Management of Fever in Children
Fever in children should be treated primarily to promote comfort and prevent dehydration, not to normalize body temperature, with paracetamol (acetaminophen) as the preferred antipyretic. 1
Definition and Assessment
- Fever is defined as a rectal temperature ≥38°C (100.4°F), which is the gold standard measurement for infants and young children 1
- For children older than infants, axillary measurement using a digital thermometer or tympanic measurement using an infrared thermometer is recommended 2
- Consider children reported to have had fever by caregivers as febrile, even if afebrile when examined 2
Age-Based Approach to Fever Management
Neonates (<28 days)
- All febrile neonates should be hospitalized due to elevated risk of severe disease 1, 3
- Complete sepsis evaluation is required 1
- Lumbar puncture should be performed in all febrile neonates 1
- Paracetamol may be used with dose adjusted to gestational age 2
Infants 29-90 days
- Risk stratification is required 1
- Consider lumbar puncture based on clinical assessment 1
- Blood work including CBC with differential and blood culture is recommended 1
- Consider urinalysis and urine culture 1
Children >3 months
- Evaluate based on clinical appearance and specific risk factors 1
- For well-appearing children with normal vital signs, focus on symptomatic management 1
- Consider blood work for children with temperature >39°C (102.2°F) and no source 1
- Consider chest radiography only in symptomatic patients 4
Treatment of Fever
Antipyretic Therapy
- Use antipyretics only when fever is associated with discomfort, not to normalize temperature 5, 2
- Paracetamol (acetaminophen) is the preferred antipyretic 1, 2
- Ibuprofen is also effective but should be avoided in children with:
Dosing Considerations
- Base antipyretic dose on the child's weight rather than age 2
- Oral administration of paracetamol is preferable to rectal administration 2
- Combined or alternating use of antipyretics is discouraged despite evidence of greater effectiveness 5, 2
Physical Methods
- Physical methods such as fanning, cold bathing, and tepid sponging are NOT recommended as they cause discomfort 4, 1
- Ensure adequate fluid intake to prevent dehydration 1
Special Considerations
Febrile Convulsions
- Antipyretics are not effective in preventing febrile convulsions 2
- For children with febrile convulsions, many pediatricians advise rectal diazepam after onset of convulsion 4
- Lumbar puncture should be performed after complex convulsions, if the child is unduly drowsy/irritable, systemically ill, or aged <18 months (especially <12 months) 4
Immunocompromised Children
- Require more aggressive evaluation and management 1
- Children with indwelling catheters should be evaluated for catheter-related infections 1
- Children with sickle cell disease are at higher risk for serious bacterial infections 1
Neutropenic Fever
- High-risk neutropenic fever requires monotherapy with antipseudomonal β-lactam or carbapenem 4
- For low-risk neutropenic fever, consider outpatient management if infrastructure ensures careful monitoring 4
Parent Education
- Explain that fever is a physiologic mechanism with beneficial effects in fighting infection 5
- Reassure that fever itself does not worsen illness or cause long-term neurologic complications 5
- Provide instructions on antipyretic use, clear return precautions, and reassurance 1
- Emphasize monitoring the child's activity, observing for signs of serious illness, and encouraging fluid intake 5
- Ensure safe storage of antipyretics 5
Warning Signs Requiring Urgent Evaluation
- Petechial/purpuric rashes with fever (may indicate meningococcemia) 1
- Prolonged seizure or incomplete recovery within one hour 4
- Signs of meningitis 4
- Persistent fever in immunocompromised children 1
By following these guidelines, clinicians can effectively manage fever in children while avoiding unnecessary interventions and providing appropriate reassurance to parents.