DEMAM PADA ANAK

Sherly Yuniarchan, dr SpA

 Demam pada anak
◦ Masalah/keluhan yang sering dijumpai
◦ Manifestasi klinis bervariasi: ringan >penyakit
infeksi bakteri yang serius
◦ Bisa mengenai neonatus ,bayi,anak dst
◦ Perlu dipahami demam yang terjadi pada anak
◦ Fever phobia tak hanya pada ortu,kadang
dokter

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• Di Instalasi Rawat Darurat (IRD)
– Demam 20-25 % keluhan penderita anak
– Resiko Infeksi Bakteri Serius 1%
• Meningitis,bakteriemi,sepsis,osteomielitis
,pnemonia dsb
– Yang lain penyakit infeksi yang umum
• OMA,Faringitis,Enteritis,
• Penyakit virus
:ISPA,bronkhiolitis,gastroenteritis,exanthema
enterovirus ,dsb

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 Pengobatan Demam
◦ Membuat ortu tak cemas,anak merasa
enak,mudah diperiksa => Antiperetik
◦ Acetaminofen dan Ibuprofen => Antipiretik
ideal
◦ Acetaminofen lebih cepat,Ibuprofen lebih lama
◦ Non medikamentosa : pendinginan eksternal

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 Demam pada anak kurang 3 bulan
◦ Suhu rektal 38 ⁰C atau lebih
◦ Kejadian/Incidence Infeksi Bakteri Serius 6-
10%, Meningitis dan atau Bakteriemi 1-2 %
◦ Lebih dari 3 bulan s/d 36 bln ,kejadian IBS
makin kurang dengan vaksinasi
HIB,S.Pnemoniae

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 Demam kurang 3 bulan
◦ Neonatus dan Bayi usia muda (Young Infant)
28-90 hr.
 Perlu full sepsis evaluation :Darah rutin,kultur
darah, Cairan serebro spinal,Urine
 Berbagai metode/kriteria membedakan resiko
rendah dan resiko tinggi Infeksi Bakteri Serius
(Rochester,Boston,Phliladelphia,Yale kriteria)
 Kriteria RBPY : Klinis dan Laboratoris

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Pendahuluan

-demam adalah temperature diatas 38 0C (100.4 F)

-bila anak membaik setelah diberi obat panas tidak berarti
penyakitnya ringan, justru evaluasi sebelum panas berkaitan
dengan SBI

-pengobatan panas (menurun atau tidak)

1. tidak ada hubungannya dengan diagnosis / proses penyebab demam
2. Menghambat penyakit
3. Mencegah kejang (no evidence that antipyretic is effective in the
prevention of seizures.)
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 ….pendahuluan

-banyak penelitian lama menyatakan tingginya demam

berkaitan dengan SBI, namun setelah penggunaan Hib and
Pneumococcal vaccines, hanya adanya occult bacteremia
yang perlu di work up.

-percayailah anamnesa tingginya demam dari orang tua

- Suhu yang normal tidak menyingkirkan adanya serious

bacterial infection

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Masalah klasifikasi demam menurut berbagai pedoman :

-berbagai penelitian dan pedoman belum memberikan satu opsi yang

utuh karena perbedaan fasilitas dan epidemiologi penyakit .
-Kejadian prevalence bacteremia yang nyata pada anak dengan
demam usia 3-36 months is 1.5- 2.0%, dan 5-20% akan cacat

--umumnya treatment strategies dibagi :

1. Neonatus (birth to 28 days)
2. bayi muda (1 – 3 bulan)
3. 3 bulan sampai 3 tahun
4. above 36 months/ 3 tahun 9
 Serious Bacterial Infection

• Meningitis
• Pneumonia
• Urinary tract infection
• Endocarditis
• Gastroenteritis
• Soft tissue infection
• Bone/joint infection

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FLOW CHART OF FEVER MANAGEMENT in the outpatients and inpatients

ROUTINE LAB : Blood culture

(seleasai dlm 3-4 jam )
DEMAM Hb, leuko, Diff. Count,
Available in: 72
hours
Platellet, Urine sediment

< 1 bln > 3 tahun

1-36 bln

Algoritme III
MRS Focus + Focus -

Severity index 3-36 bln

1-3 bln

high low
Algoritme I Algoritme II

MRS Rawat
jalan
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Work Up neonatus

-A documented fever requires a full “septic” work up and admission

The “septic” work up includes:

1. CBC with diff,
2. Blood Culture,
3. UA and Urine culture,
4. CXR,
5. LP for CSF analysis
6. Culture and Herpes PCR testing,
7. Stool culture and fecal WBC in cases of diarrhea

**If ill appearing, give antibiotics once urine and blood obtained (< 30 min from
arrival and Prior to LP)
Antibiotics:
Ampicillin PLUS Gentamycin 2.5 mg/kg IV
**According to some guidelines, in neonates younger than 28 days and those at high
risk for neonatal HSV infection (delivered vaginally to a mother with known HSV
infection at time of delivery) , the addition of acyclovir is recommended.
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 criteria of toxic /severity:
Yale scores greater than 15
Table 1. Yale Observation Scale

