REVIEW OF ANATOMY AND PHYSIOLOGY

Temperature control in children is not completed until approximately ve

years of age. This may be due to the immaturity of the nervous system. The
maintenance of body temperature is mainly coordinated by the hypothalamus, a
central control center containing large numbers of heat-sensitive neurons called
thermoreceptors. It is an important homeostatic mechanism which allows the body

enzymes to work efciently within a narrow range of 36.537.5 C. In response to

a change in temperature, the peripheral thermoreceptors transmit signals to the
hypothalamus, where they are integrated with the receptor signals from the
preoptic area of the brain.
The normal set point in childhood reflects a decreasing basic metabolic rate
(BMR) as the child grows. The body temperature of the three-month-old child is
37.5 C, whereas at thirteen years it is 36.6 C. Even as the temperature regulatory
mechanisms mature through childhood, babies and small children are highly
susceptible to temperature fluctuations, as they produce more heat per kilogram of
body weight than older children. Changes in environmental temperature, increased
activity, crying, emotional upset and infections all cause a higher and more rapid
increase in the younger child.
The younger the child the less able he or she is to vocalize the feeling of hot
or cold or to do something about it. All children may also become too cold. Small
individuals who do not have warm clothes and warm homes will not grow if the
temperature of their environment is consistently low. They will use much of the
energy from their food intake to generate heat (metabolic rate) and leave no spare
calories for tissue growth.
The smaller the child, the larger the surface area for heat loss in relation to
body mass. The head of a small child is relatively larger in proportion to the rest of
the body, and covering the head in a cold environment conserves heat for growth.
Schoolchildren may experience a sequence of small growth spurts and at times be
relatively thin with minimal body fat.

At the swimming pool, for example, where children enjoy jumping in and
out of the water as they play, thin children may become cold more quickly than
their fatter friends who have an insulation layer beneath their skin.
Heat can generated through the metabolism of the liver, muscles, and other
chemical activities. When children are exposed in a cold environment, it can result
to hypoglycemia, elevated serum bilirubin, metabolic acidosis, and increased
metabolic rate.
When heat loss occurred, non-shivering thermogenesis (NST) heat
production takes place in the subcutaneous tissue, hypothalamus, and spinal cord to
compensate for the sudden change in temperature.
Heat loss transpires through the contact in a cold environment, vasodilation,
sweating where the preoptic area of the brain stimulates secretion of water to the
skin for evaporation. There are different areas in the body where we can measure
the temperature such as axillae, tympanic membrane, and mouth

PATHOPHYSIOLOGY

Non-Modifiable Factors:
Underdeveloped
hypothalamic control
centre
Family history of febrile
convulsion
Infection

Modifiable Factors:

Hygiene
Diet
Environment

Immune
response

Endogenous
pyrogens
Mucus
production

Production of proinflammatory
cytokines, such as
interleukins 1 (IL-1)
and 6 (IL-6), interferon

WBC

Hypothalamic
circulation

Release of
prostaglandin E2

Anterior
hypothalamus

Elevated
thermoregulatory
set-point

Heat
conservation

Heat
production

 Urine
output

Irritable and
restless

Fluid
conservation

Metabolism
of the liver

Vasoconstrict
ion

Glucose
breakdown

Cerebral
perfusion

Muscle
contraction

Fever

Immature
hypothalamic
control
Temperature
fluctuates to >39
C

Bronchospas

Neuronal
excitability

Difficulty of
breathing

Febrile
seizure

RR

Energy
demand

MEDICAL-SURGICAL MANAGEMENT
Medical Management:
1. Administration of due medications as ordered by the physician.
The following medications are:
Cefuroxime, an anti-infective, cephalosporin 0.33 g, IV, q8h
Salbutamol, a bronchodilator, sympathomimetics 1 nebule (1cc +
1cc NSS), inhalation, q6h
Paracetamol, an antipyretic, nonsteroidal anti-inflammatory drug
1.2 ml in a 100g/1ml, PO, PRN
Diazepam, an anticonvulsant, benzodiazepine 2 g, IV, for active
seizure
Chloramphenicol, anti-infective 125 mg, IV, q6h
2. Intravenous Replacement Therapy
IV replacement therapy is the fastest way of replacing fluid loss and
electrolyte imbalances. It can also be used to keep the vein open for the
administration of medications.
The following IV solutions administered:
D5 0.3 NaCl, a hypotonic solution, 500 cc x 8 - causes cell
shrinkage therefore reducing body heat.
D5 IMB, a hypertonic solution, 1 L at 41 cc/hr for cell
rehydration.

3. Oxygen Therapy
Oxygen therapy is used during emergency medical services. It is for
the difficulty of breathing during active convulsion. Oxygen inhalation at 23 L was given via face mask.
4. Laboratory and Diagnostic Procedures
August 30, 2010
Complete Blood Count It is used as a broad screening test to check
for such disorders as anemia, infection, and many other diseases. This
evaluates the three types of cells in the blood which are red blood
cells, white blood cell, and platelets. This provides an overview of the
general health of the patient.

NURSING MANAGEMENT

Vital signs monitoring every 1 hour

Input and Output of Fluid Measurement
Administer medication due as ordered by the physician
Patient, a toddler, has developed a stranger anxiety as manifested by
white coat syndrome. A nursing intervention would be is to

establish rapport by playing with the patient.

Encourage the mother to increase and continue breastfeeding for
faster recovery of the patient.
Provide opportunity for the patient to rest from time to time.

