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Fever in children

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by Dr B.J.C.Perera 
MBBS(Cey), DCH(Cey),
DCH(Eng), MD(Paed), MRCP(UK), FRCP(Edin), FRCP(Lond), FRCPCH(UK),
FSLCPaed, FCCP, Hony. FRCPCH(UK), Hony. FCGP(SL)
 

Specialist Consultant Paediatrician and Honorary Senior Fellow, Postgraduate Institute of Medicine, University of Colombo, Sri Lanka.
Joint Editor, Sri Lanka Journal of Child Health Section Editor, Ceylon Medical Journal

Fever is a common symptom of a variety of diseases in children. At the outset, it is very important to clearly understand that it is only a symptom and not a disease in its own right. When the body temperature is elevated above the normal level of around 98.6 degrees Fahrenheit (F) or 37 degrees Celsius (C), the condition is referred to as fever. It is a significant accompanying symptom of a plethora of childhood diseases. All children would get a fever at some time or another in their lives, and in the vast majority of cases, this is due to rather mild illnesses, and they are completely back to normal within a few days. Some may have a rather low-grade fever, while others may have quite a high fever. However, in certain situations, fever may be an important indication of an underlying serious problem. The significance depends entirely on the circumstances under which this occurrence is seen.

 Irrespective of the actual underlying reason for the fever, the basic mechanism of causation of fever is the temporary resetting of the temperature-regulating thermostat of the brain to a higher level. The consequences are that the heat generated within the body is not effectively dissipated. It is merely a body response to a harmful agent and is a very important defence mechanism. Turning up the core temperature is the body’s way of fighting the germs that cause infections and making the body a less comfortable place for them. However, less commonly, it is also a manifestation of other inflammatory disorders in children. The significance of fever in such situations is a little bit different to that which is seen as a response to an infection.

The part of the human brain that controls body temperature is not fully developed in young children. This means that a child’s temperature may rise and fall very quickly and the child is also more sensitive to the temperature of his or her surroundings. Although parents often worry and get terribly scared with the child developing fever, it does not cause any harm by itself. It is a good thing in the sense that it is often the body’s way of fighting off infection.

It is quite important to note that the actual level of the temperature is not always a good guide to how ill the child is. A simple cold or other viral infection can sometimes cause a high fever in the region of 102 to 104 degrees Fahrenheit or 39 to 40 degrees Celsius. However, this does not always indicate a serious problem. It is also true to say that some more sinister infections could sometimes cause a much lower rise in the body temperature. Because fevers may rise and fall, a child with a fever might experience chills and shivering as the body tries to generate additional heat as the body temperature begins to rise. This may be followed by sweating as the body releases extra heat when the temperature starts to drop. Children with fever often breathe faster than usual and generally have a higher heart rate. However, fever accompanied by obvious difficulties in breathing, especially if the breathing problems persist even at times the temperature is normal is of significance and requires urgent medical evaluation of the situation. Generally, in the case of children, the way they act is far more important than the reading on the thermometer, and most of the time, the exact level of a child’s temperature is not particularly important, unless it is persistently very high.

Although many fevers need just simple remedies, under certain conditions the symptom of fever needs rather urgent medical attention. This is the case in babies younger than three months. Same is true even in a bigger child if the fever is accompanied by uncontrollable crying or pain in the neck with a severe headache. Marked coughing and or difficulty in breathing coupled with fever needs to be medically sorted out. Fever combined with pain and difficulty in passing urine, significant tummy pains or marked vomiting and diarrhoea too would need medical attention. Reddish rashes and bluish spots on the skin with fever also need to be seen by a doctor. The illness is probably not serious if a child with a history of fever is still interested in playing, is eating and drinking well, is alert and smiling, has a normal skin colour and looks well when his or her temperature comes down. However, even with rather low levels of fever, under certain conditions, medical attention should be sought. In situations such as when the child seems to be too ill to eat and drink, has persistent vomiting or diarrhoea, has signs of dehydration, has specific complaints like a sore throat or an earache or when fever is complicated by some other chronic illness, it is prudent for him or her to be seen by a qualified doctor.

