Pediatric Dental Health

June 1, 2002

FEVER IN CHILDREN
Fever is the most common reason why parents seek medical care for a child. Fever is a symptom that consistently causes alarm in parents. Far from being an enemy, however, fever is an important part of the body’s defense against infection.

Fever indicates that something is wrong with a child. Fever activates the body’s immune system, which speeds-up the production of antibodies, white blood cells, and other infection-fighting agents.

Myths and misconceptions about fever still abound. The fact is that fever does not necessarily need to be treated. For example: if a child is playful, comfortable, able to sleep, and drinking plenty of fluids, then medical treatment is not likely to be needed. On the other hand, steps should be taken to decrease fever in a child who is uncomfortable, dehydrated, vomiting, of having difficulty sleeping.

During the first two years of life, children experience an average of five acute fevers, with medical care being sought for two thirds of these. An occult (obscure cause) life-threatening illness occurs in approximately 1% of children who present to an acute care setting with fever.

WHAT IS FEVER?

Most physicians define fever in children younger than 2 months of age as body temperature (rectal temperature) greater than or equal to 38 degrees centigrade.
In older children, an oral temperature of 37.8°C (100°F) is considered abnormal.

WHAT CAUSES FEVER IN CHILDREN?
Fever is a symptom, not a disease. Fever helps fight harmful infections by activating the body’s immune system.
Viruses cause the vast majority of febrile illnesses in children during the first two years of life.
Infectious causes of fever include:
Viral upper respiratory tract infection, bacterial or viral pneumonia, bacterial meningitis, skin infection, otitis media (earache), urinary tract infection, or oral infection.
Noninfectious causes of fever include:
Recent immunization (DTP, MMR), rheumatoid disease, or malignancy.
Chronic illnesses which can cause fever include:
Sickle cell disease, human immunodeficiency virus infection, leukemia, or diabetes.
Up to 20 percent of infants with fever have positive urine cultures – indicating a UTI (urinary tract infection).
Most pneumonias in infants and children are viral in nature, and are caused by respiratory syncytial virus, parainfluenza and influenza viruses, and Chlamydia species.
A recent study found that 26 percent of children who had a fever and WBC (white blood cell count) greater than 20,000 per cubic mm had pneumonia. Streptococcus pneumonia has become the main cause (90%) of serious bacterial infection in infants and young children.

WHAT IS FEVER OF UNKNOW ORIGIN?
About one in five children younger than 3 years of age will have fever of unknown origin. Of these children who have a temperature of 39°C (102.2° F), 2 to 5 percent will have occult bacteremia. Results of several studies indicate that most cases of occult bacteremia are now caused by Streptococcus pneumoniae infection, which often resolves spontaneously without treatment.
Approximately 10 percent of young infants who appear healthy and have a temperature higher than 38°C (100.4°F) have meningitis or other serious bacterial infection.
Approximately 10 percent of young children and infants with S. pneumoniae bacteremia and fever develop a serious bacterial infection. Therefore, more aggressive management of fever in infants is indicated than in older children.

WHAT ABOUT ORAL INFECTIONS?
Today, parents still attribute many infant symptoms to teething. They incorrectly believe that teething causes fever, pain, irritability, sleep disturbance, biting, drooling, rashes, ear pulling, feeding problems, runny nose, loose stools, and infections. The truth is that many symptoms previously thought to be associated with teething are simply coincidental findings! There is no evidence that teething causes fever or illness in babies. Current medical and dental research shows that fever, diarrhea, and symptoms of illness, are simply coincidental findings during teething.
Strep throat (GABHS) is uncommon in children less than 2 years old, but can cause fever. The symptoms of GABHS include: very high fever (104 F / 40 C), chills, pain on swallowing, swollen lymph nodes of the neck, nausea, and absence of cough.
Herpetic gingivostomatitis (oral herpes) can also cause fever.
Most dental infections in children can be prevented by obtaining regular dental checkups, and by prompt treatment of any dental caries. Post-treatment antibiotics should be prescribed for patients who have clinical infection, particularly when the infection is associated with fever.

