6. Management of Sick Children with Fever
Study Session 6. Management of Sick Children with Fever 4
Learning Outcomes for Study Session 6 4
6.1 Assess and classify fever 4
Box 6.1 Malaria symptoms and possible complications 5
Box 6.2 Measles: symptoms and complications 5
6.2 Assess fever 5
ASK: Does the child have fever? 6
Box 6.3 Assessing for fever and possible related illnesses 6
6.2.1 Assessing for malaria 7
6.2.2 Assessing for other diseases 8
ASK: How long has the child had fever? 8
ASK: Has the child had measles within the last three months? 8
LOOK or FEEL for stiff neck 8
LOOK or FEEL for bulging fontanelle (age less than 12 months) 11
LOOK for runny nose 11
6.2.3 Assessing measles 11
Generalised rash 11
Cough, runny nose or red eyes 11
LOOK to see if the child has mouth or eye complications 11
LOOK for mouth ulcers. Are they deep and extensive? 11
LOOK for pus draining from the eye 12
LOOK for clouding of the cornea 12
6.3 Classifying fever 12
6.3.1 Classification of malaria 14
High malaria risk 14
Low malaria risk 15
No malaria risk 15
6.4 Treatment for fever and malaria 16
6.4.1 Very severe febrile disease or severe malaria 16
6.4.2 Malaria 17
6.4.3 Fever (no malaria) 17
6.4.4 Follow-up care and treatment for fever or malaria 17
Box 6.4 Follow-up care for malaria (low or high risk) 17
6.5 Classifying measles 18
6.5.1 Severe complicated measles 18
6.5.2 Measles with eye or mouth complications 18
6.5.3 Measles 18
6.6 Treatment of measles 19
6.6.1 Severe complicated measles 19
6.6.2 Measles with eye or mouth complications 19
6.6.3 Follow-up care for measles with eye or mouth complications 20
Case Study 6.1 Pawlos’s story 20
Summary of Study Session 6 21
Self-Assessment Questions (SAQs) for Study Session 6 22
SAQ 6.1 (tests Learning Outcomes 6.1 and 6.2) 22
Case Study 6.2 for SAQ 6.2 22
SAQ 6.2 (tests Learning Outcomes 6.2 and 6.3) 23
Case Study 6.3 for SAQ 6.3 23
SAQ 6.3 (tests Learning Outcomes 6.1, 6.2, 6.3 and 6.4) 23
Study Session 6. Management of Sick Children with Fever
Fever is a common symptom in many sick children. Think about your health post — many of the mothers who bring their children to see you are likely to say that the reason for their visit is that the child has fever. Being able to assess fever and classify the illness that is causing the fever is therefore an important task for you as a Health Extension Practitioner.
This study session will introduce you to the common causes of fever in children. A child with fever may just have a simple cough or other viral infection. However fever may also be caused by a more serious illness, such as malaria, measles or meningitis.
Malaria is a major cause of death in children so it is important that you are able to identify the symptoms and ensure the sick child receives urgent treatment as quickly as possible.
In this study session you will learn how to recognise and assess fever and which focused questions to ask so that you are able to classify the illness causing the fever. You will also learn how you treat the illness as effectively as possible and to support the mother in providing home care for her child.
Learning Outcomes for Study Session 6
When you have studied this session, you should be able to:
6.1 Define and use correctly all of the key words printed in bold.
(SAQs 6.1 and 6.3)
6.2 Assess a child with fever. (SAQs 6.1, 6.2 and 6.3)
6.3 Classify the illness in a child with fever. (SAQs 6.2 and 6.3)
6.4 Treat and give follow-up care for very severe febrile illness, malaria, measles and other causes of fever. (SAQ 6.3)
6.1 Assess and classify fever
Malaria and measles are the two major illnesses where fever is likely to be a symptom (although you should not rule out either illness even if fever is not present).
Measles and malaria are both described in Communicable Diseases, Part 1; see Study Sessions 4 and 8 respectively.
Box 6.1 outlines the key symptoms and signs of malaria and the complications that can arise in an infant or child who has malaria.
Box 6.1 Malaria symptoms and possible complications
Fever is the main symptom of malaria. It can be present all the time or recur at regular intervals during the illness. Other signs of malaria are shivering, sweating and vomiting. A child with malaria may have chronic anaemia (with no fever) as the only sign of illness.
In areas with very high malaria transmission, malaria is a major cause of death in children. A case of uncomplicated malaria can develop into severe malaria within 24 hours of onset of the illness. The child can die if urgent treatment is not given.
Measles is another cause of fever. It is a highly infectious disease with most cases occurring in children aged between six months and two years. Box 6.2 below outlines the main symptoms and possible related infections that you need to be aware of if you are treating a child with measles.