Observation Item Normal = 1 Moderate impairment = 3 Severe impairment = 5

Weak or moaning, high-pitched,

Quality of cry Strong or none Whimper or sob
continuous cry or hardly responds
Reaction to
Cries brief or no
parent Cries on and off Persistent cry with little response
cry and content
stimulation
If awake, stays
Eyes close briefly when awake
awake or if
State variation or awakens with prolonged No arousal and falls asleep
asleep, awakens
stimulation
quickly
pale extremities or
Color pink pale or cyanotic or mottled or ashen
acrocyanosis
Skin and eyes Skin and eyes normal and Skin doughy or tented and dry mucous
Hydration
normal and mouth slightly dry emmbranes and/or sunken eyes

Response to Smiles or alerts No smile, anxious, dull; no alerting to

Brief smile or alert
social overtures (consistently) social overtures

A total score of less than 11 signifies a less than 3% probability of serious illness.
A total score of 11-15 signifies a 26% probability of serious illness. 13
A total score of greater than 15 signifies a greater than 92% probability of serious illness.
 Admit to hospital Cultures Viral infection
FEVER WITHOUT for sepsis negative
Low-risk criteria met:
any FOCUS evaluation,
Previously healthy empiric antibiotic
Nontoxic clinical appearance treatment
No focal bacterial infection on Urinary tract infection
Cultures Bacteremia/sepsis
examination (except OM)
positive
YES NO Meningitis
Osteomyelitis
Labs:
YES Bacterial enteritis
WBC 5,000 to 15,000/mm3,
<1,500 bands/mm3
28 to 90 Normal urynalisis (<5
Outpatient management:
days of WBCc/hpf) 4
Obtain blood culture, urine
<5 WBCs/hpf in stool (when
culture, lumbar puncture, 
NO ages diarrhea present)
stool culture

Empiric antibiotic treatment

Perform
3 and P
H
<28 days NO Follow-up at 24 hours See page 2
1
of age See page 293
OR
Obtain urine culture
Follow-up at 24
hours

YES
Admit to Viral infection
Cultures
hospital for negative
Sepsis
evaluation,
empiric Cultures Urinary tract infection
antibiotic positive Bacteremia/sepsis
treatment Meningitis
Osteomyelitis
Bacterial enteritis

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USIA 1-3 BULAN DIBAGI JADI RISIKO TINGGI DAN RENDAH

High Risk: tidak memenuhi kriteria diatas

Most Conservative work up:

1. Full septic workup with early (< 30 min) antibiotics and admission
2. Ceftriaxone 100mg/kg OK after six weeks of age
Less Conservative
1. UA, Blood and Urine cultures, No antibiotics and 24 hour follow up

Disposition
1. All neonates aged 0-28 days should be admitted.
2. All infants aged 29-90 days should be admitted if their clinical
presentation or laboratory data suggest that they are at high risk.
3. Infants aged 29-90 days may be discharged home if they meet all of the
low-risk criteria as discussed above.
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USIA 1-3 BULAN DIBAGI JADI RISIKO TINGGI DAN RENDAH

Low Risk:

1. term infant, not given antibiotics at any point, No h/o elevated

bilirubin, not hospitalized,
2. No bacterial focus on exam, Non-toxic, previously healthy,
3. Reliable parents with close follow up
4. All lab work negative
5. Normal UA results (i.e., negative nitrite findings and/or <10
WBC/high-power field [hpf])
6. WBC count of 5000-15,000 with <1500 bands, bands not
exceeding 20% of neutrophils
7. If diarrhea is present, no heme and few to no WBCs in stool
8. CSF with fewer than 8 WBC/mm3 in bloodless specimen,
Negative CSF Gram stain findings
9. No infiltrate on chest radiograph, if performed 16
The following are the most common etiologies of
SBI in infants younger than 28 days:
• Group B streptococci
• Streptococcus pneumoniae
• Listeria monocytogenes
• Escherichia coli

The following are the most common above 28 days:

- All of the above plus:
•Neisseria meningitidis
•Haemophilus influenzae
•Group A Strep
•Salmonella species (gastroenteritis)
•Staph aureus
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 Membedakan infeksi virus atau bakteri

• sebagian besar penyebab demam pada anak adalah virus yang

menyerang saluran nafas atas (>80)%, infeksi virus hanya
nmembutuhkan pengobatan symptomatic.
• namun sisa 10-20% yang disebabkan oleh bakteri ini, harus
mampu di deteksi , sehingga mampu memberikan pengobatan yang
sesuai.
• Adanya stomatitis, varicella, atau exanthema lain yang jelas, berarti
penyebab demam sudah lebih jelas , sehingga tidak memerlukan
penyidikan diagnosis lanjutan
• Penderita dengan impaired immune status (human
immunodeficiency virus infection) dianggap menderita infeksi
bacterial sampai dibuktikan sebaliknya.
• Membedakan kedua jenis infeksi ini dari sisi demam saja agak sulit, namun
patokan dibawah dapat dicoba untuk diterapkan. 20
 Diagnosis infeksi virus

• Diagnosis of viral infection can be made using detection

of viral antigen with enzyme immunoassay (ELA),
fluorescent antibody (FA), or electron microscopy.

