FEVER
 

1. Fever is due to a normal reaction of the body in its fight against chemical, physical or microbiological (bacterial , viral , parasitical ) attack   . When fever exceeds 39C (rectal temperature) ,  it must be treated , because it can be dangerous for the child (e.g. by causing convulsions , dehydration).

Fever is a sign for which a cause must be sought and treated. One must always consider malaria , proof of which need not be available before  beginning specific treatment in an endemic or hypoendemic zone , or in the case of a recent traveller in such a zone in the previous 1 to 4 years.

One must always make an examination and take a complete history and be sure that all possible causes of fever are investigated.

3. Complications to look for and prevent:

        ·  Convulsions

        ·  dehydration (which can occur even without diarrhoea or vomiting).  

Take the rectal temperature and record it; if it is more than 39C , undress the child wrap him in a damp cloth and get him to drink.

Question to the accompanying person: any complaints? such as recent vaccination?

Weigh the child , evaluate his nutritional state enter it in the health record or card.

Examine the whole child: always look for symptoms of meningitis , especially if there is any suggestion of convulsions.

If possible , take a thick film and if appropriate begin ant malarial treatment.

       1.    In  all cases , even if there is no precise diagnosis:

          a)   administer at the same time:

  aspirin,    50 mg/kg/d in 3 doses

       and chloroquine, 10 mg/kg/d in one dose, for 3 days;

      or mefloquine, 25 mg/kg/12 hours,

                   in 3 doses of 12.5 mg/kg,

                   7.5 mg/kg and 5 mg/kg, respectively, once,

   or halofantrine, 25 mg/kg/12 hours , in 3 doses , once , depending on the local chloroquine resistance pattern;

             b)    if the infant is not conscious , give :

      inject able quinine, 25mg/kg/d IM in 2 doses

     or inject able chloroquine , 5 mg/kg/d IM in 1 or 2 doses;

depending on the local chloroquine resistance pattern , being particularly careful about sterility when injecting (risk of necrosis);

             c)    if the child is conscious: get him to drink:

        2.  a) If the child is having convulsions:

     diazepam, 1 mg/kg/dose , by rectal tube or IM (see convulsions).

     b) If the child has had convulsions:

    diazepam,                          4mg/kg/d in 2 doses,

   or Phenobarbital,               6mg/kg/d in 2 doses,

   orally for as long as the fever persists.

   c) In addition geve an intramuscular injection  of :

   inject able quinine,               25mg/kg/d in 2 doses,

   or inject able chloroquine,   5mg/kg/d in 1 or

                                               2 doses,

depending on the local chloroquine resistance pattern, being particularly careful about sterility when injecting (risk of necrosis).

Then give oral chloroquine , mefloquine or halofantrine (depending on the local chloroquine resistance pattern ) as soon as practicable , and institute a programme of antimalarial prophylaxis

      3.   If meningitis is suspected (bulging fontanelle, stiff neck , vomiting ,vacant look), being treatment immediately unless the reference centers is nearby (less than 10 minutes journey ) and  TRANSFER  urgently.

      4.   In cases of haemorrhagic fever , with cutaneous haemorrhagic lesions, hepatosplenomegaly , haematuria , TRANSFER very URGENTLY.

      5.  If there is diarrhoea and/or dehydration , see diarrhoea and treat accordingly. Keep the child on the breast if he is being breast-fed; get him to drink small quantities of ORS solution , frequently (above all if he is vomiting).

Reintroduce normal feeding as soon as possible, so as to cover his increased fluid , caloric and protein requirements.

6.                 To exclude a gastro-intestinal or other intra-abdominal infection (peritonitis , appendicitis, shigellosis): palpate the abdomen. If there is guarding , tenderness or contraction: TRANSFER urgently.

7.                 If there is a cough , see cough and dyspnoea, and treat accordingly.

8.                 If there is ENT infection:

         a) Purulent nasal discharge:

     ·    teach the mother to wipe the nose often and carefully;

     ·  if the fever persists into the 3 rd day;

long-acting penicillin, 50 000 units/kg/d IM, in 1 dose , for 5 days.

Inspect for progress on the 5 th day;

b)                examine the external auditory meatus, pulling the ear downwards and backwards;

      ·  if this is painful:

anti-inflammatory “medication” by the mouth (e.g.paracetamol);

      ·  if there is suppuration:

long-acting penicillin, 50 000 units/kg/d IM in 1 dose for 5 days.

Inspect for progress on the 5th day;

c)                 examine the mouth and throat:

     ·  sores or coated: stomatitis;

     ·   whitish coating on enlarged tonsils: tonsilitis.

     ·  painful tooth on percussion and swelling of the gum: dental abscess:

long-acting penciling , 50 000 units/kg/d lM in 1 dose , for 5 days.

Inspect for progress on the 5th day.

      · do not confuse an abscess or tonsilitis with mumps (epidemic parotiditis)-no treatment.

9.        in the case of suspected urinary tract infection (pain on micturition and/or urinary abnormality)- see urinary tract infection and treat accordingly.

10.             Look for inflammation (pain , warmth , swelling) of the skin , eyes , muscles , joints , bones etc.-see dermatology , ophthalmology , osteomyelitis etc. and treat accordingly.

11.             In the absence of specific signs:

      ·    Look  for evidence of contact with another child with a childhood illness;

      ·   check that the child has been vaccinated against measles;

      ·   look for early signs of a childhood illness (e.g. rash, eruption ,adenopathy etc.).

     ·    If the fever lasts more than 5 days and a repeat examination reveals nothing new,

     ·   Ii there is no cure on inspection of the 3 rd or 5th day as expected,

     ·   if there is recurrent fever without an established diagnosis,

     ·   REFER to exclude tuberculosis, typhoid or other causes.

·  Only give an antipyretic (aspirin) if the temperature exceeds 38C , especially at night before going to bed.

·  Be prepared to give  ant malaria chemoprophylaxis in the young child or in a recent traveler:

Chloroquine, 10mg/kg once a week or 2 mg/kg/d , and treat any episode which  may be malaria, which can happen in spite of preventive measures.

In addition , chloroquine resistance is possible in certain regions. In this case , it will be necessary to consider local therapeutic recommendations, e.g.:

   -     combinations of chloroquine with chlorhydrate of proguanil , 5 mg/kg/d

or

   -      quinine , 10 mg/kg/d,

e.g., in drops : R/quinine bichlorhydrate , 6 g; sodium bisulfite , 15 mg; aqua ad 30 ml, in a brown bottle; 0.05 ml/kg/day , or drop/kg/d, if 20 drops/ml.

       ·  Prevention against mosquito bites by the use of nontoxic repellents and impregnated mosquito nets.

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