
*In a prospective series of 103 children with a [[temperature]] >41 °C, almost 50% had an SBI.
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*[[Temperatures]] above 41 °C have also been associated with a higher risk of [[meningitis]].
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*[[Children]] with SBI may also have a normal [[temperature]] or be [[hypothermic]].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].


==Diagnosis==
==Diagnosis==
===Diagnostic Criteria===
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]
   
   
===Symptoms===
===Symptoms===


*[Disease name] is usually asymptomatic.
*[[Fever]] is often characterised by:<ref name="pmid21843857">{{cite journal| author=Ogoina D| title=Fever, fever patterns and diseases called 'fever'--a review. | journal=J Infect Public Health | year= 2011 | volume= 4 | issue= 3 | pages= 108-24 | pmid=21843857 | doi=10.1016/j.jiph.2011.05.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21843857  }} </ref>
*Symptoms of [disease name] may include the following:
**[[Chills]]
**[[Rigors]]
**[[Sweating]]
**[[Headache]]
**[[Malaise]]
**[[Anorexia]]


:*[symptom 1]
:*[symptom 2]
:*[symptom 3]
:*[symptom 4]
:*[symptom 5]
:*[symptom 6]
===Physical Examination===
===Physical Examination===


*Patients with [disease name] usually appear [general appearance].
*Initial [[history]] and [[physical examination]] in [[infants]] and [[young children]] with [[fever]] is aim to identify serious [[illness]]. [[Immunocompromised]] patients ([[cancer]], [[asplenia]], or [[HIV infection]]) need more [[evaluation]] and [[treatment]].  
*Physical examination may be remarkable for:
*[[Benign]] causes of [[fever]] such as [[vaccination]] in the past 24 hours are reassuring. [[Teething]] is rarely associated with a [[fever]] of more than 100.4°F
*A meta-analysis of [[febrile]] [[children]] older than one month has identified red flags associated with a high likelihood of serious [[infection]].


:*[finding 1]
*Clinical Red Flags for Serious [[Infection]] in Children Older than One Month<ref name="pmid20132979">{{cite journal| author=Van den Bruel A, Haj-Hassan T, Thompson M, Buntinx F, Mant D, European Research Network on Recognising Serious Infection investigators| title=Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: a systematic review. | journal=Lancet | year= 2010 | volume= 375 | issue= 9717 | pages= 834-45 | pmid=20132979 | doi=10.1016/S0140-6736(09)62000-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20132979  }} </ref>
:*[finding 2]
*'''Global assessments'''
:*[finding 3]
**Parental concerns
:*[finding 4]
**Physician instinct
:*[finding 5]
*'''Child behavior'''
:*[finding 6]
**Changes in crying pattern
**[[Drowsiness]]
**[[Inconsolability]]
**[[Moaning]]
*'''Circulatory/respiratory'''
**[[Crackles]]
**[[Cyanosis]]
**Decreased [[breath sounds]]
**Poor peripheral [[circulation]]
**Rapid [[breathing]]
**[[Shortness of breath]]
*'''Other factors'''
**Decreased [[skin]] elasticity
**[[Hypotension]]
**[[Meningeal irritation]]
**[[Petechial rash]]
**[[Seizures]]
**[[Unconsciousness]]


===Laboratory Findings===
===Laboratory Findings===


*There are no specific laboratory findings associated with [disease name].
*[[History]] and [[physical examination]] cannot identify all children with serious [[bacterial infections]], hence sensible use of imaging and laboratory testing is valuable.


*A  [positive/negative] [test name] is diagnostic of [disease name].
'''Urinalysis and urine culture'''
*An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
*Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].


===Electrocardiogram===
*[[Urinalysis]] is a key factor in the evaluation of [[fever]] in [[infancy]] and early [[childhood]] because [[UTI]] is a common cause of serious [[bacterial infection]].
There are no ECG findings associated with [disease name].
*Urine sample should be obtained for all children younger than 24 months with unexplained fever. It may be obtained by [[catheterization]] or [[suprapubic aspiration]].
*In [[children]] with [[voluntary urine control]], a [[clean catch]] method (urination into a specimen container after cleaning the area around the urethra) may be used.
*Cultures of specimens collected in a urine bag may have an 85 percent false-positive rate, and urine dipstick testing has a 12 percent false-negative rate.
*All specimens should be sent for formal urinalysis and culture.
*[[UTI]] rates vary with patient sex and age.
*In the first three months of life, [[UTIs]] are more common in boys than in girls, and much more common in [[uncircumcised]] boys. After three months of age, [[UTIs]] are more common in girls.


