1. fever do n dont pit idi
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feverTRANSCRIPT
Fever in Children: Do and Don’t
Dwiyan' Puspitasari Divisi infeksi dan Penyakit Tropik Dept/ SMF Ilmu Kesehatan Anak FK UNAIR/ RSUD dr. Soetomo Surabaya
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Outline:
• What is fever?
• Do and don’t in children with fever
• Take home massage
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FACTS Demam : 70% keluhan orang tua § 50% sdh menganggap demam suhu rektal < 38oC § 25% mulai memberi antipiretik pada suhu < 37,8oC § 85% membangunkan anaknya untuk memberikan
antipiretik § 50% memberi antipiretik dengan dosis tidak benar § 15% memberikan dosis supraterapeutik
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Outline:
• What is fever?
• Do and don’t in children with fever
• Take home massage
4
Fever
is an elevation of body temperature above
the normal circadian range as the result of
a change in the thermoregulatory center
located in the anterior hypothalamus and pre-
optic area
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• Normal body temperature reached highest level in early evening (5-‐7 p.m)
• Young children: relaLvely high rectal temperature predominate
• Diurnal temperature – children have more fluctuated than adult – Gradually decreased towards adult levels beginning at 2 years of age, trend stabilizes soon aQer puberty
Normal Body Temperature
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Diurnal pa9ern of body temperature
Diurnal temperature in children more fluctuated than in adults
Normal bod
y tempe
rature
36.2-‐37.5oC
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Location Thermometer Normal
temperature Range, mean
(oC)
Fever (oC)
Axilla Mercury, electronic 34.7 – 37.3; 36.4 37.4 Sublingual Mercury, electronic 35.5 – 37.5; 36.6 37.6 Rectal Mercury, electronic 36.6 – 37.9; 37.0 38.0 Ear Infra red emission 35.7 – 37.5; 36.6 37.6
FEVER ? Measurement of body temperature
Recommenda'on site of measurement: Age < 4 weeks: electronic thermometer axilla
Age >4 weeks to 5 years: electronic thermometer axilla, mercury thermometer axilla, infrared tympanic thermometer 8
Outline:
• What is fever?
• Do and don’t in children with fever
• Take home massage
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Children with fever DO: ü consider the age: neonates/ < 3 mos/ infants/ child ? • the younger age ≈ higher risk of serious bacterial infecLon (SBI) -‐ Febrile neonates : SBI ≈ 13% -‐ Febrile infants < 3 mos: SBI ≈ 10% -‐ Febrile infants 3-‐36 mos: bacteremia ≈ 1.6%
• Febrile infants < 3 mos: UTI account for 1/3 all bacterial diseases
Avner JR, Baker MD. Management of fever in infants and children. Emerg Med Clin North Am. 2002 Feb;20(1):49-‐67. 10
Serious Bacterial Infec'on
• Bacteremia • MeningiLs • Urinary tract infecLon • SoQ Lssue infecLon • Bone/joint infecLon • EndocardiLs • Pneumonia • GastroenteriLs
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Fever in neonate
Suspect -‐ serious bacterial infec'on (SBI) ü DO: consider hospitaliza'on 12
Sustained/ con'nuous: Temp remains above normal, minimal
variaLons (< 1oC). Seen in persons with drug fever, typhoid, viral pneumonia.
Remi9ent: Temp does not return to normal, varies a few degrees. Associated with viral URI, legionella, mycoplasma inf.
Intermi9ent: Temp return to normal at least once every 24 hours. Associated with: gram+/-‐ sepsis, abscess, acute bacterial endocardiLs
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History taking & physical examina'on: ü DO: Seek type of fever
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Relapsing/Periodic: one/ more episodes of fever, each lasted several days, with one/ more days of normal temp between. May caused by a variety of infecLous diseases, including viral infecLon (measles, polio), malaria.
Undula'ng: Temp increases and decreases as in waves.
It is seen in brucellosis, Hodgkin's disease.
