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Fever and its treatment
Actuality of the topic
• 1/ Frequency of feverish events in children,
• 2/ Informations targeting fever treatment
• from uncontrolled sources easily reached on the
internet,
• 3/ Parental anxiety . Lack of authentic information
about the appropriate measures when a child has
fever – this leads to unnecessary medical visits,
• 4/ Recent changes in medical view about fever and
its treatment.
The most important changes during the
lest decade concerning fever and its
treatment:
• The treatment of fever in an otherwise well
child routinely is not indicated. If the only
indication of the treatment of fever is the
decrease of body temperature, then
treatment is not justified. Treatment of the
fever can be considered if the child is unwell,
pain is present (Evidence degree IV).
Basic causes of change in the
consensus of the treatment of fever:
• 1/ Fever is a physiologic reaction to infection.
• 2/ There are several immunologic reactions which are
stimulated by fever: fever decreases the replication rate of
bacteria and viruses, increases phagocytic function. In
some diseases (e.g.. varicella) antifebrile treatment
increases morbidity. It is important to mention that the
seroconversion after some vaccinations is decreased if
antifeibrile treatment is applied following the vaccination.
Unnecessary, routinely applied antifebrile drug treatment
can delay recovery. Antifebrile treatment is recommended
only if it improves the general wellbeing of the child or it
provides pain relief.
• 3/ There are several side effects: acetylsalicylic acid –
Reye syndrome; paracetamol – liver, kidney demage;
aminophenazone –agranulocytosis.
• 4/ The main cause of antifebrile treatment is the fear
of febrile convulsion. This is clear nowadays that
fever is not the cause of convulsion and the
treatment of fever cannot prevent or treat the
convulsion.(Level of evidence I)
Causes of changes in body
temperature
• Change of the regulation of body temperature
• Disbalance between heat production and heat
dissipations while the normal regulation is
maintained.
Fever
• Exogenous and endogenous pyrogenes
• The „set-point” of body temperature regulation is
switched to higher body temperature.
• Consequence:
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Dissipation of heat is decreased
Heat production is increased
Body temperature increases
Heat production and heat dissipation reaches a balance at
higher body temperature
Hyperthermia
• Increase of body temperature at a normal
body temperature regulation
• Causes:
– Increased heat production: vigorous physical
activity, hyperthyreosis, increased heat irradiation,
etc.
– Decreased heat dissipation: high envirtonmental
humidity, inhibition of sweating, etc.
Temperature measured in the axillary pit
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36-37°C
37-38 °C
38-39 °C
39-40,5 °C
40,5 °C felett
normal body temperature
subfebrile body temperature
mild fever
high fever
very high fever
If the temperature is measured rectaly then 0.5
°C has to be deducted
Thermometers
•Traditional mercury thermometers are not recommended any
more
•Digital thermometers
•Skin thermometers
•Ear thermometers (measures the temperature at the ear drum)
Site of measurement
• Rectal (over 3 years of age it is not
recommended)
• Axillary pit
• Mouth
• Ear
• Forehead
The fever is a normal, physiologic response
of the body to and against infections
• Fever stimulates the immune response to
infections
• Helps the eradication of bacteria and viruses
• Non-indicated, surplus antifebrile treatment
hinders recovery
• Antifebrile treatment is recommended only if
it improves the general wellbeing of the child,
relieves pain and suffer
Clinical signs of fever
• Flushing of the cheeks
• Increased pulse and breathing rate
• Malaise, sleepiness, influenced consciousness,
headache, restlessness, irritability
Febrile siezure
• Febrile seizure develops during diseases with
high body temperature
• The febrile convulsion cannot be prevented or
treated by the reduction of body temperature
Methods of antifebrile treatment
• physical
– bath
– Wet pack, cold compress
pharmacologic
Physical method
• In the last decade lots of countries opposed physical
treatment of fever because it causes more harm than
adavantage. In many countries therefore the physical
method is not recommended any more The Hungarian
Pediatric Board is more liberal or conservative: in the case
of high fever it agrees to use tolerable physical treatment
together with pharmacologic treatment.
• Pysical therapy may reduce the application of drugs and
their side effect.
• For children a bath can be the most tolerable method of
antifebrile treatment
• Shivering shoud be avoided, since it increases heat
production.