OR
'''Blood cell counts and blood culture'''


An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
*[[White blood cell]] ([[WBC]]) counts and absolute [[neutrophil]] counts have been used to point out serious [[bacterial infection]], including occult [[bacteremia]].
*[[Blood cell]] counts have higher value in neonates than in older children.
*[[WBC]] counts lower than 5,000 per mm3 (5 × 109 per L) or more than 15,000 per mm3 (15 × 109 per L) had a PPV of 44% for serious [[bacterial infection]], and an [[absolute neutrophil count]] of more than 10,000 per mm3 (10 × 109 per L) had a PPV of 71% according to a study of neonates up to 28 days of age.
*Current guidelines recommend a [[complete blood count]] with differential and [[blood culture]] for infants three months or younger with [[fever]].


===X-ray===
'''Stool testing'''
There are no x-ray findings associated with [disease name].


OR
*[[Diarrhea]] with [[fever]] in neonates and young infants submit [[systemic illness]] therefore [[stool culture]] and [[fecal]] [[WBC]] counts are supported.


An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
'''Inflammatory markers'''


OR
*The clinical value of [[C-reactive protein]] levels in recognizing serious infection in neonates, infants, and young children is being explored.
*[[C-reactive protein]] ([[CRP]]) level of 2 mg per dL (19 nmol per L) or greater has better [[sensitivity]], [[specificity]], and predictive value than a [[WBC]] count of greater than 15,000 per mm3 or less than 5,000 per mm3.
*Elevated levels of [[procalcitonin]] (another marker of [[inflammation]] and [[bacterial infection]]) also appear to have better [[sensitivity]], [[specificity]], and predictive value than [[WBC]] counts.


There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
'''Lumbar puncture'''
*[[Vaccination]] against [[S. pneumoniae]] and [[Hib]] has greatly reduced the [[incidence]] of [[meningitis]] limiting the need for [[lumbar puncture]].
*[[Fever]] with clinical signs of [[meningitis]] such as [[nuchal rigidity]], [[petechiae]], or abnormal [[neurologic]] findings in neonates, infants and young children is indication for [[lumbar puncture]].
*In children older than 3 months, the test is not suggested unless [[neurologic]] signs are present.
*Two guidelines recommended a [[lumbar puncture]] for well-appearing, previously healthy young infants with no focal signs of infection, a [[WBC]] count between 5,000 and 15,000 per mm3, and no [[pyuria]] or [[bacteriuria]] on [[urinalysis]].
*Although low peripheral [[WBC]] counts (less than 5,000 per mm3) are more often associated with [[meningitis]] than with [[bacteremia]], [[WBC]] counts should not be used alone to determine which infants need [[lumbar puncture]].


===Echocardiography or Ultrasound===
===Electrocardiogram===
There are no echocardiography/ultrasound findings associated with [disease name].
There are no [[ECG]] findings associated with [[fever]] in children.


OR
===X-ray===


Echocardiography/ultrasound  may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
*[[Chest X ray]] is recommended in all neonates with unexplained [[fever]].
*[[Chest X ray]] is also recommended for young children older than one month revealing [[respiratory]] symptoms and for patients with a [[fever]] of more than 102.2°F (39°C) and a [[WBC]] count of more than 20,000 per mm3 (20 × 109 per L).


OR
===Echocardiography or Ultrasound===
 
There are no [[echocardiography]]/[[ultrasound]] findings associated with [[fever]] in [[children]].
There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound  may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===CT scan===
===CT scan===
There are no CT scan findings associated with [disease name].
There are no [[CT scan]] findings associated with [[fever]] in children.
 
OR
 
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].


===MRI===
===MRI===
There are no MRI findings associated with [disease name].
There are no [[MRI]] findings associated with [[fever]] in children.
 
OR
 
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
OR
 
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
 
===Other Imaging Findings===
There are no other imaging findings associated with [disease name].
 