History taking & physical examina'on
DO: ü Search cause of fever with careful history taking & physical examinaLon • idenLfy potenLal focal infecLon (e.g., pneumonia, abscess, celluliLs, sinusiLs, oLLs media, osteomyeliLs, impeLgo, lymphadeniLs, strep. pharyngiLs)
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Physical examinaLons
Detail physical
examinaLons are needed
Special akenLon to certain part
Heart sound (endocardi's) Joint, lymph nodes, muscle
(myalgia), Pain of extrimi'es (SLE)
Icterus (hepa''s) Skin rash (vascular-‐collagen disease, Kawasaki disease)
Peritonsillar abscess Mass intra abdominal
Blood stool
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Fever Unknown Origin in children:
The ELology
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ü Seek the Danger Signals • Changes in behaviour • Severe headache • Constant vomi'ng or diarrhea
• Skin rash • Dry mouth • Sore throat that doesn't improve
• Earache that doesn't improve
• S'ff neck • Stomach pain
• Fever comes & goes over several days
• High-‐pitched crying • Swelling on the sod spot on the head
• Irritable • Unresponsive or limp • Not hungry • Wheezing or problems breathing
• Pale • Whimpering
DO:
à Consider hospital admission 18
Table 1. Yale Observation Scale Observation Item Normal = 1 Moderate impairment
= 3 Severe impairment = 5
Quality of cry Strong or none Whimper or sob Weak or moaning, high-pitched, continuous cry or hardly responds
Reaction to parent stimulation
Cries brief or no cry and content Cries on and off Persistent cry with little response
State variation If awake, stays awake or if asleep, awakens quickly
Eyes close briefly when awake or awakens with prolonged stimulation
No arousal and falls asleep
Color pink pale extremities or acrocyanosis
pale or cyanotic or mottled or ashen
Hydration Skin and eyes normal and
Skin and eyes normal and mouth slightly dry
Skin doughy or tented and dry mucous membranes and/or sunken eyes
Response to social overtures
Smiles or alerts (consistently) Brief smile or alert No smile, anxious, dull; no
alerting to social overtures
A total score of less than 11 signifies a less than 3% probability of serious illness. A total score of 11-15 signifies a 26% probability of serious illness. A total score of greater than 15 signifies a greater than 92% probability of serious illness.
Criteria of toxic /severity: Yale scores greater than 15 19
DiagnosLc Test of Yale ObservaLon Scale
NaLonal CollaboraLng Centre for Women’s and Children’s Health
Skor YOS + anamnesis + pemeriksaan fisik: sensiLfitas
89%-‐93% dan NPV 96%-‐98%. Nilai total skor 6 pada kelompok umur 3 bulan-‐3 tahun, dapat mendeteksi occult bacteriemia dengan NPV 97,4%.
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DiagnosLc Test of Yale ObservaLon Scale
PraLwi , Tumbelaka AR. dkk. Departemen IKA FKUI/RSCM, RS FatmawaL, dan
RS Harapan Kita, Jakarta, 2010
256 kasus demam dengan skor 8 : sensiLvitas 69,35%, spesifisitas 90,2%,
PPV 69,35%, NPV 90,2%, rasio kemungkinan posiLf 7,08, dan rasio kemungkinan neg 0,34
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ü DON’T consider admission if they meet the following criteria:
• was healthy prior to onset of fever • has no significant risk factors • appears non-‐toxic & otherwise healthy • laboratory results are within reference ranges defined as low risk
• parents/ caregivers appear reliable & have access to transportaLon if symptoms worsen
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DO: Differen'ate viral or bacterial infec'on? ü Fever in children mostly caused by VIRAL URTI (>80%) ü Only 10-20% caused by BACTERIAL Infection, should be
searched to prevent delay in diagnosis and treatment ü Presence of stomatitis, varicella, or other exanthema à clue to
diagnosis, further examination mostly not necessary ü Children with impaired immune status (HIV, malignancy)
considered having BACTERIAL infection until proven otherwise
Work up in a child with fever
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Work up in a child with fever
Likely VIRAL Likely BACTERIAL
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Risk of Occult Bacteremia
OB has a low prevalence, so even though WBC is a sensiLve and specific screening test, it has a low PPV. So the test does not discriminate between children who have FWS who are bacteremic and those who are not.
Therefore, blood culture is the gold standardàsLll has a high number of false posiLves, take 24-‐48hrs, and most cases of occult pneumococcal bacteremia clear without treatment.
