Fever in Common Infectious Diseases

Infection of the upper airways is very common and is the most common acute illness evaluated in the outpatient setting. The infection is usually caused by viruses including rhinoviruses, influenza viruses, parainfluenza and respiratory syncytial viruses. Influenza is the only viral infection preventable by vaccination and occurs predominately during annual winter epidemics. Bacterial infection such as acute rhinopharyngitis is uncommon and usually presents with either persistent symptoms of an URTI lasting over a week or worsening course after initial improvement or acute onset with high fever and inflammatory changes confined to the pharynx.

Fever is common in both bacterial and viral gastroenteritis. High fever is commonly present in many bacterial causes (e.g. Shigella, Salmonella, Shiga toxin-producing E. coli). Fever is often absent or low-grade in other diseases (e.g. enteropathogenic E. coli, cholera). Other febrile conditions cause diarrhoea and need to be differentiated.

Fever in CNS infection is the most common presenting symptom in children beyond the neonatal age owing to the presence of inflammatory mediators, particularly IL-1 and TNF in the blood or within the CNS. In MCD, fever was the first symptom in children younger than 5 years and 94% developed fever at some point.

Viral exanthems are common causes of febrile illness in children. More than 50 viral agents are known to cause a rash. Historically, exanthems were numbered in the order in which they were differentiated from other exanthems. Thus the first was measles; second, scarlet fever; third, rubella; forth, so-called Filatov-Dukes disease (no longer recognized as an entity); fifth, erythema infectiosum; and sixth, exanthema subitum. As more exanthems were described, numerical assignment became impractical.

Management of common neonatal problems

The important causes of neonatal mortality are congenital malformations, birth trauma, neonatal infections, and respiratory, metabolic and heart diseases. Although many of the neonatal problems are benign, self-limited and treatable, some are life-threatening and a direct cause of disability and death. Professionals who provide care for children must be aware of these problems, their natural history, their impact on children's heath and their treatment. Birth marks are common and often harmless, but parents need explanation and reassurance. Follow-up appointments are often necessary to ensure the general wellbeing of the affected children. Birth trauma, such as intracranial haemorrhage or arm paralysis, may occur during delivery, and treatment at a specialised unit is usually required. The prognosis of neonatal infections is generally poor, with high mortality unless treatment is started promptly and adequately. Respiratory diseases occur mainly in low birth-weight infants who may require mechanical ventilation. Metabolic and heart diseases are rare, but early detection is essential to ensure a high survival rate.

Management of common behaviour and mental health problems

Behavioural problems are usually influenced by both biological and environmental factors. Disruptive behavioural problems such temper tantrums or attention deficit hyperactivity disorder are displayed during the first years of childhood. Breath-holding attacks are relatively common and are an important problem. Although the attacks are not serious and the prognosis is usually good, parents often fear that their child may die during an attack. Parents therefore require explanation and reassurance from health professionals. Conduct disorders (often referred to as antisocial behaviours), such as aggression to others or theft, are more serious as they tend to be repetitive and persistent behaviours where the basic rights of others are violated. Emotional problems, such as anxiety, depression and post-traumatic stress disorder tend to occur in later childhood, and are often unrecognised because young children often find it difficult to express their emotions, or it may go unnoticed by the child's parents. This article briefly discusses the most common behavioural problems, including autism, that affect children of all ages.

Safeguarding the welfare of children: what is the nurse's role?

Everyone who works with children, including teachers, GPs, other medical professionals and the police, has a responsibility to keep children safe and protect them from harm. Simply put, safeguarding children is everyone's responsibility. Children should be protected from maltreatment and any impairment that may affect their health and development. In addition, we all have to ensure that children grow up with safe and effective care. At particular risk, and therefore in particular need of safeguarding, are children who are disabled; who have educational or other specific additional needs; and who bear signs of child abuse, substance abuse, or domestic violence. Under the Children Act 1989, local authorities are required to provide services for children in need for the purposes of safeguarding and promoting their welfare. Nurses are well-placed to identify children and young people who may be at risk, and to act to safeguard them. Nurses and other health professionals should be familiar with local referral arrangements, usually to children's social care.

Appropriate care for children with eating disorders and obesity

Eating disorders are essentially psychological diseases that are characterised by abnormal eating habits. Anorexia nervosa and bulimia are the most common forms of eating disorders. There is an increased recognition of eating disorders among both men and women, and growing numbers of children and teenagers seeking help for eating disorders. Fear of body-weight gain is central to both anorexia nervosa and bulimia. Before the diagnosis of an eating disorder is made, it is essential to exclude organic diseases that may present with similar symptoms to eating disorders. Management initially should focus on correcting the nutritional deficiencies and dehydration at a paediatric or paediatric gastroenterology department, followed by a multidisciplinary approach. At the other extreme, the prevalence of obesity in children is increasing at an alarming rate, and presents a serious public health challenge.

