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Aetiological profile of fever in neonatal and paediatric population in hospital setting

Febrile illness in children is a common cause of admission to hospital globally, with significant associated morbidity and mortality.Infectious diseases are leading causes of morbidity and death in tropical countries. In developing countries this is frequently compounded by low rates of immunization, untreated co-morbidities, and late presentations. The World Health Organization (WHO) reports that each of the main infectious aetiologies (pneumonia, diarrhea, HIV/AIDS, malaria, tuberculosis and neonatal infections) causes death to the tune of 0.24 to 1.05 million per year in low income countries. In resource limited settings, fever may be treated empirically or self-treated due to lack of access to diagnostic tests. Dengue, malaria, scrub typhus, typhoid and leptospirosis have been identified as major causes of acute undifferentiated febrile illness in Thailand, Malaysia, and Nepal. Climate variation, over population and urbanization may all contribute to the emergence and reemergence of infections in tropical regions like Tamil Nadu. This study was conducted to describe the aetiology of fever in hospitalized neonatal and Pediatric population. ABSTRACT


INTRODUCTION
Febrile illness in children is a common cause of admission to hospital globally, with significant associated morbidity and mortality.Infectious diseases are leading causes of morbidity and death in tropical countries. 1 In developing countries this is frequently compounded by low rates of immunization, untreated co-morbidities, and late presentations. [2][3][4] The World Health Organization (WHO) reports that each of the main infectious aetiologies (pneumonia, diarrhea, HIV/AIDS, malaria, tuberculosis and neonatal infections) causes death to the tune of 0.24 to 1.05 million per year in low income countries. 5 In resource limited settings, fever may be treated empirically or self-treated due to lack of access to diagnostic tests. 6 Dengue, malaria, scrub typhus, typhoid and leptospirosis have been identified as major causes of acute undifferentiated febrile illness in Thailand, Malaysia, and Nepal. [7][8][9][10][11][12][13] Climate variation, over population and urbanization may all contribute to the emergence and reemergence of infections in tropical regions like Tamil Nadu. 14 This study was conducted to describe the aetiology of fever in hospitalized neonatal and Pediatric population.
Period of study was 6 months. All children admitted to the hospital with fever of any duration, with axillary temperature of equal or more than 38°C (100.4 F) at admission or documented at home were included in study. After admission, detailed history regarding fever and associated, symptoms, general and systemic examination, history of chronic disease symptoms and findings, final diagnosis were documented.
Basic laboratory tests were done in all cases, however selection of individual test depended upon clinical condition of disease (complete blood count, CRP, urine analysis).
Additional investigations including blood culture ,urine culture, chest X-ray, Widal test, peripheral smear for malaria parasite and dengue IgM ,stool routine and culture, CSF analysis and culture, Monteux test, AFB culture, KOH mount, RA and ASO titre, HIV Elisa, salmonella typhi dot IgM, scrub typhus IgM, Leptospira IgM, HSV IgM, Hbs Ag, TORCH profile, ANA, CSF serology, Pleural and ascetic fluid examination were performed to establish the cause of fever. Only culture proven cases of enteric fever were termed as confirmed typhoid fever. Serology positive but culture negative cases were considered as probable typhoid fever.
Presence of Pyuria but negative urine culture was termed as probable urinary tract infection. Imaging like chest x ray, ultrasonography, CT scan, MRI scan were performed as clinically indicated. Written informed valid consent was taken from each parent. Data was collected individually by proforma at the of admission in the emergency room (ER) and child was followed till discharge. Sample size was calculated to be 650. Additional investigations were also done.

Exclusion criteria
• Children who develop fever after hospitalization, Febrile post-surgical patients and out patient Department patients were excluded in the study.

Statistical analysis
Statistical analysis was done using SPSS 19.0.

RESULTS
Out of a total of 650 children, 61% (n=397) were boys and 39% (n=253) girls. Ages of all patients were between 1 st day of life to 18 years.

DISCUSSION
Febrile illness in children is a common cause of admission in hospital globally, with significant associated morbidity and mortality. 15 Similar predilection of age group as in present study was seen in a study done by Kheng et al, where 1 to 5 years was the most common age group. 16 In studies conducted in Cambodia by Kheng Present study had a slightly higher ratio of 1.5:1. The median duration of hospital stay in children with febrile illness in present study was found to be 3 days which was less than that in the study by Abrahamsen et al. 18 Neonates had a higher likelihood of having prolonged hospitalization when compared to older children.  19 In present study maximum number of cases, 81.4% (n=211) cases were diagnosed as probable viral fever. Hence probable viral fever was the most common infectious aetiology of fever.

CONCLUSION
Infectious aetiology was more common than noninfectious aetiology. Among all aetiologies, viral fever particularly dengue was the most common aetiology. Enteric fever was the second most common infectious cause of fever after viral fever.
Short febrile illness (1 to 5 days) was the most common type of fever in children admitted in hospital. In neonates, the most common cause of fever was probable sepsis followed by dehydration fever.