Fever is a common reason for consulting a doctor in children. Fortunately, 90% of febrile children, who develop acute fever from full wellbeing, develop the symptom fever to ward off viral infections. Then the most important task of the doctor is to calm the parents. Nevertheless, the rarer bacterial infections or other causes of fever must of course be clarified in a structured manner in order not to delay a necessary (antibiotic) therapy.
We have all learned and know that fever itself is a symptom and not a disease. However, many parents do not know this and since many families lack the experienced grandmother, parents are often very worried when they discover that their child has a fever. Values between 38 and 38.5 oC are referred to as elevated temperature, 38.6 oC and above as fever. As far as the need for antipyretic measures is concerned, up to a temperature of 40.5 oC the general condition alone is decisive.
In over 90% of cases, the cause of fever in children is a viral infection in which specific treatment is not possible – the body’s defences are designed to overcome the infection and strengthen its immune system.
Children of kindergarten age suffer from about ten to twelve virus infections in one year, usually they are then restricted for two to four days, need rest, plenty of fluids, fever-reducing medication if needed and otherwise symptomatic treatment (e.g. cough remedies, nose drops). Only about 10% of all children have a bacterial infection, e.g. of the lungs or urinary tract, which should usually be treated with an antibiotic. In addition, there are rare causes in approx. 1 % which require more precise clarification.
Since cooling down feverish children is good for them, it does no harm to feverish children to be packed into a car and driven into the practice. If the child is now introduced to the doctor, he should first clarify these two questions:
- What is the general condition of the child?
- Are there any warning signs (see box “Red Flags”)?
If one of these warning signs is present, the child should immediately be referred to a specialist (clinic) for further diagnosis and therapy.
Infants under six months of age
Desiccation mark (sunken fontanelle, lips lacquer red, flabby)
Centralization signs (cold hands, fever above 39 oC)
However, over 95% of the children can be further clarified and treated. The following information must be collected:
- Does the fever last longer than three days?
- How long has the child been sick?
- Does the child drink well?
- Does the kid have a stomach ache?
- Does the child cry while urinating?
- What infectious diseases are there in kindergarten?
- Has the kid taken any medication yet?
- Has the child already been examined and treated by another doctor?
- Is the child suffering from an underlying disease?
Once all these questions have been clarified, the physical examination of the partially clothed child follows the following scheme:
- cervical lymph nodes, nuchal lymph nodes
- wiretap the lungs
- Scanning the abdomen
- throat inspection
If we have not raised any conspicuous status, we can assume a banal virus infection, and if the child is in a good general condition (which can be affirmed in over 90 % of cases), then it is actually only a matter of calming the parents and instructing them to let the child drink as much as possible, possibly supported by naturopathic homeopathic remedies.
A further presentation should always be made if the little patient is still feverish after three days or if the general condition deteriorates.
If there is an exanthema in addition to the fever, we must expect a “childhood disease”, as we see it in rubella, exanthema subitum, Coxsackieviren or streptococcal infections. Thanks to vaccination, measles and rubella are so rare today that hardly any doctor in private practice can still see them.
If the fever lasts longer than three days, one must expect that the child’s immune system is weakened and a bacterial superinfection develops, which can be ruled out in the case of a renewed status with regard to otitis, bronchitis or urinary tract infection.
If we do not find an explanation here, then the differential diagnosis may be primarily stomatitis (aphthae in the mouth, drooling child), mononucleosis (thick, enlarged cervical lymph nodes, abdominal pain) or rarer diseases such as endocarditis (changes in heart auscultation) or Kawasaki syndrome, which should then either be clarified chemically by our laboratory or referred to a specialist.
Fever cramps are a rare but highly dramatic event for parents. They occur more frequently in the family, usually between the ages of 8 months and 4 years, usually in the form of an increase in fever or a rapid drop in fever. When the parents come to the doctor with the fevered child, the danger of a fever cramp is usually over and the parents can be reassured: “You see, your child is one of 98% of children who can withstand a high fever well without getting a fever cramp. Febrile convulsions have no further consequences for your child’s health and are not a predisposition to epileptic seizures.
Fever and exanthema:
The wrong track
The 5-year-old Liane is presented by the excited mother in the family doctor’s practice. She is cranky, has 39 oC fever since the day before and makes a sick impression. There is a cheek and trunk exanthema. The pharynx is irritated, with low LN swelling. The laboratory results show high measles IgG and low IgM in Z. n. vaccination.
Since the fever is still around 38 oC, the mother goes three days later to the paediatrician who diagnoses measles. The next day the fever is still over 39 oC and Liane is now presented in the children’s outpatient clinic. There it is noticeable that she had been treated with amoxicillin two weeks before because of a high fever infection (Epstein-Barr infection), which the mother had stopped after four days.
In the following two years, therapy resistant fever attacks of 39 – 40 oC occur approximately every six to eight weeks, which do not respond to antibiotics and only stop after a tonsillectomy.
The diagnosis PFAPA syndrome (stands for periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis) can be made retrospectively. The former exanthema was probably due to the administration of amoxicillin for glandular fever infection.
The case clearly shows how important it is to take a precise anamnesis, including previous illnesses and treatments, and that disease progressions can overlap and make diagnosis difficult.
Conflicts of interest: none declared
Appeared in: The general practitioner, 2014; 36 (1) Page 32-34