ABSTRACT: Fever in children is a common concern for parents and one of the most frequent presenting complaints in emergency department visits, often involving non-pediatric emergency physicians. Fever remains a major cause of laboratory investigation even after introduction of conjugate vaccines. While the majority of febrile children have mild, self-resolving viral illness, a minority may be at risk of life-threatening infections. Clinical assessment differs markedly from adults. Hands off evaluation is paramount for the correct evaluation of breathing, circulation and level of interaction. Laboratory tests and clinical prediction rules provide limited help in children at risk for serious infections; however, clinical examination, prudent utilization of laboratory tests, and post discharge guidance are still the cornerstones of safe management of febrile children.4
KEYWORDS: Fever, Homoeopathy, children, infection.
ABBREVIATIONS: TB (Tuberculosis), CMV (Cytomegalovirus), RA (Rheumatoid arthritis), SLE (Systemic Lupus Erythromatosus), IBD (Inflammatory Bowel Disease), HIV (Human Immunodeficiency Virus), MP (Malarial Parasite), CBC (Complete Blood Count), CRP(C-reactive protein), CSF (Cerebrospinal Fluid), ESR (Erythrocyte Sedimentation Rate)
INTRODUCTION: Fever, a physiologic response characterized by an elevation of body temperature above normal daily variation, is one of the most common causes for medical consultations in children, being responsible for 15 to 25% of consultations in primary care and emergency department. The normal body temperature in children is higher as compared to adults varies between 36.1 to 37.8O or 97 to 100o F on rectal measurement and exhibits a normal circadian diurnal variation being lowest between midnight and 6 AM and maximum between 5 PM and 7 PM. We performed the narrative review on causes, approach, management and homoeopathic remedies for the same with an aim of providing pediatric as well as non-pediatric physicians with up to date information on the approach to febrile children.4
MEASUREMENT: The core body temperature can be measured inside the oral cavity, axilla, rectum, ear canal and over the temporal artery. The rectal method being the most accurate method for measuring temperature of more than 38o C or 100.4o F. In children below the age of 4 to 5 years axillary temperature may be used. The axillary temperature is on an average 0.5 to 1o C or 1 to 2o F lower than the rectal temperature and fever is defined as axillary temperature over 99o F. 1
Thermometers: 1) Mercury: Takes 2 to 4 minutes to record temperature, are inexpensive, suitable for home use
2) Electronic: More convenient, takes 30 seconds to record temperature, but sometimes subject to calibration errors
3) Infrared thermometers: Used for measuring ear or temporal artery temperature, measures rapidly and closely approximate rectal temperature, are comparatively expensive.1
PROBABLE CAUSES:
- Viruses or bacteria: for instance, a common cold, middle ear infection, urinary tract infection or gastroenteritis, enteric fever, TB, viral hepatitis, mastoiditis, CMV, kala azar, toxoplasmosis, malaria. Or typical childhood diseases such as mumps, measles, rubella, scarlet fever, chickenpox, etc
- Vaccination: Because the child’s immune system is developing antibodies to fight the germs that the vaccine aims to protect them from
- Auto-immune: Systemic onset juvenile RA, Kawasaki disease, SLE, IBD, polyarteritis nodosa
- Malignant: Leukemia, lymphoma
- Sunburn, sunstroke or skin conditions such as urticaria
- Serious illnesses such as pneumonia, meningitis, appendicitis or an infection of the joints, bone marrow
- In very rare cases: Metabolic diseases, rheumatic diseases or allergic reactions to foods or medications 4
If a fever develops after traveling to a faraway place then it can also be the probable cause even several weeks after returning, it’s important to get this history
Special tests can be done to find out whether the child picked up an infection while traveling
EVALUATION
- First step is to identify sick patients who need stabilization and urgent referral
- Subsequently all attempts are made to identify the etiology/focus of infection
- A detailed history is of paramount importance
This should include:
– Whether and how the fever was documented
– Duration and pattern of fever
– symptoms referable to various organ systems
– Recurrent infections and or oral thrush (HIV infection)
– Joint pain, rash, photosensitivity (Autoimmune disease)
– Contact with TB patient, animals (Brucellosis)
– Travel to endemic zones (Kala azar) 4
- Complete physical examination should include documentation of fever, followed by assessment of general activity, nutrition and vital signs.