OR
 
[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
 
===Other Diagnostic Studies===
 
*[Disease name] may also be diagnosed using [diagnostic study name].
*Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===


*There is no treatment for [disease name]; the mainstay of therapy is supportive care.
*[[Fever]] plays a [[physiologic]] role in response to [[infection]], [[inhibiting]] [[bacterial growth]] and [[viral replication]], and [[enhancing]] the [[immune]] response.
*There is no evidence that use of [[antipyretics]] prolongs [[illness]] in children.
*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[[Antipyretic]] treatment should be reserved for distressed children, aiming at improving the child’s wellbeing rather than achieving normothermia.
*[Medical therapy 1] acts by [mechanism of action 1].
*[[Antipyretic]] treatment has not been shown to prevent recurrence of [[febrile]] [[seizures]].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
*Response to [[antipyretics]] cannot predict the severity of the underlying [[illness]], since children with [[bacterial]] and [[viral]] [[illnesses]] have a similar response to [[antipyretics]]. However, evaluating if the child’s conditions markedly improve with [[antipyretic]] treatment may be useful to discern whether it was related to fever or to the severity of the underlying illness.  
*In children with [[inherited]] [[metabolic]] and [[mitochondrial]] diseases, [[catabolic]] [[stressors]] should be avoided, and both [[fever]] and underlying [[infections]] should be treated
===Surgery===
*[[Fever]] may increase [[metabolic]] and [[oxygen]] [[consumption]]; therefore, aggressive treatment may be more important in children with a limited [[cardiopulmonary]] or [[metabolic]] reserve, and it is recommended in patients recovering from [[cardiac arrest]].
 
*[[Ibuprofen]] and [[acetaminophen]] are the only drugs approved for [[treatment]] of [[fever]] in children and they are generally considered to be equally safe and effective for reducing temperature and relieving discomfort.  
*Surgery is the mainstay of therapy for [disease name].
*Combination therapy with [[acetaminophen]] plus [[ibuprofen]] seems to be slightly more effective in reducing body [[temperature]] compared with monotherapy alone<ref name="pmid28862659">{{cite journal| author=Barbi E, Marzuillo P, Neri E, Naviglio S, Krauss BS| title=Fever in Children: Pearls and Pitfalls. | journal=Children (Basel) | year= 2017 | volume= 4 | issue= 9 | pages=  | pmid=28862659 | doi=10.3390/children4090081 | pmc=5615271 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28862659  }} </ref>
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].
===Prevention===
 
*There are no primary preventive measures available for [disease name].
*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
 
*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].


==References==
==References==
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[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Primary care]]

Latest revision as of 00:32, 28 March 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Zaida Obeidat, M.D.

Synonyms and keywords: Fever in kids

Overview

Fever can be defined as any elevation of body temperature above 38°C, it is a normal physiological response as a result of the encounter of an infectious agent producing exogenous and endogenous pyrogenes affecting the central set point of body temperature. It is mostly caused by a benign viral infection, but it can be an indicator of a serious sickness such as meningitis, septicaemia, pneumonia. The risk for severe change depends on the clinical condition and the age of the infant. Most predictive for serious sickness are situations in which infants are younger than 3 months with body temperature > or = 38°C, infants between 3 and 6 months with body temperature > or = 39°C, and children of any ages with critical clinical signs. Uncomplicated fever is benign and should not be treated.

Historical Perspective

Classification

Body temperature °C °F
Normal 37-38°C 98.6-100.4°F
Mild/low grade fever 38.1-39°C 100.5-102.2°F
Moderate grade fever 39.1-40°C 102.2-104.0°F
High grade fever 40.1-41.1°C 104.1-106°F
Hyperpyrexia >41.1°C >106.0°F

Pathophysiology

The role of pyrogens and cryogens

Pryogens

Cryogens


The pathophysiological mechanisms for the injurious effects of a fever, classified as follows:[3]

Causes

Common conditions that can cause fevers include:

Fever in children can sometimes associated with more serious signs and symptoms, such as:

Serious bacterial infections include:

Causes of undiagnosed fever in children include:[4]

