Management of Systemic Viral Illness with Fever in Pediatrics
Initial Risk Stratification and Assessment
Most children with fever and systemic viral illness can be managed at home with supportive care (antipyretics and fluids), but you must systematically exclude serious bacterial infections and identify high-risk features that require immediate medical intervention. 1, 2
Immediate Red Flags Requiring Hospital Admission
Refer immediately if any of the following are present: 1
- Signs of respiratory distress: markedly raised respiratory rate, grunting, intercostal recession, breathlessness with chest signs 1
- Cyanosis 1
- Severe dehydration 1
- Altered conscious level or extreme lethargy 1
- Complicated or prolonged seizure 1
- Signs of septicemia: extreme pallor, hypotension, floppy infant 1
- Vomiting >24 hours 1
Age-Specific Management Algorithm
Children with Mild Fever and Cough (Low Risk)
Treat at home with antipyretics and fluids for children with coughs and mild fevers. 1 Note that aspirin must never be used in children under 16 years of age due to Reye's syndrome risk. 1, 2
Children with High Fever (>38.5°C) and Influenza-Like Symptoms
For otherwise healthy children with high fever (>38.5°C) and cough or influenza-like symptoms, treat with oseltamivir (if >1 year of age and symptomatic for ≤2 days), plus antipyretics and fluids. 1
Children under 1 year of age and those at risk of complications should be assessed by a GP. 1
High-Risk Children Requiring Antibiotics
Children with fever >38.5°C plus either chronic comorbid disease OR any of the following features require both antibiotics and oseltamivir (if >1 year): 1
For children under 12 years, co-amoxiclav is the antibiotic of choice. 1 Use clarithromycin or cefuroxime in penicillin-allergic children. 1 For children over 12 years, doxycycline is an alternative. 1
Children under 1 year with none of the above high-risk features should be treated with antipyretics and fluids, with a low threshold for antibiotics if they become more unwell. 1
Supportive Care Management
Antipyretic Therapy
The primary goal of treating fever should be to improve the child's overall comfort rather than normalize body temperature, as fever itself is a beneficial physiologic response. 3 Use acetaminophen or ibuprofen based on the child's weight rather than age. 4 There is no substantial difference in safety and effectiveness between acetaminophen and ibuprofen in generally healthy febrile children. 3
Avoid combined or alternating use of antipyretics due to concerns about complicated dosing and unsafe use. 3, 4
Fluid Management
For children with vomiting and dehydration, begin oral rehydration therapy with small, frequent volumes (5 mL every minute) using a spoon or syringe. 2 Replace ongoing vomit losses with appropriate volumes of oral rehydration solution. 2 Simultaneous correction of dehydration often lessens vomiting frequency. 2
When children are unable to maintain oral intake, supplementary fluids should be given by the enteral route when possible. 1 Intravenous fluids in those with severe pneumonia should be given at 80% basal levels. 1
Dietary Management
Once rehydration is achieved, immediately resume age-appropriate diet without withholding food. 2 Recommended foods include starches, cereals, yogurt, fruits, and vegetables. 2 Avoid foods high in simple sugars and fats. 2
Hospital Management
Admission Criteria and Initial Assessment
Children admitted to hospital are likely to need oxygen therapy and/or intravenous support as well as antibiotics and oseltamivir. 1
Patients whose oxygen saturation is ≤92% while breathing air should be treated with oxygen given by nasal cannulae, head box, or face mask to maintain oxygen saturation above 92%. 1
Laboratory Investigations
A full blood count with differential, urea, creatinine and electrolytes, liver enzymes, and blood culture should be done in all severely ill children. 1 A chest x-ray should be performed in children who are hypoxic, have severe illness, or who are deteriorating despite treatment. 1 Pulse oximetry should be performed in every child being assessed for admission to hospital with pneumonia. 1
Antibiotic Coverage for Hospitalized Children
Children with disease severe enough to merit hospital admission should be treated with an antibiotic that provides cover against S. pneumoniae, S. aureus, and H. influenzae. 1
Children who are severely ill with pneumonia complicating influenza should have a second agent added to the regimen (e.g., clarithromycin or cefuroxime) and drugs should be given intravenously to ensure high serum and tissue antibiotic levels. 1
Discharge Criteria
Children can be safely discharged from hospital when they: 1
- Are clearly improving 1
- Are physiologically stable 1
- Can tolerate oral feeds 1
- Have a respiratory rate <40/min (<50/min in infants) 1
- Have an awake oxygen saturation of >92% in air 1
Antiviral Therapy Specifics
Oseltamivir Dosing
In the setting of a pandemic or confirmed influenza, children should only be considered for treatment with antivirals if they have an acute influenza-like illness, fever (>38.5°C), and have been symptomatic for ≤2 days. 1 Oseltamivir is the antiviral agent of choice. 1
For children 2 weeks to <1 year: 3 mg/kg twice daily for 5 days 5 For children 1-12 years: dose based on weight (see Table 1 in FDA label) 5 For adolescents ≥13 years: 75 mg twice daily for 5 days 5
In severely ill hospitalized children, oseltamivir may be used if the child has been symptomatic for <6 days, though there is no evidence to demonstrate benefit or lack of it in such circumstances. 1
Critical Pitfalls to Avoid
Do not rely solely on clinical appearance—many children with serious bacterial infections may appear well initially. 2, 6 Always consider that recent antipyretic use may mask fever and severity. 2, 6
Do not assume viral gastroenteritis without excluding serious causes—meningitis, pneumonia, UTI, and surgical emergencies can present identically. 2
Do not use physical methods of reducing fever (e.g., tepid sponging), as these are discouraged except in cases of hyperthermia. 4
Do not delay oral rehydration—early aggressive oral rehydration prevents progression to severe dehydration. 2