One could take several steps to bring down a fever. It is very useful to remove most of the clothes and keep under a fan to facilitate heat loss from the body. If there is no fan available, one could try fanning with a newspaper. A very effective way of bringing down a temperature is to sponge the body with a towel soaked in water. The water must be at room temperature or a bit higher. One should not use ice or iced water on the body. Ice will lead to contraction of the blood vessels of the skin and the purpose would be lost as more heat will be conserved within the body. There is no evidence that ice on the head helps to bring down the fever or to prevent a convulsion. If a medicine is to be used, paracetamol is probably as good as any other drug, but the correct dosage according to the instructions on the container should be used for optimal benefit. The best way of calculating the appropriate dose is by using the body weight. It is very important to stress that aspirin and aspirin-containing medications should not be used in children, merely to bring down a fever.

A child with fever loses a considerable amount of fluid from the body, particularly due to sweating. It is beneficial to ensure that the child drinks plenty of fluids. A good index of the adequacy of fluid intake is the passing of normal amounts of urine. A reduced solid food intake would not matter that much just for a couple of days of fever, but in prolonged fevers adequate nutrition too becomes quite important. A child with a high temperature also needs rest and sleep. They do not have to be in bed all day if they feel like playing, but they must have the opportunity to lie down. Sick children are often tired and bad-tempered. They sleep a lot, and when they are awake, they want their parents around all the time. Perhaps it is quite useful to spoil them a little bit when they are ill and to read to them, play with them or just spend time with them. It is best to keep a child with a fever home and not send him or her to school or child care. Most doctors would agree that in simple fevers, it is quite satisfactory for the child to return to school or child care when the temperature has been normal for over 24 hours.

Trying to get the temperature down would make the child more comfortable. However, it is not essential to get it down to normal and to keep it there scrupulously. Parents often worry that either the fever simply refuses to abate or springs up again after a couple of hours. It must be realised that certain fevers have to run their course and will not come down to normal in a hurry, despite whatever measures that are undertaken. This is particularly true of viral fevers. Some parents are terribly worried at the slightest elevation of the temperature and go running to doctors looking for a “magic cure” for the fever. Many fevers do not need urgent medical attention and one could watch it for a few days and see how it progresses. Yet for all that, if there are some worrying signs then it is advisable to seek advice from a qualified doctor.

It is a familiar occurrence that many people believe that a high fever is quite dangerous. Fever by itself has no major long-lasting effects. If one appreciates that high fever is just a symptom and that it is only a reaction of the body to something untoward going on, then it is easy to consider it to be just like any other symptom of a disease. Some are also under the misconception that a high fever could cause a convulsion. This is not always the case, and a convulsion would occur only in those children who have the constitutional tendency to get them. Convulsions are not always related to high fever, and in those who are susceptible, even moderate and sometimes mild fever could trigger a convulsion. High fever does not lead to lasting brain damage in its own right either. Fever is sometimes an indication of a significant infection, but in those circumstances, the primary disease itself is the real problem. In situations where medical help is desirable, what is most important is the way a fever is sorted out and some kind of a diagnosis being made as to the real cause of the fever. The crucial component of the treatment of a fever caused by an underlying problem is the treatment of the root cause.



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Trump’s tariffs, AKD’s gazette and Sri Lanka’s diplomatic slumber

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“We are rather respectable in Colombo. We go to bed fairly early, and we remain there till morning. “

According to Sri Lanka’s diplomatic folklore, the late S.W. R. D. Bandaranaike uttered these words while explaining the reasons for Sri Lanka’s abstention on the UN resolution condemning the Soviet invasion of Hungary. Apparently, SWRD’s foreign ministry officials were asleep at home when the diplomatic cable seeking instructions was received from New York. In those days, there were no cell phones, Internet, or even fax or telex machines. The diplomatic cables were sent through post offices. Decoding them was a slow and time-consuming process. Thus, the government could not provide appropriate instructions to our mission in New York in time, and the Sri Lankan delegation abstained on that sensitive UN vote.

Sri Lanka’s Absence from Section 301 Consultations

But then, how does one explain Sri Lanka’s absence from the crucial bilateral consultation held in Washington by the Office of the United States Trade Representative (USTR) during March-April on “Forced Labour” under the Section 301 of the US Trade Act of 1974? Didn’t our foreign and trade ministries send appropriate instructions to Washington in time? Even if the instructions from the foreign ministry were transmitted to our embassy in Washington by pigeon carriers, there was enough time for Sri Lanka to participate in those meetings.