Differential diagnoses for fever in children

Cause Differential Diagnosis
Infectious; Bacterial or mycobacterial Brucellosis, dental abscess, endocarditis, non-tuberculous mycobacteria (eg, Mycobacterium chelonae), occult bacterial infection, recurrent bacterial infections, relapsing fever (Borrelia spp other than Borrelia burgdorferi), Yersinia enterocolitica
Parasitic Malaria (eg, Plasmodium vivax, Plasmodium ovale)
Inflammatory or Immunologic Behçet syndrome, inflammatory bowel disease (eg, Crohn disease), hereditary fever syndromes (eg, FMF), juvenile dermatomyositis, PFAPA syndrome, sarcoidosis, systemic lupus erythematous, systemic juvenile idiopathic arthritis (Still disease), vasculitis (eg, polyarteritis nodosa)
Malignant Leukemia, lymphoma
Other Benign giant lymph node hyperplasia (Castleman disease), CNS abnormalities (eg, hypothalamic dysfunction), drug fever, factitious fever, IgG4-related disease, immunodeficiency syndromes with recurrent infections


Epidemiology and Demographics

Age

Prognosis

Diagnosis

Symptoms

Physical Examination

Laboratory Findings

Urinalysis and urine culture

  • Urinalysis is a key factor in the evaluation of fever in infancy and early childhood because UTI is a common cause of serious bacterial infection.
  • Urine sample should be obtained for all children younger than 24 months with unexplained fever. It may be obtained by catheterization or suprapubic aspiration.
  • In children with voluntary urine control, a clean catch method (urination into a specimen container after cleaning the area around the urethra) may be used.
  • Cultures of specimens collected in a urine bag may have an 85 percent false-positive rate, and urine dipstick testing has a 12 percent false-negative rate.
  • All specimens should be sent for formal urinalysis and culture.
  • UTI rates vary with patient sex and age.
  • In the first three months of life, UTIs are more common in boys than in girls, and much more common in uncircumcised boys. After three months of age, UTIs are more common in girls.

Blood cell counts and blood culture

Stool testing

Inflammatory markers

Lumbar puncture

Electrocardiogram

There are no ECG findings associated with fever in children.

X-ray

  • Chest X ray is recommended in all neonates with unexplained fever.
  • Chest X ray is also recommended for young children older than one month revealing respiratory symptoms and for patients with a fever of more than 102.2°F (39°C) and a WBC count of more than 20,000 per mm3 (20 × 109 per L).

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with fever in children.

CT scan

There are no CT scan findings associated with fever in children.

MRI

There are no MRI findings associated with fever in children.

Treatment

Medical Therapy

References

  1. Stein MT (1991). "Historical perspective on fever and thermometry". Clin Pediatr (Phila). 30 (4 Suppl): 5–7. doi:10.1177/0009922891030004S02. PMID 2029820.
  2. 2.0 2.1 2.2 Ogoina D (2011). "Fever, fever patterns and diseases called 'fever'--a review". J Infect Public Health. 4 (3): 108–24. doi:10.1016/j.jiph.2011.05.002. PMID 21843857.
  3. Walter EJ, Hanna-Jumma S, Carraretto M, Forni L (2016). "The pathophysiological basis and consequences of fever". Crit Care. 20 (1): 200. doi:10.1186/s13054-016-1375-5. PMC 4944485. PMID 27411542.
  4. BREWIS EG (1965). "CHILD CARE IN GENERAL PRACTICE. UNDIAGNOSED FEVER". Br Med J. 1 (5427): 107–9. PMC 2165027. PMID 14218464.
  5. Soon GS, Laxer RM (2017). "Approach to recurrent fever in childhood". Can Fam Physician. 63 (10): 756–762. PMC 5638471. PMID 29025800.
  6. Van den Bruel A, Haj-Hassan T, Thompson M, Buntinx F, Mant D, European Research Network on Recognising Serious Infection investigators (2010). "Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: a systematic review". Lancet. 375 (9717): 834–45. doi:10.1016/S0140-6736(09)62000-6. PMID 20132979.
  7. Barbi E, Marzuillo P, Neri E, Naviglio S, Krauss BS (2017). "Fever in Children: Pearls and Pitfalls". Children (Basel). 4 (9). doi:10.3390/children4090081. PMC 5615271. PMID 28862659.