Low Risk Age >3yr Temp <39.4ºC WBC >5000 and
<15,000
High Risk <2yr >40ºC(104ºF) <5000 or >15,000 Hx of contact with H. Flu or N. meningitidis
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Step 1 WBC, blood smear, blood cell morphology
Chest x-‐ray Thick blood smear (endemic malaria) BSR, CRP Urine analysis LCS, other body fluid depend on indicaLon Blood, urine, stool, nasopharyngeal swab culture Tuberculin test Liver funcLon test
ü DO: Gradual Laboratory examina'on
* Note: in serious case, lab procedure should be performed more rapidly 26
Step 2 Serological test: Salmonella, toxoplasma, leptospira, mononucleosis, CMV, histoplasma Ultrasonography: abdominal, skull
Step 3 Bone marrow puncture
Intravenous pyelography Paranasal sinus photography AnLnuclear anLbody (ANA) Barium enema examinaLon Scanning examinaLon Liver biopsy Laparatomy diagnosLc
Laboratory examinaLon
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DON’T: Laboratory examinaLon
ü Don’t tests or give anLbioLcs if infant or young child looks well and no possible bacterial source is idenLfied – Schedule a follow-‐up appointment within 24-‐48 hours and sooner if the condiLon worsens
ü Don’t test serological anLbody in fever< 5 days
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ü MedicaLon is only needed to make child comfortable • If child has a fever yet is content, eaLng, drinking, or playing, they may not need medicaLon
ü Always give your child medicaLon for fever if he has had febrile seizure
ü AnLpyreLc therapy: • Paracetamol (Acetamniophen):15 mg/kg /dose q 4 h • Ibuprofen : 12 mg/kg /dose q 8 h • Mefanamic acid – 2.5 mg/kg/ dose q 8 h • Nimesulide – 4 mg/kg/dose q 8 h
DO: Fever Management: ANTIPYRESIS
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An'pyresis § Many parents aim for “normal” temperature
o Daycare, school & work can drive this § AnLpyresis therapy DOES NOT
o Reduce morbidity or mortality from a febrile illness
o Decrease the recurrence of febrile seizures § AnLpyresis DOES
o Relieve discomfort o Decrease insensible fluid loss
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An9pyre9cs is indicated for ………. 1. Symptoms such as pain, discomfort, delirium,
excessive lethargy 2. A situaLon associated with limited energy
supply/ metabolic rate § burn, cardiovascular, pulmonary diseases, prolonged feVER, young children, undernourish, postoperaLve
3. Young children at risk of hypoxia because of acute respiratory condiLon such as bronchioliLs
4. A high degree of fever > 40 ℃
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ü Dress in lightweight clothing to allow heat loss through skin ü Use a lightweight blanket if they feel cold/ shivering ü Try to keep them quiet -‐ acLvity increases body temperature ü Give extra fluids to prevent dehydraLon/extra loss of water ü Make sure room has a comfortable temperature -‐ not too
hot or too cold ü Sponge bath with lukewarm water if fever> 40° C and not
decreased 30-‐60 minutes aQer medicaLon is given-‐-‐ NEVER LEAVE ALONE IN THE TUB
• Stop the sponge bath if your child starts to shiver
DO: Fever Management: Others
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ü Don't wake them up to give medicines. If the fever is high enough to need medicaLon, your child will waken
ü Aspirin -‐ Do not use Aspirin for fever (related to a serious illness, Reye's Syndrome)
ü Do not use ibuprofen in child < 6 moths ü Never use rubbing alcohol for baths or sponging
DON’T: Fever Management: AnLpyresis & other
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DO: Fever Management: ANTIBIOTIC
ü As clinical diagnosis of Bacterial infecLon is rarely possible within the first 2-‐3 days of fever à prescribing anLbioLc is not recommended during this period
ü for most community infecLons, oral amoxycillin, or cotrimoxazole is sufficient (first line drugs)
ü If the response to the first anLbioLc is poor, another drug may be tried. If two drugs have failed, it is logical to reconsider the diagnosis rather than change the anLbioLc
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An'bio'c prescrip'on in bacterial infec'on
Bacterial infec'on
Culture (Gram stain)
Pathogen iden'fica'on
Defini've therapy
Narrow spectrum of an'bio'c
Cured Empirical therapy
Confirma'on
Guess
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DON’T: Fever Management: ANTIBIOTIC
ü Do not prescribe an anLbioLc without presumpLve diagnosis -‐ RouLne invesLgaLons must be carried out to support it
ü Do not try empirical treatment for tuberculosis except in life threatening situaLons
ü Injectable anLbioLcs are almost never needed in office pracLce
ü Newer anLbioLcs are not recommended for rouLne community acquired infecLons
ü Steroids should never be used for undiagnosed fever 36
Outline:
• What is fever?
• Do and don’t in children with fever
• Take home message
37
Take home message
• AkenLon should be paid to toddlers (below three years of age) with high fever for detect SBI
• History taking, physical examinaLon, Yale ObservaLon Scale could help to detect the serious infecLon
• Most fever in children are caused by viral infecLon • AnLpyresis is only needed to comfort child • AnLbioLc only used for bacterial infecLons
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