In March, the USTR initiated these 301 investigations on 60 trading partners, and invited all of them for confidential consultations. Out of the 60, 46 participated in these consultations. Sri Lanka was not one of them. Other countries that didn’t participate in these consultations included China, Russia, and Venezuela! In addition to that, the Section 301 Committee conducted a public hearing with interested parties on April 28 and 29. Washington-based diplomats, representatives from few trade ministries as well as representatives from many foreign trade associations and chambers participated in these hearings. Sri Lanka was once again conspicuously absent.

As a result, when the USTR published the proposed forced labour tariffs on June 2nd, Sri Lanka ended up with a 12.5% duty. Pakistani and Indonesian diplomats participated in these consultations and took appropriate follow-up measures, and managed to enter the 10% duty category. As even a threat of a modest tariff hike could disrupt supply chains and reduce competitiveness, particularly in an industry such as garments, I discussed this issue on 15 June and underscored the importance of Sri Lanka’s participation at the next hearing, which was scheduled to be held from July 7th .

Awakening from Diplomatic Slumber and AKD’s Gazette

Fortunately, Sri Lanka finally awoke from weeks of diplomatic slumber, and Ambassador Mahinda Samarasinghe participated in the public hearing on 9 July, and promised, “…. · We have agreed to the text in our negotiations with the USTR on forced labour, …. The gazette as we speak is being printed and I’m getting the gazette tomorrow morning, and the gazette will be shared with USTR as I get it“.

As promised, President Anura Kumara Dissanayake issued a gazette on 10 July banning the imports of goods produced by forced labour. These new regulations are very similar to what Pakistan and Indonesia enacted in April, after their consultations with USTR in March. Why couldn’t we do it in April? Why did we wait till the very last minute?

Challenges ahead

“War is too important to be left to generals alone,” is a famous saying attributed to former French Premier Georges Clemenceau. Similarly, monitoring our main markets is too important to be left to diplomats alone. The United States is the largest single-country market for Sri Lanka. Therefore, Sri Lankan trade chambers and associations should become more proactive in these markets and participate in these events. For example, the chairman of the Pakistani apparel exporters association participated in the April hearings. Similarly, representatives from the Indian Agricultural and Processed Food Products Export Development Authority, the Federation of Indian Chambers of Commerce and Industry, the Confederation of Indian Industry, and Reliance Industries also participated in July hearings. At an event where each speaker is given only five minutes (strictly enforced), having a number of speakers from a country is an advantage. The presence of industry representatives in these kinds of events also help them understand the market dynamics and the future challenges. This is important, particularly because there will be many more challenges with Trump’s tariffs.

With the gazette issued on 10 July, Sri Lanka has imposed a prohibition on the importation of goods produced with forced labour. Now, the challenge will be to effectively enforce the prohibition. And what are the goods produced with forced labour? The USTR list only focuses on aluminum, cotton, electronics, lithium-ion batteries, rice, and tobacco. However, according to the U.S. Department of Labour, the list is much longer. Hence, this list may change continuously during the next two years and tariffs may fluctuate once again.

So, this is definitely not the time to slumber.

(The writer, a retired public servant, can be reached at senadhiragomi@gmail.com)

by Gomi Senadhira ✍️

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Tales of Mystery and Suspense 10 Casino for Sale

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After the overwhelming grotesquerie of J K Rowling’s latest Cormoran Strike novel (written, I should have noted, as the others were, under the pseudonym Robert Galbraith), I thought I should return to the world of fun, and also a much shorter description since this thriller moves quickly without the layers of detail that Rowling engages in.

I then move to the second comic thriller by Caryl Brahms and S J Simon. This, their second story to feature Vladimir Stroganoff and Adam Quill, was Casino for Sale, as lunatic a romp as the first, though without the emphasis on the ballet that characterized A Bullet in the Ballet.

This one begins with the impresario Stroganoff buying a casino cheap from Baron Sam de Rabinovich, only to find that it was a rundown place, not the grand casino of La Bazouche, a resort on the Frenc+h Riviera, as he had initially thought. The grand one belonged to Lord Buttonhooke, and Stroganoff could  not compete, until he thought of bringing the Ballet Stroganoff to the casino – which of course leads to Buttonhooke deciding to have ballet performances in his Casino too.

