REVIEW OF ANATOMY AND PHYSIOLOGY

Temperature control in children is not completed until approximately ve years of age. This may be due to the immaturity of the nervous system. The maintenance of body temperature is mainly coordinated by the hypothalamus, a central control center containing large numbers of heat-sensitive neurons called thermoreceptors. It is an important homeostatic mechanism which allows the body enzymes to work efciently within a narrow range of 36.537.5 C. In response to a change in temperature, the peripheral thermoreceptors transmit signals to the hypothalamus, where they are integrated with the receptor signals from the preoptic area of the brain.The normal set point in childhood reflects a decreasing basic metabolic rate (BMR) as the child grows. The body temperature of the three-month-old child is 37.5 C, whereas at thirteen years it is 36.6 C. Even as the temperature regulatory mechanisms mature through childhood, babies and small children are highly susceptible to temperature fluctuations, as they produce more heat per kilogram of body weight than older children. Changes in environmental temperature, increased activity, crying, emotional upset and infections all cause a higher and more rapid increase in the younger child. The younger the child the less able he or she is to vocalize the feeling of hot or cold or to do something about it. All children may also become too cold. Small individuals who do not have warm clothes and warm homes will not grow if the temperature of their environment is consistently low. They will use much of the energy from their food intake to generate heat (metabolic rate) and leave no spare calories for tissue growth. The smaller the child, the larger the surface area for heat loss in relation to body mass. The head of a small child is relatively larger in proportion to the rest of the body, and covering the head in a cold environment conserves heat for growth. Schoolchildren may experience a sequence of small growth spurts and at times be relatively thin with minimal body fat. At the swimming pool, for example, where children enjoy jumping in and out of the water as they play, thin children may become cold more quickly than their fatter friends who have an insulation layer beneath their skin.Heat can generated through the metabolism of the liver, muscles, and other chemical activities. When children are exposed in a cold environment, it can result to hypoglycemia, elevated serum bilirubin, metabolic acidosis, and increased metabolic rate. When heat loss occurred, non-shivering thermogenesis (NST) heat production takes place in the subcutaneous tissue, hypothalamus, and spinal cord to compensate for the sudden change in temperature.Heat loss transpires through the contact in a cold environment, vasodilation, sweating where the preoptic area of the brain stimulates secretion of water to the skin for evaporation. There are different areas in the body where we can measure the temperature such as axillae, tympanic membrane, and mouth

PATHOPHYSIOLOGY

Modifiable Factors:HygieneDietEnvironmentNon-Modifiable Factors:Underdeveloped hypothalamic control centreFamily history of febrile convulsionInfection

Immune response

Endogenous pyrogens

Mucus production WBCProduction of pro-inflammatory cytokines, such as interleukins 1 (IL-1) and 6 (IL-6), interferon (INF)-, and tumor necrosis factor (TNF)

Hypothalamic circulation

Release of prostaglandin E2

Anterior hypothalamus

Heat production Heat conservationElevated thermoregulatory set-point

Urine output Metabolism of the liver Fluid conservation

Glucose breakdownVasoconstriction

Irritable and restless Energy demand Cerebral perfusion

Muscle contraction

Fever

Immature hypothalamic control

Temperature fluctuates to >39 C

BronchospasmNeuronal excitability

Febrile seizureDifficulty of breathing

RR

MEDICAL-SURGICAL MANAGEMENTMedical Management:1. Administration of due medications as ordered by the physician.The following medications are: Cefuroxime, an anti-infective, cephalosporin 0.33 g, IV, q8h Salbutamol, a bronchodilator, sympathomimetics 1 nebule (1cc + 1cc NSS), inhalation, q6h Paracetamol, an antipyretic, nonsteroidal anti-inflammatory drug 1.2 ml in a 100g/1ml, PO, PRN Diazepam, an anticonvulsant, benzodiazepine 2 g, IV, for active seizure Chloramphenicol, anti-infective 125 mg, IV, q6h2. Intravenous Replacement TherapyIV replacement therapy is the fastest way of replacing fluid loss and electrolyte imbalances. It can also be used to keep the vein open for the administration of medications.The following IV solutions administered: D5 0.3 NaCl, a hypotonic solution, 500 cc x 8 - causes cell shrinkage therefore reducing body heat. D5 IMB, a hypertonic solution, 1 L at 41 cc/hr for cell rehydration.