HEALTH EDUCATION
Medications
Instruct and explain to the mother that the medication, especially the
antibiotics, is important to continue depending on the duration that the
doctor ordered for the total recovery of the
patient.
Inform the mother of the side and adverse
effects of the drugs she is giving to her
daughter.
Instruct to report immediately any side or adverse effects when taking the
prescribed drug such as nausea, vomiting, diarrhea, rashes.
Take the entire course of any prescribed medications. After a patients
temperature returns to normal, paracetamol is administered if fever
occurs. Avoid using paracetamol more than 5 days.
Instruct the mother to avoid over-the-counter drugs without the
consultation of the physician to avoid any drug-drug interaction.
Exercise
Encourage the mother to have her daughter rest from time to time for
faster recovery.
Treatment
Comply with the established treatment regimen given by the doctors
including prescribed medications.
Encourage the mother to expose the patient to early morning sunlight
Advise the mother to provide tepid sponge bath when fever occurs
Provide oxygen therapy during active convulsion to alleviate the difficulty of
breathing.

Hygiene
Encourage and explain to the mother that it is vital to maintain proper
hygiene by frequently washing her hands.
Out-patient
Its important for the toddler to have her follow-up check up to ensure
and have the patients progress monitored.
Diet
Encourage the mother to continue breastfeeding the patient. Instruct the
mother that the head must be in upright position when breastfeeding to
avoid aspiration and let the baby burp after feeding.

FEBRILE SEIZURE
Definition
Seizure that is occured when body temperature (rectal) increases (38 OC), which
usually happened among babies and children between 6 month old and 5 years
old, which is caused by an extracranium process, without any specific cause. It
should be differed from epilepsy which have other seizure events without fever.
Ferbrile seizure is divided into 2 types:
1. Simple febrile seizurelast less than 15 minutes, general, single
2. Complex febrile seizure last more than 15 minutes, or focal, or
multiple (more than 1 seizure in 24 hours). It may indicate more serious
diseases such as meningitis, abcess, or encephalitis.
Risk factors for developing febrile seizures
Family history of febrile seizures
High temperature
Neonatal discharge at an age greater than 28 days (perinatal illness that
need hospitalization)
Children with delayed development
Children under suspicion
Low sodium level
If a child has 2 of these risk factors, then the probability of a first febrile
seizure increases about 30%. Maternal alcohol intake and smoking during

pregnancy increases the risk by 2-fold. Interestingly, there is not any data
which show that a rapid increase in body temperature causes of febrile
seizures.

Risk factors for recurrent febrile seizures include the following:

Age at time of first febrile seizure <12 months

Relatively low fever at time of first seizure (below 38OC)
Family history of a febrile seizure in a first-degree relative
Short duration between fever onset and initial seizure
Multiple initial febrile seizures during same episode
Family history of epilepsy

Patients who have 4 risk factors have >70% possibility of recurrence, while
those with no risk factors have <20% chance of recurrence.
Risk factor for epilepsy (less than 5%)
- Abnormal child development before the first febrile seizure
- Complex febrile seizure
TYPES OF FEBRILE SEIZURE
1.Simple febrile seizure
The most common type of febrile seizure (~90% of cases)
Features:
Tonic clonic seizure
Does not last >15 minutes

2. Complex febrile seizure

Less common than simple febrile seizures (~10% of cases)
Has one or more of the following features:
Seizure lasts >15 minutes
Partial or focal seizure
Seizure reoccurs within 24 hours of the first seizure or
during the period in which they have an illness
The child does not fully recover from the seizure within
one hour

Does not reoccur within 24 hours or during the period in which the child
has an illness
ETIOLOGY
Febrile seizures happen among young children when they have lower
threshold of seizure, when they are prone to infections such as upper respiratory
infection, otitis media, viral syndrome, and they respond with comparably
higher temperatures. Some studies on animals show a possible role of
endogenous pyrogens, such as interleukin 1beta, in the increase of neuronal
excitability, which may link fever and seizure activity. This statement is also
supported by studies in children, although there is no specific pathological
significance.

Moreover, although there is not any exact molecular mechanisms of febrile

seizures, underlying mutations have been found in genes encoding the sodium
channel and the gamma amino-butyric acid A receptor.

CLINICAL MANIFESTATION

Seizure usually occurs at the beginning of the fever.

Tonic clonic seizure could be started by crying,
Then unconsciousness and muscle stiffness.
Limbs twitching
Lose of conciousness
Urine incontinence soiling
Vomiting
Foam at the mouth
Lasting <5 minutes
Sleepiness/drowsiness after seizure ~1 hour
It could be accompanied by apnea and incontinentia,
then ended by lethargic seizure and sleep.
the movement of eyeballs to the top, accompanied by stiffness of

weakness of muscles.
encephalitis or meningitis (lumbal puncture might be indicated.
COMPLECATION
Risk of developing epilepsy ~1.5%
Risk rises to 2.5% if the child was under 12 months old when they had
their first seizures (in those who had multiple simple seizures.
Risk also increases with:
Neurological abnormalities, or a developmental delay before the
onset of febrile seizures.
A family history of epilepsy.

 A brief fever (<1 h) before the seizure.

Complex seizures.

INVESTIGATION
Source of infections! Do not forget ear and throat examinations!!
FBC
BUSE, Ca2+
Glucose level
Urinalysis
CXR
ENT swab
Further investigations:
EEG
Lumbar puncture (particularly if the child is <12 months old)

NURSING DIAGNOSIS
1. Increased body temperature relation : the presence of pyrogens which
disrupt the thermostat, the average increase in metabolism and disease
dehydration.
2. Risk for Ineffective airway clearance related to neuromuscular
damage

and

obstruction

tracheo

broncial.

3. Knowledge Deficit : family related to misinterpretation and lack of

information.
4. Self-concept Disturbance (low self esteem) related to epilepsy and
wrong perceptions and uncontrolled.