Stroganoff invites Quill to visit him, which Quill decides to do since he has left Scotland Yard, having come into a legacy. No one believes this, and he has to face questions as to what he did to have been sacked, with sympathy for having been found out.

Caryl and Simon

The day he arrives in La Bazouche there is a murder, of a vitriolic critic called Citrolo, in Stroganoff’s office. He had been going to write a damning review of the opening night of the ballet and Stroganoff, when he realizes Citrolo cannot be swayed, drugs him and dictates the review himself to the papers. He leaves Citrolo sleeping and finds him shot the next morning, whereupon he decides to muddy the waters and leave a suicide note and lots of other murder weapons. So much overkill, as it were, of course ensures that he is arrested.

But the excitable French detective who makes the arrest follows up his suggestion that Buttonhooke was also involved, and so the two casino owners find themselves in cells next door to each other, with the detective Gustave quite happy to provide creature comforts for a fee.

Quill decides he must investigate, and finds Gustave most cooperative, since he has a laid back attitude to work. So it is Quill that finds a notebook which makes it clear Citrolo is an accomplished blackmailer, and that there are lots of possible murderers, including Stroganoff’s croupier, who was crooked, Rabinovich, who was now working for Buttonhooke, a confidence trickster called Kurt Kukumber, whose prospectus for a dud gold mine was found in the office and Prince Alexis Artishok who was engaged in a deal to buy diamonds from the ballerina Dyra Dyrakova.

Stroganoff had been trying to get Dyrakova to dance for him, but having done so previously she had refused. But then to Stroganoff’s chagrin she agreed to dance for Buttonhooke. The clearly crooked Artishok had told Buttonhooke’s mistress Sadie Souse, who was not very bright, that Dyrakova possessed diamonds she was willing to sell cheap, and Sadie was determined to have them.

Quill meanwhile finds out that there was a secret passage to Stroganoff’s office, the obvious solution to what had begun as a locked room mystery, and that this was known by almost everyone apart from Stroganoff himself. And then Rabinovich is murdered, just after Gustave had released his two original suspects, leading him to blame Quill for having insisted on that and thus allowing them to kill again.

Soon afterwards Dyrakova arrives, and the town is full of posters announcing that she will appear in the casinos, elaborate posters for either one, since Stroganoff is determined that she will dance for him, and if she does not come willingly, he has devised a scheme to make her do so unwillingly. So, though Buttonhooke has her taken off to his yacht immediately she arrives at the station, Quill along with Arenskaya gets her into a launch and to Stroganoff’s casino, where she performs to tumultuous applause, not knowing for whom she is dancing.

When Quill asked her about the diamonds, she said she had sold them long ago, and that gave Quill the solution to the mystery. Rabinovich had known about this, and Artishok had killed him to prevent Sadie learning it from him, he had killed Citrolo who had recognized him for an accomplished card sharper, not a Russian prince at all. But before he is arrested, he gets away in a boat, and the police launch that pursues him is on the point of catching him up when it runs out of petrol.

Again, lots of excitement, and entertaining references  – Gustave grows marrows – and if not quite as brilliant as its predecessor, Casino was certainly a delightful read.

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The challenge of being positive about SAARC

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The RCSS forum addressed by SAARC Secretary General Ambassador Md. Golam Sarwar in progress. (Pic courtesy RCSS)

It was a few years back that a former President of Sri Lanka took it on himself to pronounce SAARC ‘dead’. Since then there have been other sections of Sri Lankan opinion that have joined the critics of SAARC and taken the solemn stance that SAARC has indeed died what may be called a natural death.

Their fatalism is understandable. SAARC has failed to meet at heads of government or state level for the past several years to take the SAARC process notably forward. Regional cooperation has more or less been only an appealing idea. No substantive concrete projects have taken off to make the idea a hard reality. ‘Inner paralysis’ seems to be SAARC’s lot. Hence the fatalism in these circles.

However, being one of the worst cash-strapped regions of the world and a teemingly populated one with people virtually left to their devices, what choices do the ‘SAARC Eight’ have other than to try their best to band together and continue with their cooperation efforts, however small they may be?

