IDENTIFICATION OF THE PROBLEM
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
2. Essential diagnoses
-gastrointestinal infection: e.g. salmonella , shi gella , E. coli;
intra-abdominal infections , e.g. peritonitis , appendicitis;
-urinary tract infection;
-site of infection in the skin , eyes , muscles , joints , bones;
-beginning of measles or other childhood contagious disease.
3. Complications to look for and prevent:
dehydration (which can occur even
without diarrhoea or vomiting).
HISTORY AND PHYSICAL EXAMINATION
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
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
In all cases , even if there is no
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,
or halofantrine, 25 mg/kg/12 hours , in 3 doses , once , depending on the
local chloroquine resistance pattern;
if the infant is not
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
careful about sterility when injecting (risk of necrosis);
if the child is conscious:
get him to drink:
a) If the child is having convulsions:
diazepam, 1 mg/kg/dose , by rectal tube or
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
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
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.
In cases of haemorrhagic fever , with cutaneous
haemorrhagic lesions, hepatosplenomegaly , haematuria , TRANSFER
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
Reintroduce normal feeding as soon as possible, so as to cover his
increased fluid , caloric and protein requirements.
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.
If there is a cough , see cough and
dyspnoea, and treat accordingly.
If there is ENT infection:
teach the mother to wipe the nose often
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;
examine the external auditory meatus,
pulling the ear downwards and backwards;
if this is painful:
anti-inflammatory “medication” by the
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;
examine the mouth and throat:
sores or coated: stomatitis;
whitish coating on enlarged tonsils:
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.
in the case of suspected urinary tract infection (pain
on micturition and/or urinary abnormality)- see urinary tract
infection and treat accordingly.
Look for inflammation (pain , warmth ,
swelling) of the skin , eyes , muscles , joints , bones etc.-see
dermatology , ophthalmology ,
osteomyelitis etc. and treat accordingly.
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
look for early signs of a childhood
illness (e.g. rash, eruption ,adenopathy etc.).
IF THERE IS NO IMPROVEMENT
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
REFER to exclude tuberculosis, typhoid or
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
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.