- 1 to 3 months old febrile infants who appear well should undergo a complete sepsis evaluation through the OPD including CBC, urine and blood culture and if indicated smear for MP and chest X-ray. CSF examination is undertaken if there is no clue to focus. If the screen is positive, all attempts should be made to overcome the infection
- Children upto 3 years, the risk of serious bacterial infection decreases to 5%. Detailed history is taken about vaccination, H/O sick contacts in the family and the condition of the child when fever is down. If the child looks toxic, he requires hospitalization and appropriate evaluation and treatment. In a non – toxic child with fever < 39oC one can merely observe. Children with fever more than 39oC, a high risk of bacteremia and testing with leucocyte count and examination of smear for malarial parasite are recommended
- In PUO, preliminary investigations should be done which include complete blood count, peripheral smear, ESR, blood culture, hepatic aminotransaminases and ultrasound. Inability to make a specific diagnosis merits reassessment and further investigations
- Fever with rash is a common and vexing problem. It may signify serious disorders such as meningococcemia or dengue fever or may be associated with minor drug allergy. The nature of rash often provides clues to determine the etiology of the exanthematous febrile illness. Rashes may be macular, maculopapular, vesicular, nodular, urticarial or purpuric and considerable overlap may occur with various presentations of the same etiology. Other factors that assist in diagnosis include epidemiological factors, season, history of exposure, incubation period, age, vaccination status, previous exanthems, prodromal symptoms, relation of rash with fever, distribution and progression of the rash, involvement of mucus membranes, drug intake and associated symptoms. All efforts should be made to diagnose serious entities earlier. For stable children, a specific diagnosis may not always be possible. In this situation, symptomatic therapy, close observation, explanation of danger signs to parents and staying away from school until rash resolves is recommended 1
AUXILIARY MEASURES
- Offer extra fluids to drink all through the day
- Dress the child in minimum clothes or without clothes. Do not cover the baby with blankets or anything that may make them hotter
- Make sure he gets enough rest
- Never use rubbing alcohol or cold baths to bring the fever down, instead use normal tap water
- Advice parents not to give antipyretics without measuring temperature.8
HOMOEOPATHIC APPROACH
- Today homoeopathy sections offers treatment for lots of health issues and various homoeopathic medicines used for with other health issues such as bodyache, cold, sneezing and more
- Following Homoeopathic remedies are frequently indicated remedies in fevers in children
1) Aconite: Often indicated in the first 24 hours of fever, if given in the first 24 hours then no fever will ever progress to pneumonia and other serious conditions. Fever with restlessness and anxiety. There will be increased thirst for cold water and intolerable body aches. Considered in fevers which have increased post sudden exposure to cold winds. One cheek pale and cold and other hot and red. Mouth and tongue will be dry.5,3
2) Bryonia alba: Often indicated after 36 to 48 hours of fever. Gradual onset of symptoms. Fever is usually associated with body aches. Wants to lie down all the time when fever is there. Increased thirst for large quantities of cold water for long interval. Desire to be uncovered.5
3) Nux vomica: Usually thought of during the first 24 hours of fever. Fever associated with shivering and chills. Wants to be covered from head to foot, cannot tolerate uncovering. Oversensitive to all the external impressions. Conjunctivitis with fever. Rest ameliorates. Cold stage predominates. Aching in limbs and back with gastric symptoms. Dry heat of the body. Perspiration sour smelling; only on one side of the body.7