• Serologic proof requires demonstration of a significant

rise in IgG antibody between acute and convalescent
sera or demonstration of virus-specific IgM antibody.

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viral

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Differential diagnosis:

•Pneumonia, Croup, Infectious Gastroenteritis, Fever Without a Source, Viral

disease (to Include the numbered diseases), Sepsis, Pneumococcal Bacteremia,
Pneumococcal Infections, Pyelonephritis, RSV, UTI, Varicella.

•Viral Syndrome -When a recognizable viral syndrome is present, febrile children

are at low risk for occult Bacteremia (0.2% rate of occult Bacteremia)

•UTI -Occult UTI occur in 3-4 % of boys < 12 months and 8-9% of girls <24
months -Nitrate +, > Mod. LE, + Gram Stain, >10WBC/hpf and bacteruria are all
very specific

•for UTI on cath UA. (Bag urine is not reliable). UA indicated for boys < 12
months and girls < 2 years. If a UA is obtained, also obtain a urine culture.

•-75% of children under age five with febrile UTI’s actually have pyelonephritis

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Pneumonia
-Remember to consider occult pneumonia in work-up of febrile infants and
young children.
-Pulse oximetry is more sensitive for pulmonary infections than respiratory
rate.
-Although most pediatric pneumonias (like other respiratory infections) are
considered secondary manifestations of viral infections, 51% of pediatric
patients with pneumonia have serologic evidence of bacterial infection.
-“chest radiography should be obtained in febrile children aged younger than
3 monthsWith evidence of acute respiratory illness”
-“Consider a chest radiograph in children older than 3 months with
temperature greater than 39 o C and a WBC count greater than
20,000/mm3.”
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Indication: Pneumonia, age < 3 months

Common Unknown, empiric therapy and waiting for the result of the blood culture, within 3 days.
organism:

Choice: 1 2 3 Remarks

Procain Penicillin G IM Ampisilin 50 Ampisilin

50.000-100.000 iu mg/kgBW/24 hrs + 200mg/kgbw/24hrs +
/kgBW/24 hrs + Gentamicin 5-7 genatmycin 5-7
Gentamicin 5-7 mg/kgBW/24jam mg/kgbw/day
mg/kgBW/24jam

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Indication: Sepsis neonatorum

Common Unknown, empiric therapy and waiting for the result of the blood culture, within 3 days.
organism:

Choice: 1 2 3 Remarks

Ampicillin IV 100- Cefosporin gen IV Meropenem 50

200mg/kgBW/ 24h 100mg-200mg mg/KgBW/ 24h +
(3days) + gentamicin /kgBW/24hrs amikacin IM/IV 15
IM/IV 4-6mg/kg/24h mg/kgBW/24h

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Indication: Sepsis, non neonatus

Common Unknown, empiric therapy and waiting for the result of the blood culture, within 3
organism: days.

Choice: 1 2 3 Remarks

Ampicillin IV 100- Cephalosporin 3rd gen Cephalosporin 4rd gen Change therapy with
200mg/kgBW/ 24h IV 100 mg/KgBW/ 24h IV 100 mg/KgBW/ 24h the microbiological
(3days) + gentamicin (3days) + amikacin (3days) results. Minimal
IM/IV 4-6mg/kg/24h IM/IV 15 mg/kgBW/24h duration is 2 days.
(3days)

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Indication: Meningitis, age < 2 months

Common
organism:

Choice: 1 2 3 Remarks

Cefotaxime IV Ampicillin 200 Ceftriaxone IV

100mg/kgBW/24hrs mg/kgBW/24 hrs + 100mg/kgBW/24hrs
Chloramphenicol IV 50
mg/kgBW /24 hrs

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Indication: Meningitis, age > 2 months

Common
organism:

Choice: 1 2 3 Remarks

Ampicillin 200 mg/kgBW/24 hrs + Ceftriaxone IV

Chloramphenicol IV 100 mg/kgBW /24 hrs 100mg/kgBW/24hrs

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Indication: Salmonellosis

Common Salmonella typhi, salmonella paratyphi (A,B,C)

organism:

Choice: 1 2 3 Remarks

Chloramphenicol Po Cotrimoxazole Ceftriaxone 80-100

50mg/ kgBW/ 24 hrs (trimethoprim+ mg/kgBW/24 hrs, IV
or sulfamethoxazole PO 8-
Amoxycillin PO 10mg TMP/kgBW/24hrs
100mg/kgBW/24 hrs

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Indication: Febrile neutropenia

Common High risk to bacteremia

organism:

Choice: 1 2 3 Rema
rks

Amoxicillin-clavulanate IV Cephalosporin 3rd gen IV Cephalosporin 4th

IV 200mg/kgBW/24 hrs + 200mg/ kgBW/24 hrs + generation 50-100
gentamicin IV/im amikacin IV 15mg/kgBW/ 24hrs mg/kgBW/24 hrs
7mg/kg/24h

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