There is no escaping the mounting debt trap for many of these countries and bankrupt Sri Lanka is a glaring example, but ‘throwing in the towel’ and abandoning themselves entirely to the diktats of the strongest economies and their agencies will prove a ‘living death’ for many countries in the SAARC fold.

The gains may be meagre but giving-up on SAARC cooperation in full would prove self-defeating for the organization and South Asia. Right now, the collective intention ought to be to salvage what the region could from the tenuous cooperative efforts. Moreover, such initiatives could go some distance to generate a degree of goodwill among the Eight and help in sustaining a dialogue process.

Given this backdrop it proved ‘a stich in time’ for the Regional Centre for Strategic Studies (RCSS), Colombo, to recently host the SAARC Secretary General Ambassador Md. Golam Sarwar to a round table discussion on the unifying potential of SAARC and its future possibilities, besides other related issue areas.

Held on June 24th and moderated by RCSS Executive Director and former ambassador Ravinatha Aryasinha, the forum brought together a vibrant, wide ranging audience comprising academicians, diplomats, senior public servants, civil society activists and many others. Following the presentation by Ambassador Golam Sarwar titled, ‘Reigniting SAARC: Achievements, Challenges and the Way Ahead’, a lively Q&A followed.

The above forum could be described as an act of lighting the proverbial ‘candle’ rather than ‘cursing the darkness.’ It surely is a ‘darkness’ that could be seen as daunting considering that the region’s pivotal powers, India and Pakistan, are failing to act in a spirit of accord but are engaged in bitter finger-pointing on a number of questions of vital importance to SAARC.

On the other hand, what is the rest of the region doing to bring the above sides together? It is disappointing that to date the rest of SAARC has failed to launch a major diplomatic drive to bring peace between the feuding regional heavyweights. It needs to act without delay and establish its earnestness and this effort would need to prove SAARC’s staying power in the unfolding months and even years.

In assessing SAARC’s seeming failure local opinion in particular has failed to factor in what could be described as weak leadership. Since Sheikh Mujibur Rahman of Bangladesh, the founding father of SAARC, the region has failed to produce a visionary leader who could advance the SAARC cause with charisma and drive.

Among other reasons, weak leadership accounts considerably for the faltering and stuttering status, as it were, of SAARC. Badly needed are leaders who could go the extra mile, think less of narrow national interests and work diligently towards the collective well being of the region but SAARC’s millions of ordinary people have been made to wait in vain for leaders of such stature. Instead, they have been burdened with politicians who seem to be relishing the apparently moribund state of SAARC.

Looking back, it could be said that it was the dynamic leadership factor that led to the launching of the Non-Aligned Movement and for its sustenance for a few decades. True, it could be seen in some quarters that NAM is no more, but as in the case of SAARC, the former too has been unfortunate to be burdened over the years with politicians who lack the vision and drive to unflaggingly advance the fortunes of the South. NAM and SAARC lack the dynamism and vision of leaders of the stature of Jawaharlal Nehru, for example, to give them the required guidance and intellectual depth.

The reasons are complex for there not being among us currently political leaders with the vision and the steadfast commitment to advance the legitimate interests of the South. However, it could be stated with conviction that the majority of Southern leaders have too easily caved in to the demands of the global North and its financial agencies.

These leaders have failed to see, for instance, that the largely market economy oriented Northern governments would not view with favour a centrist economic model that attaches priority to the interests of the dis-empowered publics of the South. This realization ought to have dawned on the current government in Sri Lanka, for instance, some while ago but it has no choice but to abide by IMF dictates since economic survival at present is unthinkable without the latter’s succour.

Accordingly for SAARC this should be the time for some soul-searching. Priority needs to be attached to ending the feuding between India and Pakistan since at present the material fortunes of the region hinge largely on these regional giants giving peaceful relations among them a try. This is no easy challenge to meet but some daring, visionary diplomacy needs to take hold among the rest of SAARC.

There is some sense in SAARC bringing the peoples of the region together through programs that address their best collective interests. A meeting of minds among SAARC nations could enable SAARC and its agencies to build a region-wide people’s movement for progressive political and economic change that could in turn lead to the region’s political leaders sensitizing themselves more to the neglected needs of their publics.

However, the time is ‘now’ for the initiation of these progressive changes and the voice of SAARC well wishers would need to drown out those of their critics.

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