Diagnosis and Treatment of the Febrile Child

Excerpt

Fever is one of the most common presenting symptoms of pediatric illnesses. Fever in children under age five years signifies systemic inflammation, typically in response to a viral, bacterial, parasitic, or less commonly, a noninfectious etiology. Patients’ ages and geographic settings can help direct the appropriate diagnostic approach and treatment, if local epidemiology is well understood.

The combined proportion of deaths due to AIDS, diarrheal diseases, pertussis, tetanus, measles, meningitis/encephalitis, malaria, pneumonia and sepsis was 58.5 percent for children ages 1–59 months in 2015; it was 23.4 percent for neonates (Liu and others 2016, chapter 4 of this volume). Evidence regarding fever incidence is variable, with country-specific reports from cross-sectional surveys or weekly active case detection ranging from two to nine febrile episodes per child under age five years per year, a mean of 5.88 fever episodes per child under age five years per year (Gething and others 2010). National survey data from 42 Sub-Saharan African countries (excluding Botswana, Cabo Verde, Eritrea, and South Africa) were collected and analyzed for an estimated 655.6 million under-five fever episodes in 2007; 32 percent of these episodes occurred in 11 outpatient units in the Democratic Republic of Congo, Ethiopia, and Nigeria (Gething and others 2010). At the health facility and community levels, fever is by far the most common pediatric presenting symptom. Multiple studies summarized in table 8.1 highlight the most common presenting symptoms at the facility and community levels.

Before the availability of affordable and accurate malaria rapid diagnostic tests (RDTs), most health care providers in malaria-endemic countries presumed that malaria was the cause of fever; the proportion of fevers due to malaria was very high in the early 1990s, and the priority was to reduce malaria mortality by any means.

The 1997 World Health Organization’s (WHO’s) initial Integrated Management of Childhood Illness (IMCI) guidelines recommended the use of injectable antimalarials and antibiotics in children in malaria- endemic areas who were suspected of having severe disease with the presence of danger signs (Gove 1997; Communicable Disease Surveillance and Response Vaccines and Biologicals 1997). Until 2010, the first edition of the WHO guidelines for the treatment of malaria recommended empiric, oral, antimalarial therapy for fever without other source in children under age five years living in malaria-endemic areas (WHO 2006). The decline of malaria incidence; rise of antimicrobial resistance; and availability of accurate, low-cost, point-of-care diagnostics have challenged the effectiveness of the presumptive treatment of febrile illnesses and reopened the discussion of the most accurate and cost-effective approaches for fever diagnosis and treatment. There are settings with very high malaria transmission and limited availability of diagnostic test where presumptive treatment would be most practical and cost-effective (DCP3 volume 6, Babigumira, forthcoming). In 2009, experts debated whether sufficient information was available to abandon presumptive treatment guidelines and move to an emphasis on diagnosis before treatment (D’Acremont, Lengeler, and Genton 2007; D’Acremont and others 2009; English and others 2009).

Mounting evidence demonstrated the decline of Plasmodium falciparum infections in response to intense national and multinational initiatives to control malaria. In 2012 more than US$2.5 billion was invested from global partners, including the Global Fund to Fight AIDS, Tuberculosis and Malaria; the World Bank Malaria Booster Program; the U.S. President’s Malaria Initiative; the Bill & Melinda Gates Foundation’s Malaria Control and Evaluation Partnership in Africa; and the Roll Back Malaria Partnership (D’Acremont, Lengeler, and Genton 2010; Feachem and others 2010; Leslie and others 2012; WHO 2013a). Countries with previously defined high-transmission regions are reporting decreasing malaria incidence, making the management of nonmalarial fevers critically important (Feachem and others 2010; WHO 2013a; Hertz and others 2013; Ishengoma and others 2011).

In 2010, the WHO revised its fever treatment guidelines to recommend antimalarial treatment only for those with a positive malaria test result, either point-of-care or microscopy (WHO 2010a). This new strategy is being implemented in the public sector in most Sub-Saharan African countries (Bastiaens and others 2011). However, many patients first present for care in the informal private sector, and more research is needed to better understand treatment decision making in this context and how to reduce overuse of antimicrobials and ensure appropriate care. The epidemiology of pediatric febrile illness is undoubtedly shifting; understanding the etiology of nonmalarial fevers in each context is the logical next step to improve pediatric clinical outcomes of other treatable serious febrile illnesses, such as pneumonia, sepsis, bacterial meningitis, enteric fever, rickettsioses, and influenza. Given rampant and expanding antimicrobial drug resistance globally, care must be taken to use antibiotics only when indicated and to develop careful guidelines when resources are limited. Present guidelines are based on clinical features that are unfortunately poorly predictive of the diseases causing fever. Low-cost, accurate, point-of-care diagnostics are needed to determine which children can benefit from antibacterial therapies to guide the most effective use of antibiotics.

This chapter discusses the evidence that informs current etiologies of fever, stratified by regional geography. It presents the clinical presentation, diagnosis, and treatment of the most common diseases, with special considerations for certain age groups, the burden of disease for different conditions, classification and treatment strategies, and a review of available diagnostic tests. In addition, different health systems approaches to diagnosis and treatment of the febrile child at the community and health-facility levels are discussed, as is the evidence base for WHO-sponsored approaches such as IMCI and Integrated Community Case Management (iCCM). Fever in adults and RDT use for malaria are discussed further in volume 6 (Holmes, Bertozzi, Bloom, Jha, and Nugent, forthcoming).