Box 6.2 Measles: symptoms and complications
Fever and a generalised rash are the main signs of measles. Most cases occur in children between six months and two years of age. Measles is highly infectious. Overcrowding and poor housing increases the risk of measles occurring early in a child’s life.
Measles affects the skin and the layer of cells that line the lung, gut, eye, mouth and throat. The measles virus damages the immune system for many weeks after the onset of measles. This leaves the child at risk of other infections.
Complications of measles occur in many cases. The most important are: diarrhoea (including dysentery and persistent diarrhoea), pneumonia, stridor, mouth ulcers, ear infection and severe eye infection and blindness.
Measles also contributes to malnutrition because it causes diarrhoea, high fever and mouth ulcers, all of which can interfere with feeding. Malnourished children are more likely to have severe complications due to measles. This is especially true for children who are deficient in vitamin A. One in ten severely malnourished children with measles may die. For this reason, it is very important to help the mother to continue to feed her child during measles.
6.2 Assess fever
Whether or not the mother says the child has fever, it is important that you assess all sick children for fever.
A child has the main symptom of fever if:
the child has a history of fever or
the child feels hot or
the child has an axillary temperature of 37.5°C or above.
ASK: Does the child have fever?
Check to see if the child has a history of fever, feels hot or has a temperature of 37.5°C or above.
The child has a history of fever if the child has had any fever with this illness. Use words for ‘fever’ that the mother understands. For example, ask the mother if the child’s body has felt hot. Feel the child’s abdomen or armpit and determine if the child feels hot.
If the child’s temperature has not been measured, and you have a thermometer, measure the child's temperature.
If the child has fever, assess the child for additional signs related to fever (if the child has no fever you should ask about the next main symptom, which is an ear problem. You will learn how to assess and classify ear problems in Study Session 13).
When a child presents with fever you should assess the child following the steps set out in Box 6.3 below. You will see that it lists the steps for assessing a child for fever and what the related illness may be.
The fontanelle is the ‘soft spot’ on top of an infant’s head where the skull bones have not yet fused. Meningitis is described in detail in Study Session 3 of Communicable Diseases, Part 1.
There are two parts to the box. The top section (above the broken line) describes how to assess the child for signs of malaria, measles, meningitis and other causes of fever. In meningitis there will be bulging fontanelle in infants and stiffness of the neck. The bottom section of the box describes how to assess the child for signs of measles complications if the child has measles now, or has had measles within the last three months.
Therefore, if your assessment is that the child does have fever, you should follow the steps in Box 6.3:
Box 6.3 Assessing for fever and possible related illnesses
Decide malaria risk: high or low or no.
If ‘low or no’ malaria risk, then ask:
Has the child travelled outside this area during the previous 15 days?
If yes, has the child been to a malarious area?
LOOK AND FEEL:
● For how long has the child had
● If more than seven days, has the
fever been present every day?
● Has the child had measles within
the last three months?
● Look or feel for stiff neck
● Look or feel for bulging
fontanelles (under one year old)
● Look for runny nose
● Look for signs of MEASLES
● Generalised rash and one of these:
cough, runny nose, red eyes
If the child has measles now or within the last three months
● Look for mouth ulcers
Are they deep and extensive?
● Look for pus draining from the eye
● Look for clouding of the cornea
You are now going to look in more detail at how to classify illnesses associated with fever.
6.2.1 Assessing for malaria
You need to decide whether the malaria risk is high or low. The practical criteria for classification of risk of malaria in Ethiopia, where malaria is seasonal, should be based on altitude and season.
High risk: areas at altitude range of less than 2,000 metres above sea level, especially during the months of September to December and from April to June.
Low risk: areas at altitude range of 2,000–2,500 metres above sea level, especially during the months of September to December and from April to June.
No risk: areas at altitude range of above 2,500 metres above sea level.
If you are not sure whether the child has been to a malarious area you should assume the malaria risk is high.
If the malaria risk in the local area is low or absent, ask whether the child has travelled outside this area during the previous 15 days. If yes, then you should ask if the child has been to a malarious area. You should identify the malaria risk as high if there has been travel to a malarious area.
If the mother does not know or is not sure, ask about the area and use your own knowledge of whether the area has malaria. If you are still not sure, then you should assume the malaria risk is high.
Why do you think it is important to assess all sick children for fever?
Although fever may be caused by a simple cough or other virus infection, it can also be caused by a more serious illness, such as measles or malaria. As you read, malaria is a major cause of death for children so it is important than you know how to identify the signs.
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6.2.2 Assessing for other diseases
If you assess the child as not having malaria, you need to consider other possible causes for the child’s fever.
ASK: How long has the child had fever?