Physical treatment of fever
• It can help if the temperature of the bath is
adjusted to the actual body temperature and is
decreased gradually. The temperature of the bath
is to be decreased slowly to a temperature not
lower than 31 C°.
• Do not use ice-cold water.
• Do not continue cooling if the body temperature
drops below 38 C°
Pharmacologic treatment
• International guidelines prefer paracetamol
and ibuprofen. These two drugs are the most
widely used drugs for the treatment of fever.
Pharmacologic treatment
• Paracetamol
4-6 hourly
– Panadol
– Neo Citran
– Mexalen
– Coldrex
– Béres Febrilin
– Ben-U-Ron
– etc.
supp., syrup, pill; 10-15mg/kg
Pharmacologic treatment
• Ibuprofen
– Nurofen – supp., syrup, pill
• 5-10 mg/kg/dosi, 20-30 mg/kg/day
Pharmacologic treatment
• Metamizole-sodium
– Algopyrin
per os 30mg/kg/day in 4-5 portions;
injection: 10 mg/kg im. 1-2 × a day; below 3
months of age and/or 5 kg bw. not recommended
Pharmacologic treatment
• Acetylsalicylic acid 10-15 mg/kg 6 hourly
– Kalmopyrin
– Aspirin
– Etc.
• Below 12 years of age salicylates must not be
used!!
• The administration of two types of antifebrile
drugs at the same time is not recommended!
• The shift from paracetamol to ibuprofen
routinely is not supported.
• The shift from one to other drug can be
considered if the first drug is ineffective (level
of evidence IV).
advices
• Under the age of 6 months fever is relatively rare. If
it appears then it should be taken as a sign of
severe illness.
• 38 C° or higher fever under the age of 3 month
• and 39 C° or higher fever between the age of 3-6
months needs medical attention
advices
• Fluid intake is important
• Signs of dehydration have to be checked
• In the case of „Non-fading rash” medical help is
necessary*
• Feverish child should not attend communities
• Cold bath is not recommended
Glass test: press a glass onto the skin rash. Looking
through the glass watch if the rash fades or not.
Immediate medical help is necessary
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„non-fading” rash
convulsion
Sleepiness
It is difficult to wake up
Signs of dehydration
Appearance of new symptomes
General status of the child deteriorates
The fever lasts for more then 3 days
If the supervision, care of the child cannot be assured at home
Tasks in the case of convulsion:
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Do not be anxious, stay calm
Record the start and the end of the convulsion
Stay beside the child,
Turn the head of the child to the side
Put something soft under the head of the ch.
Do not give anything to drink or eat
Consult to a medical doctor
convulsion
• Diazepam 0,3-0,5 mg/ kg iv
• Rectal administration – 5 and 10 mg is
available. Between 10-15 kg (1-3-year-olds)
5mg; beyond 15 kg (above 3 years) 10 mg
Hyperpyrexia syndrome
(haemorrhagic shock and encephalopathy syndrome)
• Earlier healthy child with mild illness presents
hyperpyrexia with altered consciousness,
convulsion, shock, hepatomegaly diarrhoe,
bleeding.
• Etiology not known
• Prognosis is poor
Malignant hyperthermia
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Rare sy
autosomal dominant
The gene is located on chromosome 19.
the intracellular Ca2+ - transport is disturbed.
Drugs used in general anaesthesia
(succinylcholin, halothan) can provoke,
precipitate the dis.
Malignant hyperthermia
• Clinical characteristics:
– Increased oxigen demand
– Increased CO2 production
– Very high fever
– Muscle rigidity
– rhabdomyolysis
consequencies
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Comb. resp and metab acidosis
Tachycardia, tachypnoe
Hyperkalaemia
Myoglobonuria
Malignant arrhythmia
Acut renal failure
Therapy
• The administration of the triggering drug has
to be suspended
• Agressive supportive therapy
– cooling, hyperventilation, correction of acidosis
and hyperkalemia - dialysis
Start the administration of dantrolen (2,5 mg/kg
during 15 min) that can be repeated 4 times,
followed by the continuous infusion of dantrolene
(7,5 mg/kg/day) for 48-72 hours
• Similar diseases – different genetically and/or
triggers - malignant neuroleptic sy., acute
rhabdomyolysis
Questions?