Mostly harmless and easy to treat
Fever is a common reason to consult a doctor in children. Fortunately, 90% of the feverish children, who become acutely ill from full well-being, develop the symptom fever to ward off viral infections. Then the most important task of the doctor is to reassure the parents. Nevertheless, the rarer bacterial infections or other causes of fever must of course be clarified in a structured manner so as not to delay the necessary (antibiotic) therapy.
We have all learned and know that fever in itself is a symptom and not a disease. However, many parents do not know this and since many families lack the experienced grandma, parents are often very worried when they find that their child has a fever. At temperatures between 38 and 38.5 oC one speaks of an elevated temperature, from 38.6 oC a fever. With regard to the need for antipyretic measures, the general condition alone is decisive up to a temperature of 40.5 oC.
In over 90% of cases, the cause of fever in children is a viral infection, for which specific treatment is not possible – the body is supposed to use its defenses to overcome the infection and strengthen its immune system.
Children of kindergarten age go through about ten to twelve viral infections in a year, usually they are restricted for two to four days, need rest, plenty of fluids, antipyretic if necessary and other symptomatic treatment (e.g. cough medicine, nose drops). Only about 10% of all children have a bacterial infection, e.g. B. the lungs or urinary tract, which should usually be treated with an antibiotic. In addition, there are about 1% rare causes that require a more precise clarification.
Since feverish children do good to cool off, it doesn’t harm any feverish child to be packed in a car and driven into practice. If the child is introduced to the doctor, the doctor 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 be referred to specialist treatment (clinic) immediately for further diagnosis and therapy.
Infants under six months
Desiccation mark (sunken fontanelle, lips lacquer red, floppy)
Centralization sign (cold hands, with fever over 39 oC)
However, we can clarify and treat more than 95% of the children. The following information is to be collected:
- The fever lasts longer than three days?
- How long has the child been sick??
- The child drinks well?
- Does the child have abdominal pain??
- The child cries when urinating?
- What contagious diseases are there in kindergarten??
- Has the child already taken any medication??
- Has the child been examined and treated by another doctor??
- The child has an underlying disease?
When all of these questions have been answered, the physical examination of the partially undressed child follows the following scheme:
- Cervical lymph nodes, nuchal lymph nodes
- Eavesdrop on lungs
- Palpate the abdomen
- revenge 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 answered in the affirmative in over 90% of cases), then it is really only a matter of calming down and instructing the parents, letting the child drink as much as possible, possibly supported by naturopathic homeopathic remedies.
A further presentation should always be made if the little patient still feverish after three days or the general condition worsens.
If there is an exanthem in addition to the fever, we must take one "childhood disease" count as we see it for ringed rubella, exanthema subitum, Coxsackieviruses or even with streptococcal infections. Thanks to vaccination, measles and rubella are so rare today that hardly any resident doctor can see them.
If the fever persists for more than three days, one has to reckon with the fact that the child’s immune system is weakened and a bacterial superinfection develops.
If we do not find an explanation here, stomatitis (mouth sores, drooling child), mononucleosis (thick, enlarged throat lymph nodes, abdominal pain) or less common diseases such as endocarditis (changes in cardiac auscultation) or Kawasaki syndrome are the main reasons for differential diagnosis into consideration, which should then either be clarified by our laboratory or referred to a specialist.
Febrile seizures are a rare, but highly dramatic event for parents. They occur frequently in families, usually between the ages of 8 months and 4 years, usually when the fever rises or the fever drops rapidly. If the parents come to the doctor with the feverish child, this risk of febrile seizure is usually over and the parents can be reassured: "You see, your child is among the 98% of children who can withstand high fever without having a febrile seizure. Febrile seizures have no further health consequences and are also not to be considered as a predisposition for an epileptic seizure disorder.
Fever and rash:
The wrong track
The 5-year-old Liane is introduced to the family doctor’s office by the excited mother. She is lumpy, has had a fever of 39 ° C the day before and makes a sick impression. There is a cheek and stem rash. The throat is irritated with little LN swelling. The laboratory values show high measles IgG and low IgM when vaccinated.
Since fever persists at 38 oC, the mother goes to the pediatrician three days later, who diagnoses measles. The day after, the fever is still above 39 oC and Liane is now presented in the children’s outpatient clinic. It is noticeable that she was treated with amoxicillin two weeks beforehand because of a highly febrile infection (Epstein-Barr infection), which the mother had stopped after four days.
Therapy-resistant febrile episodes at 39 – 40 oC occur every six to eight weeks in the following two years, which do not respond to antibiosis and only cease after tonsillectomy.
The diagnosis of PFAPA syndrome (stands for periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis) can be made retrospectively. The exanthem at that time was probably due to the amoxicillin administration in glandular fever infection.
The case clearly shows how important it is to take a precise medical history, including previous illnesses and treatments, and that the course of illnesses overlap and can make our diagnosis more difficult.
Conflicts of interest: none declared
Published in: Der Allgemeinarzt, 2014; 36 (1) page 32-34
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