If the fever has been present for more than seven days, ask if the fever has been present every day.
Most fevers due to a virus infection go away within a few days. A fever which has been present every day for more than seven days can mean that the child has a more severe disease. In this case you should refer the child for further assessment.
ASK: Has the child had measles within the last three months?
A child with fever and a history of measles within the last three months may have an infection due to complications of measles.
LOOK or FEEL for stiff neck
A child with fever and a stiff neck may have meningitis. A child with meningitis needs urgent treatment with injectable antibiotics and referral to a hospital.
While you talk with the mother during the assessment, look to see if the child moves and bends his neck easily as he looks around. If the child is moving and bending his neck, he does not have a stiff neck.
Figure 6.1 Checking the child’s neck movements (1).
If you did not see any movement, or if you are not sure, draw the child’s attention to his umbilicus or toes. For example, you can shine a flashlight on his toes or umbilicus or tickle his toes to encourage the child to look down (see Figure 6.1). Look to see if the child can bend his neck when he looks down at his umbilicus or toes.
Figure 6.2 Checking the child’s neck movements (2).
If you still have not seen the child bend his neck himself, ask the mother to help you lie the child on his back. Lean over the child; gently support his back and shoulders with one hand. With the other hand, hold his head. Then carefully bend the head forward toward his chest (see Figure 6.2). If the neck bends easily, the child does not have a stiff neck. If the neck feels stiff and there is resistance to bending, the child has a stiff neck. Often a child with a stiff neck will cry when you try to bend his neck.
LOOK or FEEL for bulging fontanelle (age less than 12 months)
Hold the infant in an upright position. The infant must not be crying. Then look at and feel the fontanelle. The fontanelle is the soft (not hard or bony) part of the head normally found in infants. If the fontanelle is bulging rather than flat, this may mean the young infant has meningitis.
A runny nose in a child with fever may mean that the child has a common cold. When malaria risk is low, a child with fever and a runny nose does not need antimalarial drugs. The fever is probably due to the common cold.
6.2.3 Assessing measles
Assess a child with fever to see if there are signs suggesting measles. Look for a generalised rash and for one of the following signs: cough, runny nose or red eyes.
In measles, a red rash begins behind the ears and on the neck. It spreads to the face first and then over the next 24 hours, the rash spreads to the rest of the body, arms and legs. After four to five days, the rash starts to fade and the skin may peel.
Measles rash does not have blisters or pustules. The rash does not itch. You should not confuse measles with other common childhood rashes such as chicken pox, scabies or heat rash. Chicken pox rash is a generalised rash with vesicles (raised, fluid-filled spots). Scabies occurs on the hands, feet, ankles, elbows and buttocks, and is itchy. Heat rash can be a generalised rash with small bumps and is also itchy. A child with heat rash is not sick. You can recognise measles more easily during times when other cases of measles are occurring in your community.
Cough, runny nose or red eyes
To classify a child as having measles, the child with fever must have a generalised rash and one of the following signs: cough, runny nose or red eyes.
If the child has measles now or within the last three months:
LOOK to see if the child has mouth or eye complications
You have already looked at how to assess other complications of measles, such as stridor in a calm child, pneumonia and diarrhoea, in earlier study sessions in this Module. You will learn about other complication such as malnutrition and ear infection in later study sessions.
LOOK for mouth ulcers. Are they deep and extensive?
Mouth ulcers are common complications of measles which interfere with the feeding of a sick child. Look for mouth ulcers in every child with measles and determine whether they are deep and extensive.
The mouth ulcers should be distinguished from Koplik spots. Koplik spots occur inside the cheek during the early stages of measles infection. They are small irregular bright spots with a white centre. They do not interfere with feeding.
LOOK for pus draining from the eye
Pus draining from the eye is a sign of conjunctivitis. If you do not see pus draining from the eye, look for pus on the eyelids.
Often the pus forms a crust when the child is sleeping and seals the eye shut. It can be gently opened with clean hands. Wash your hands before and after examining the eye of any child with pus draining from the eye.
LOOK for clouding of the cornea
The cornea is the transparent covering of the front part of the eye.
Look carefully for corneal clouding in every child with measles. The corneal clouding may be due to vitamin A deficiency which has been made worse by measles. If the corneal clouding is not treated, the cornea can ulcerate and cause blindness.
A child with clouding of the cornea needs urgent referral and treatment with vitamin A.
What kinds of complications might a child have who had measles a month ago?
If a child has had measles at any time in the past three months you should check to see if he has any mouth complications such as ulcers, which interfere with feeding if they are deep and extensive. You should also look to see if the child has eye problems such as conjunctivitis or corneal clouding which can ulcerate and cause blindness.
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