4) Gelsemium: Usually indicated after 36 to 48 hours of fever. Fever associated with dullness, dizziness and drowsiness. Child wants to be held during a fever. During chills constantly wants to pass urine. There is absence of thirst in all stages. Chill, along spine wave like, extends upward from sacrum to occiput. Dumb ague with much muscular soreness, great prostration and violent headache. Pulse slow, full, soft and compressible.3
5) Pulsatilla: usually indicated after 36 to 48 hours of fever. Sensation of heat with external chilliness but without thirst. Chilly about 4 PM. Intolerable burning heat at night. External heat is intolerable. Yellowness of discharges. During apyrexia, headache, diarrhea, loss of appetite and nausea. Patient is generally better in open air and worse in warm room and towards evening.5
6) China: Usually indicated in the first 24 hours of fever. All stages of fever are very prominent and well marked. Free perspiration caused by every little exertion, especially on single parts. Debilitating night sweats. Wants covering in all stages uncovering causes shivering. Great periodicity of symptoms is marked. Hay fever with watery coryza and pain in temples. Very hungry in chill and heat stage. Lot of desire of tea, coffee and soups. 7
7) Belladonna: Indicated during the first 24 hours of fever. A high feverish state with comparative absence of toxemia. Perspiration is dry and only on head. Child will be playful during fever. Strawberry like tongue. Thirstless during fever. Food tastes salty. Child may get convulsions or delirium during fever. Forehead will be hot and feet will be cold. Lips very red and congested. General aggravation by slightest jar and all external impressions.6
In certain complicated cases of fever when indicated remedies fails to bring complete cure following remedies can be thought of:
1) Pyrogen: It is the great remedy for septic states, with intense restlessness. In septic fevers, pyrogen has demonstrated its great value as a homoeopathic dynamic antiseptic. It has dullness like gelsemium, offensiveness like baptisia and periodicity like china. All discharges are terribly offensive. Great pain and violent burning in abscesses. Chronic complaints that date back to septic conditions. Chill begins in back, temperature rises rapidly, after that great heat with profuse hot sweat, but sweating does not cause a fall in temperature. Pulse is abnormally rapid, out of proportion to the temperature. Tongue is either varnished or coated.3
2) Natrum muriaticum: Chill between 9 and 11 am, internal chilliness as if from want of natural vital heat. Heat: violent thirst, increases with fever. Fever blisters. Coldness of the body and continued chilliness is well marked. Pulse beat shakes the entire body perceptibly, extremely irregular. Heat is overrunning with most intolerably violent head pains, often with shuddering over the back, and sweat in arm pits and soles of feet, mostly with violent thirst. Sweat profuse wherein the symptoms cease which appeared during the fever, debilitating.3
3) Streptococcinum: Complicated cases of fever especially when the focus of infection is in throat or tonsils. Enlarged, swollen and infected tonsils, quinsy. Tendency of recurrent throat infection. Very chilly patient. Enlarged nodes in the neck.6
CONCLUSION: Homoeopathy can take care of both simple and complicated fevers if prescribed correctly taking into consideration all the laws and principles of the same. Children can be saved from the hazardous effects of antibiotics.
REFERENCES:
1) Vinod K Paul, Arvind Bagga, Ghai Essential Pediatrics, 8th Edition, CBS Publishers and Distributors Pvt Ltd, 2013
2) Kliegman, ST Geme, Blum, Shah, Tasker, Wilson, Nelson Textbook of pediatrics, 21st Edition, Harcourt Publishers, Asia, 2019
3) William Boericke, Pocket Manual of Homoeopathic Materia Medica, 9th edition.
4) Egidio Barbi, Pierluigi Marzuillo, Elena Neri, Samuele Naviglio, Baruch S. Krauss, Fever in Children: Pearls and Pitfalls, National library of Medicine, 2017.
5) Dr. SR Phatak, Materia Medica of Homoeopathic Medicines
6) Dr. Vikas Sharma, Homoeopathic Medicines for Streptococcal Throat Infection, 2023.
7) Dr. Saumya Avinashi, Best Homoeopathic Medicines for Child and adults, 2023
8) Community Pediatrics Committee, Fever and Temperature Taking, 2022
https://caringforkids.cps.ca/handouts/health-conditions-and-treatments/fever_and_temperature_taking