WHAT IS PFAPA SYNDROME?
PFAPA is an acronym which stands for Periodic Fever, Aphthous stomatis, Pharyngitis, and cervical Adenitis. The cause of PFAPA is unknown.
Two important features are required and discriminatory for diagnosis of PFAPA syndrome:
1. The febrile episodes must have a clockwork periodicity (every 28 days), an unheralded onset, and a brisk rise to a fever of > 39°C, sustained over 3 to 6 days, with no other symptoms, infections, or behavioral changes in the child.
2. The child is completely well between episodes.
Lab tests during the attacks show mild leukocytosis, elevation of the erythrocyte sedimentation rate, and fibrinogen.
Children with PFAPA are not sick all the time. Children seem cheerful even when they have a high fever.
Most children (67%) with PFAPA syndrome have aphthous stomatitis. These children have some small, shallow ulcers that are usually present on the day the fever began. Usually stomatitis is not the chief complaint, however.
The dramatic response to a single dose of corticosteroids is unique to this syndrome. Physicians should consider prescribing a one-time dose of oral prednisone (2 mg/kg).
Long-term sequelae do not develop from PFAPA.

MEDICAL EVALUATION OF FEVER IN CHILDREN:
The initial approach to the febrile infant or young child involves:
taking a careful medical history, observing the patient’s state of well-being, and performing a detailed physical examination.
It is essential to evaluate and document vital signs, behavior, skin color, and state of hydration. Children should be completely undressed to examine for petechia (pinpoint non-raised hemorrhage spots).
The following physical examination findings suggest serious illness:
1. Tachypnea (rapid breathing), dyspnea (difficulty breathing), nasal flaring, or neck retractions. All of these are abnormal findings.
2. Signs of dehydration, such as absence of tears when crying, dry mucous membranes, lack or urine output, or sunken fontanelle (soft spot on an infant’s skull).
3. True irritability, lethargy, or a change in level of consciousness.
4. A hemorrhagic rash, which may be due to a serious infections such as meningococcemia. Purpura (hemorrhagic spot up to 1 cm in diameter), or petechia in a febrile child. Note that 2 to 8 percent of children who have fever and petechial rash will also have a serious bacterial infection.

TREATMENT FOR FEVER IN CHILDREN:
The physician’s primary goal is to identify the child who is at risk for serious bacterial infection. Aggressive management of fever in young infants is very important.
Toxic-appearing children must be resuscitated, admitted to the hospital, have diagnostic studies done, and have empiric antibiotic therapy started.
When presenting with fever, infants younger than 60 days should be considered septic until proven otherwise. This age group is at greater risk than older children for two reasons:
1. First, the bacterial pathogens are different from those in older children. 2. Second, the immune system of infants has less ability to opsonize and compartmentalize an infection.
Children with fever who have been recently treated with antibiotics, children with chronic illnesses that affect their immune status, and children who attend day-care may require more aggressive management than other children in the same age group.
Nontoxic infants less than or equal to 1 month of age:
should be admitted to the hospital for lumbar puncture, blood and urine cultures, and parenterally administered antibiotics.
Nontoxic young infants greater than one month of age who do not meet low-risk criteria:
should be admitted to the hospital for blood and urine cultures, lumbar puncture, and IV antibiotics.
Nontoxic children who are 3 months to 3 years old with temperature less than 39°C:
should receive a physical examination to identify the cause of infection, no tests or antibiotics if the child looks well and no bacterial cause is found, be prescribed an antipyretic as needed, and be given a 48 hour follow-up if fever persists.

TIPS FOR PARENTS:
In general, how a child looks and acts during a fever is more important that the actual temperature reading.
Give your child extra fluids to drink, and have your child wear less clothing.
Give fever medicine only if the fever is over 102°F (39°C) and your child is uncomfortable. If an antipyretic is being given at home, parents should know that the safe dose for acetaminophen is 10mg/kg every 4 hours.
Do not give your child aspirin.
Sponge your child if the fever does not go down.
All children have fevers, but a small number of them (4%) have a brief convulsion due to the fever. This type of seizure is generally harmless, however.

CALL YOUR CHILD’S DOCTOR RIGHT AWAY IF:
The fever is over 105°F (40.6°C).
Your child is younger than 3 months old.
Your child acts very sick or lethargic.

An article published in American Family Physician reviews acute febrile illness in infants and children. It discusses the initial clinical approach to fever, parent vs. physician preferences, serious bacterial infection, algorithms for management of nontoxic infants and children, and current controversies regarding the management of fever.

Luszczak M: Evaluation and management of infants and young children with fever. American Family Physician. October 1, 2001; 64(7) 1219-1225.

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