Management of seizures in children

Seizures are common events in children and up to 10% of all children experience at least one seizure during their childhood. They can be triggered by many conditions such as fever, medications or injury. Febrile seizures are the most common types of seizures, affecting 3-4% of children. While epilepsy is typically recurrent and unprovoked, a single, isolated seizure is not epilepsy. Taking a detailed history of the seizure description helps establish the diagnosis. A video recording of the event can also support the diagnosis and rule out non-epileptic seizures that resemble seizures, such as pseudo-seizure. Seeing a child having a seizure, particularly if it is the first one, is usually frightening and distressing for the parents. First seizure should always be evaluated by health professionals because of a possible serious underlying cause. If the seizure occurs at home, the child should be placed in the recovery side position to prevent the swallowing of any vomit. The care of a child who does have epilepsy is best achieved by a community or hospital epilepsy specialist nurse. These nurses play a pivotal role in providing a close link between the epileptic children and their families. Such a nurse is also in an ideal position to establish a link between the doctor and affected families, offering valuable advice and support, and visiting the epileptic child at home.

Management of abdominal pain in children

Abdominal pain (AP) is a very common complaint caused by a variety of conditions. Mild or moderate AP affects practically all children of all ages. The pain usually settles spontaneously without medical intervention. AP severe enough to require medical intervention has both surgical and non-surgical causes. It is responsible for considerable morbidity, missed school days, and significant use of health resources. Children usually present either with an acute or recurrent AP. In comparison, chronic AP with persistent symptoms, lasting days or weeks, is rare in children. Surgical conditions may be the underlying causes in acute AP, but non-surgical conditions are diagnosed more commonly in children with recurrent AP. Management can be difficult, time-consuming and often clinically challenging to diagnose and treat. In most instances, the cause of AP can be diagnosed through the history and physical examination. The main objective in managing an affected child is to differentiate between benign, self-limited conditions such as constipation or gastroenteritis, and more life-threatening surgical conditions such as intussusception or appendicitis. Irritable bowel syndrome (IBS) and Crohn's disease should be considered in any child presenting with recurrent AP.

Determining fever in children: the search for an ideal thermometer

Body temperature measurement is most commonly taken to confirm the presence or absence of fever. Many decisions concerning the investigation and treatment of children are based on the results of temperature measurement alone. Determining the presence of fever in young children is particularly important. A missed fever is serious, but a false-positive fever reading can result in unnecessary septic workups. The axillary, rectal, oral and tympanic membrane sites are most commonly used to record body temperature, and electronic and infrared thermometers are the devices most commonly used. Each site and device has numerous advantages and disadvantages, which are described in this article. The search for the means of measuring body temperature that best combines accuracy, speed, convenience, safety and cost-effectiveness goes on. The infrared thermometer and the tympanic site appear to offer such a combination. Electronic thermometers are also suitable when used orally or at the axilla in newborn babies.

Fever management: Evidence vs current practice

Fever is a very common complaint in children and is the single most common non-trauma-related reason for a visit to the emergency department. Parents are concerned about fever and it’s potential complications. The biological value of fever (i.e., whether it is beneficial or harmful) is disputed and it is being vigorously treated with the belief of preventing complications such as brain injury and febrile seizures. The practice of alternating antipyretics has become widespread at home and on paediatric wards without supporting scientific evidence. There is still a significant contrast between the current concept and practice, and the scientific evidence. Why is that the case in such a common complaint like fever The article will discuss the significant contrast between the current concepts and practice of fever management on one hand, and the scientific evidence against such concepts and practice.

The clinical course of childhood asthma in association with fever

Little attention has been given to the relationship between fever and the severity of asthma. The authors studied 202 successive admissions of children with asthma over a period of 16 months to investigate the relationship between fever and the clinical course of asthma. There were 38 febrile children (18.8%), who were mostly younger than 5 years. Febrile children had a shorter mean hospital stay than afebrile children (1.7 vs 2.0 days). There were 25 episodes of acute severe asthma (13%): 2 among the 38 febrile children (5.2%), compared with 23 episodes among the remaining 164 afebrile children (14%). Three children, who had very severe asthma requiring transfer to an intensive care unit, were afebrile. Radiological abnormalities (collapse/consolidation) occurred in 13 cases: 3 from the febrile and 10 from the afebrile group. Monitoring body temperature is important in cases of asthma. Febrile children tend to be younger and are more likely to have a less severe clinical course of asthma.

