Dr Mousumi Roy

Tele Triage Guide

Fever In Children

• Typical Case Presentation

• Red Flags

• History Taking

• Screening

• Fever Type

• Common Associated Symptoms

• Other Relevant History

• Risk Profiling

• Next Steps

• Differential Diagnosis

Index

Case scenario

Ms. Fatema called as her 3 years old daughter Roshni is lethargic since morning and not eating. She is responding to social cues but not smiling and playful. Roshni had a low grade fever for last 2 weeks and complained of headache for last 2 days. She has been treated by a local doctor who has given oral antipyretic medication. Roshni was born by normal vaginal delivery at home , B.W- 2.4 kgs, fully immunised as per age. No relevant past / family /medication/ travel history. She does not have any other complaints.

Red Flags

Red Flags – Immediate referral to hospital is required

• Drowsy or unconscious

• Lethargic or irritable, continuous high pitched cry

• Not able to eat or drink

• Changed body colour- Pale or blue

• Shortness of breath or fast breathing

• Headache with stiffness of neck

• Red or purple rash

• Abnormal jerky movements of limbs or face

• Repeated vomiting or vomiting blood

• Blood in stool

• Decreased urination

• Very high fever not responding to oral Antipyretic medication

History Taking

Screening- History taking

• Onset – How did the fever started, sudden or gradually

• Duration – How long do you have fever

Acute - Viral illness, bacterial disease

Chroinc - Typhoid, Malaria, Kala-Azar

• Severity – Is it a high grade or low grade fever/ Does your body feel too hot?

• Recurrence- Does the fever come back after a few days?

Malaria, UTI, Cholangitis

• Type of fever- How does the fever progress throughout the day?

Remittent , Intermittent, Continuous, Hectic etc.

Fever type – Significance Remittent fever = Daily elevated temperature of more than 38C but return to the baseline (but not normal)

e.g . – Infective endocarditis

Intermittent fever Intermittently elevated temperature of more than 38C but return to baseline and normal

e.g Malaria

Sustained or continuous fever Daily elevated temperature of more than 38C with fluctuation of elevated temperature

(less than 0.3C)

e.g.- Lobar pneumonia, UTI, typhoid fever

Hectic fever Daily elevated temperature of more than 38C with temperature excursion more than 1.4C. It could be

either remittent or intermittent

e.g. Abscess, pyelonephritis, Ascending cholangitis

Quotidian fever Happening every day or once a day

e.g. Malaria

Undulant fever Undulant, rising and falling like a wave; bouts of continuous or remittent fever for several days, followed

by afebrile remissions lasting a variable number of days

e.g. Brucellosis

Commonly Associated symptoms• General – Pale or cyanotic, Jaundice, Chills and rigors, Weight loss, loss of appetite, night sweats

• HEENT- cough, sore throat , runny nose, headache, redness in eyes, eye pain, Ear pain or ear discharge,

neck swelling

• Respiratory- Fast breathing or shortness of breath

• Gastrointestinal – poor feed ,repeated vomiting ,diarrhoea, blood in stool , pain in right upper

abdomen

• Urinary tract- increased frequency of urination , dysuria, pain, abdomen, pain in the flank

• CNS- Drowsiness, Stiff neck, convulsions, any focal neurological signs

• Musculoskeletal – Joint pain or joint swelling, ask about poly or oligo joint involvement, whether

fleeting or not

• Skin- Red or Purple rashes, bruising, any insect bite

Other relevant history• Prevalence of any endemic diseases in neighbourhood i.e , Cholera, dengue, malaria

• Travel history to any endemic area

• Past history- Any similar illness in the past

• Family history- Positive history of any infectious disease – open Koch’s, meningitis

• Birth History- prematurity

• Immunisation history- measles , BCG, DPT, pneumococcal

• Medication history- Penicillin, cephalosporin, ATT, anticonvulsants

• History of pets or animal contact

Risk Profiling – Quick Steps

Symptoms Suggesting high-risk of serious illness

• Pale/mottled/ashen/blue skin, lips or tongue

• No response to social cues

• Appearing ill to care giver

• Does not wake or if aroused does not stay awake

• Weak, high-pitched or continuous cry

• Grunting

• Fast breathing (respiratory rate greater than 60 breaths per minute)

• Moderate or severe chest indrawing

• Shortness of breath

• Pallor of skin, lips or tongue reported by parent or carer

• Not responding normally to social cues

• No smile

• Wakes only with prolonged stimulation

• Decreased activity

• Nasal flaring

• Dry mucous membranes

• Poor feeding in infants

• Reduced urine output

• Rigors

Symptoms Suggesting intermediate -risk of serious illness

• Normal colour of skin, lips and tongue

• Responds normally to social cues

• Content/smiles

• Stays awake or awakens quickly

• Strong normal cry or not crying

• Normal skin and eyes

Symptoms Suggesting low -risk of serious illness

Recommended Actions – Next Steps

RecommendationsSigns Action

In case of emergency signs present or child is severely/ intermediately ill

Immediate referral to the hospital

Moderate illness or mild illness more than 2 days ( Low risk group)

Refer to a health care practitioner

Mild illness i.e viral URTI • Tepid sponging is not recommended• Rest• Well hydration• Continue normal nutritious diet• Oral Antipyretics- Paracetamol/ Acetaminophen, dose-

15 mg / kg body weight, ask for contraindications• Home remedies to sooth throat in case of cough or sore

throat – honey ginger, warm drinks• Watch for Emergency signs• Boast hand washing and other infection control

measures• Ask not to send the child t school for few days.

Reference Material – Differential Diagnosis ( Fever In Children)

Symptoms Probable Diagnosis High fever with rash, Headache , stiff neck, drowsiness, convulsion, any focal neurological sign

Meningeal disease

Mild to moderate acute fever, Runny nose, red eyes , sore throat, cough with or without sputum, mild illness

URTI including common cold, pharyngitis, sinusitis

High continuous fever, Fast breathing, shortness of breath, bluish discoloration of skin, mucous membrane, grunting sound

Pneumonia

Mild to moderate fever, Intermittent or continuous , Repeated vomiting, diarrhoea, loss of appetite, blood in stool

GI tract infection- Gastroenteritis

High grade fever with chills and rigor, May be recurrent, Poor feed , vomiting ,increase frequency of micturition , dysuria, pain abdomen , Pain in the flank, blood in urine

urinary tract infection , If pain in flank present suspect pyelonephritis

Differential Diagnosis – Fever in Children

Symptoms Probable diagnosis Joint pain , joint swelling, restriction of movements Oligoarthiritis - Septic arthritis

Migratory – Rheumatic feverPost viral infection – Reactive

High fever with chills and rigors in endemic areas ,Seasonal Malaria- high fever with chills and rigorsDengue- High fever with chills, severe body ache/myalgia, pain behind eyes, purpuric rash, bleedingChikunguniya- High fever with severe bone pain

Chronic low grade fever, chronic cough, weight loss, loss of appetite, night sweats

Koch’s, Neoplasm

History of Ingestion of antibiotics recently, ATT, Anticonvulsant, Rashes

Drug fever

Ear Pain or ear discharge , Pain Behind ear Otitis media, mastoiditis

Macular rashes / Vesicular rashes with flu like symptoms Measles/ chicken pox

High grade , hectic fever, Pain in right upper abdomen Liver abscess

Migratory Polyarthritis, subcutaneous nodule, erythema marginatum, fever, h/o sore throat or skin infection in past

Rheumatic fever

Differential Diagnosis – Fever in Children

Thank You