3. Oxygen TherapyOxygen therapy is used during emergency medical services. It is for the difficulty of breathing during active convulsion. Oxygen inhalation at 2-3 L was given via face mask.4. Laboratory and Diagnostic ProceduresAugust 30, 2010 Complete Blood Count It is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases. This evaluates the three types of cells in the blood which are red blood cells, white blood cell, and platelets. This provides an overview of the general health of the patient.

NURSING MANAGEMENT Vital signs monitoring every 1 hour Input and Output of Fluid Measurement Administer medication due as ordered by the physician Patient, a toddler, has developed a stranger anxiety as manifested by white coat syndrome. A nursing intervention would be is to establish rapport by playing with the patient. Encourage the mother to increase and continue breastfeeding for faster recovery of the patient. Provide opportunity for the patient to rest from time to time.

health educationMedications Instruct and explain to the mother that the medication, especially the antibiotics, is important to continue depending on the duration that the doctor ordered for the total recovery of the patient. Inform the mother of the side and adverse effects of the drugs she is giving to her daughter. Instruct to report immediately any side or adverse effects when taking the prescribed drug such as nausea, vomiting, diarrhea, rashes. Take the entire course of any prescribed medications.After a patients temperature returns to normal, paracetamol is administered if fever occurs. Avoid using paracetamol more than 5 days. Instruct the mother to avoid over-the-counter drugs without the consultation of the physician to avoid any drug-drug interaction.Exercise Encourage the mother to have her daughter rest from time to time for faster recovery.Treatment Comply with the established treatment regimen given by the doctors including prescribed medications. Encourage the mother to expose the patient to early morning sunlight Advise the mother to provide tepid sponge bath when fever occurs Provide oxygen therapy during active convulsion to alleviate the difficulty of breathing.

Hygiene Encourage and explain to the mother that it is vital to maintain proper hygiene by frequently washing her hands. Out-patient Its important for the toddler to have her follow-up check up to ensure and have the patients progress monitored.Diet Encourage the mother to continue breastfeeding the patient. Instruct the mother that the head must be in upright position when breastfeeding to avoid aspiration and let the baby burp after feeding.

FEBRILE SEIZUREDefinitionSeizure that is occured when body temperature (rectal) increases (38OC), which usually happened among babies and children between 6 month old and 5 years old, which is caused by an extracranium process, without any specific cause. It should be differed from epilepsy which have other seizure events without fever.Ferbrile seizure is divided into 2 types:1. Simple febrile seizurelast less than 15 minutes, general, single2. Complex febrile seizure last more than 15 minutes, or focal, or multiple (more than 1 seizure in 24 hours). It may indicate more serious diseases such as meningitis, abcess, or encephalitis.Risk factors for developing febrile seizures Family history of febrile seizures High temperature Neonatal discharge at an age greater than 28 days (perinatal illness that need hospitalization) Children with delayed development Children under suspicion Low sodium levelIf a child has 2 of these risk factors, then the probability of a first febrile seizure increases about 30%. Maternal alcohol intake and smoking during pregnancy increases the risk by 2-fold. Interestingly, there is not any data which show that a rapid increase in body temperature causes of febrile seizures.

Risk factors for recurrent febrile seizures include the following: Age at time of first febrile seizure 70% possibility of recurrence, while those with no risk factors have 15 minutes2. Complex febrile seizure Less common than simple febrile seizures (~10% of cases) Has one or more of the following features: Seizure lasts >15 minutes Partial or focal seizure Seizure reoccurs within 24 hours of the first seizure or during the period in which they have an illness The child does not fully recover from the seizure within one hour Does not reoccur within 24 hours or during the period in which the child has an illnessETIOLOGY Febrile seizures happen among young children when they have lower threshold of seizure, when they are prone to infections such as upper respiratory infection, otitis media, viral syndrome, and they respond with comparably higher temperatures. Some studies on animals show a possible role of endogenous pyrogens, such as interleukin 1beta, in the increase of neuronal excitability, which may link fever and seizure activity. This statement is also supported by studies in children, although there is no specific pathological significance. Moreover, although there is not any exact molecular mechanisms of febrile seizures, underlying mutations have been found in genes encoding the sodium channel and the gamma amino-butyric acid A receptor.

CLINICAL MANIFESTATION Seizure usually occurs at the beginning of the fever. Tonic clonic seizure could be started by crying, Then unconsciousness and muscle stiffness. Limbs twitching Lose of conciousness Urine incontinence soiling Vomiting Foam at the mouth Lasting