Temperature measurement in children with cancer: an evaluation

There is little agreement as to the most appropriate thermometer, the anatomical site to carry out temperature measurement in children with cancer, or the type of thermometer preferred by the patients. The authors carried out this study to assess temperature measurement in children with cancer who were admitted for febrile episodes. The body temperatures of children with cancer who were admitted consecutively between January and October 2005 to the paediatric department because of febrile episodes were measured on admission and over the next 24-36 hours using an electronic thermometer sublingually as the standard reference site. These measurements were compared with those obtained with two ear-based thermometers, a forehead thermometer, and from the axilla (representing current practice). The parents were asked about the type of thermometer they used at home and the children were asked about the type of thermometer they preferred. There were 34 admissions during this period, of which 19 (56%) were confirmed as febrile. Altogether, 108 sets of temperature measurements were obtained, producing a total of 540 measurements from these admissions. Measurements with the two ear-based thermometers in febrile children achieved higher sensitivity than that with axillary and the forehead measurements. The ear-based thermometer was the most common type used at home while the forehead thermometer was the one preferred by the children. In conclusion, ear-based temperature measurements in febrile children were more accurate than axillary and forehead temperature measurements. The current practice of axillary temperature measurement needs to be re-considered.

A randomised comparison of oral desmopressin lyophilisate (MELT) and tablet formulations in children and adolescents with primary nocturnal enuresis

AIMS

Desmopressin is a useful treatment for primary nocturnal enuresis (PNE), a common childhood condition that can persist into adolescence. This open-label, randomised, cross-over study evaluated the preference of children and adolescents with PNE for sublingual desmopressin oral lyophilisate (MELT) vs. tablet treatment, and the efficacy, safety, compliance and ease of use associated with each formulation. In total, 221 patients aged 5-15 years who were already receiving desmopressin tablets were randomised 1 : 1 to receive desmopressin treatment in the order MELT/tablet (n = 110) or tablet/MELT (n = 111) for 3 weeks each. Each formulation was administered in bioequivalent doses (0.2/0.4 mg tablets identical with 120/240 microg MELT). Following treatment, patients were questioned regarding treatment preference. Diary card data and 100 mm Visual Analogue Scale scores were also recorded.

RESULTS

Overall, patients preferred the MELT formulation to the tablet (56% vs. 44%; p = 0.112). This preference was age dependent (p = 0.006); patients aged < 12 years had a statistically significant preference for desmopressin MELT (p = 0.0089). Efficacy was similar for both formulations (MELT: 1.88 +/- 1.94 bedwetting episodes/week; tablet: 1.90 +/- 1.85 episodes/week). Ease of use of both formulations was high. Compliance (> or = 80%) was 94.5% for MELT patients vs. 88.9% for the tablet (p = 0.059). No serious/severe adverse events were reported.

CONCLUSIONS

There was an overall preference for the MELT, and a statistically significant preference for desmopressin MELT in children aged 5-11 years. Desmopressin MELT had similar levels of efficacy and safety at lower dosing levels than the tablet, and therefore facilitates early initiation of PNE treatment in children aged 5-6 years.

An evaluation of tympanic thermometry in a paediatric emergency department

BACKGROUND AND OBJECTIVES

The consequences of missing fever in children can be grave. Body temperature is commonly recorded at the axilla but accuracy is a problem. This study aimed to evaluate the accuracy of a tympanic thermometer in the paediatric emergency setting.

METHOD

In a total of 106 infants, the body temperature was measured in the daytime with an infrared tympanic thermometer, and at the axilla with an electronic thermometer and at the rectum (gold standard for measurement of body temperature). Fever was defined as a rectal temperature of 38.0 degrees C or greater, axillary temperature of 37.5 degrees C or greater, and tympanic temperature of 37.6 degrees C or greater. The temperature readings at the three sites were compared statistically.

RESULTS

There was a greater correlation of the tympanic measurement with the rectal measurement than the axillary with the rectal in both febrile and afebrile infants. The mean difference between the tympanic and rectal measurements was lower than that between the axillary and rectal measurements in both groups of infants (tympanic 0.38 degrees C and 0.42 degrees C, and axillary 1.11 degrees C and 1.58 degrees C, respectively). Tympanic measurements had a sensitivity of 76% whereas axillary measurements had a sensitivity of only 24% with rectal temperatures of 38-38.9 degrees C.

CONCLUSION

Tympanic thermometry is more accurate than measurement of temperature with an electronic axillary thermometer. It is also quick and safe, and thus it is recommended in the paediatric emergency setting.

Thermometry in paediatric practice

Body temperature is commonly measured to confirm the presence or absence of fever. However, there remains considerable controversy regarding the most appropriate thermometer and the best anatomical site for temperature measurement. Core temperature is generally defined as the temperature measured within the pulmonary artery. Other standard core temperature monitoring sites (distal oesophagus, bladder, and nasopharynx) are accurate to within 0.1-0.2 degrees C of core temperature and are useful surrogates for deep body temperature. However, as deep-tissue measurement sites are clinically inaccessible, physicians have utilised other sites to monitor body temperature including the axilla, skin, under the tongue, rectum, and tympanic membrane. Recent studies have shown that tympanic temperature accurately reflects pulmonary artery temperature, even when body temperature is changing rapidly. Once outstanding issues are addressed, the tympanic site is likely to become the gold standard for measuring temperature in children.

Providing adequate treatment for children with nocturnal enuresis

Nocturnal enuresis is the most common urological problem in children. With increasing age and persistence of enuresis, children may experience psychological problems. Active treatment is therefore required not only to achieve dryness but also to prevent and treat such an experience. Although nocturnal enuresis has multiple causes, in recent years emphasis has focused on three main causes: lack of arousal, lack of antidiuretic hormone secretion and lack of bladder stability. This article stresses the importance of applying a specific treatment based on this ‘three system approach’ for every child presenting with enuresis.

Effect of oral glucocorticoid treatment on serum inflammatory markers in acute asthma

BACKGROUND

Acute asthma is associated with elevated serum concentrations of products of activated T cells and eosinophils.

AIMS

To compare the changes in concentrations of these products with disease severity and changes in lung function following oral prednisolone treatment.

METHODS

Twenty patients (mean age 8.7 years) were recruited on admission with acute asthma to a district general hospital. Disease severity was recorded before and after treatment with oral prednisolone using a validated pulmonary index score. Serum concentrations of interleukin (IL)-4, IL-5, soluble (s)CD25 (soluble IL-2 receptor), using a specific enzyme linked immunosorbent assay, and eosinophil cationic protein (ECP), using radioimmunoassay, were measured concomitantly. Non-asthmatic children (n = 6, mean age 9.2 years) undergoing elective surgery were recruited as controls, and serum samples were obtained on one occasion without treatment. Main outcome measures were changes in serum concentrations of cytokines and ECP, clinical asthma severity score, and peak expiratory flow rate.

RESULTS

As expected, oral glucocorticoid treatment in the children with asthma was associated with clinical improvement and also with significant reductions in serum concentrations of IL-5 (mean 5.59 to 2.19 pg/ml, p = 0.0001), sCD25 (mean 2236 to 1772 pg/ml, p = 0.002), and ECP (mean 54.3 to 33. 1 pg/ml, p = 0.0001). Serum IL-4 concentrations, in most patients and all the controls, remained below the sensitivity of the assay. However, serum concentrations of IL-5, sCD25, and ECP remained significantly higher than in controls, even after treatment with oral glucocorticoids (p = 0.03).

CONCLUSIONS

These data suggest that T cell mediated inflammation may persist in childhood asthma despite apparent clinical remission associated with conventional doses of prednisolone. The long term consequences of persistent inflammation after an apparently treated acute attack of asthma require clarification. Clinical assessment and pulmonary function are inadequate surrogates for airway inflammation.

Association of fever and severe clinical course in bronchiolitis

Little attention has been given to the relation between fever and the severity of bronchiolitis. Therefore, the relation between fever and the clinical course of 90 infants (59 boys, 31 girls) hospitalised during one season with bronchiolitis was studied prospectively. Fever (defined as a single recording > 38.0 degrees C or two successive recording > 37.8 degrees C) was present in 28 infants. These infants were older (mean age, 5.3 v 4.0 months), had a longer mean hospital stay (4.2 v 2.7 days), and a more severe clinical course (71.0% v 29.0%) than those infants without fever. Radiological abnormalities (collapse/consolidation) were found in 60. 7% of the febrile group compared with 14.8% of the afebrile infants. These results suggest that monitoring of body temperature is important in bronchiolitis and that fever is likely to be associated with a more severe clinical course and radiological abnormalities.

Lower degree of fever at the initial febrile convulsion is associated with increased risk of subsequent convulsions

We studied 132 children admitted consecutively with their first febrile convulsion to assess whether the degree of fever at the onset of the convulsion can predict the risk of subsequent convulsions. The children studied were reviewed at least 2 years after the initial febrile convulsion to determine the number of children who had recurrences of febrile convulsions and/or afebrile convulsions. Children with body temperatures below 39 degrees C at the onset of their initial febrile convulsion (Group 1) were two and half times more likely to experience multiple convulsions within the same illness than those with body temperatures above 39 degrees C (Group 2). This occurred when the body temperature rose above that which had triggered the initial febrile convulsion. Children in Group 1 were also over three times more likely to experience recurrent febrile convulsion in subsequent illnesses than those in Group 2. As for subsequent development of afebrile convulsion or epilepsy, although the risk was low, it only occurred in Group 1. It is suggested that the known association between multiple convulsions, recurrent febrile convulsions and epilepsy may be due to the single predisposing factor of a low degree of fever at the onset of febrile convulsion. Each child with febrile convulsion may have his own threshold for eliciting a convulsion with fever; the lower this threshold is, the more likely are subsequent convulsions.