What are the causes, treatment, and management of fever in childhood, including red flags and febrile seizures?

Childhood Fever: Causes, Treatment, Red Flags, and Febrile Seizures

Overview of Fever in Children

Fever in children should be managed primarily to improve the child's comfort rather than to normalize body temperature, with paracetamol (acetaminophen) as the first-line treatment. 1 Fever is defined as a rectal temperature ≥38.0°C (100.4°F) and represents the most common reason for pediatric emergency visits, accounting for approximately 15% of consultations in children under 15 years. 1

Common Causes

Most febrile children have benign, self-limiting viral infections, but a small percentage will have serious bacterial infections (SBIs) that require prompt identification. 1

Typical Causes by Category:

• Viral infections: Upper respiratory tract infections are the most common cause, and indiscriminate antibiotic use is inappropriate and leads to drug resistance 2
• Bacterial infections: Urinary tract infections (most common SBI in children >1 year), occult bacteremia, pneumonia, and bacterial meningitis 1, 3
• Other considerations: Metabolic disturbances, intoxication, head trauma, and electrolyte imbalances must be excluded in specific clinical contexts 4

Red Flags Requiring Immediate Attention

Critical warning signs that indicate potential serious bacterial infection include:

• Age <3 months: These infants have immature immune systems and higher risk of SBI, requiring immediate pediatric assessment 1, 5
• Toxic or ill appearance: Poor peripheral circulation, cyanosis, petechial rash, inconsolability 1, 3
• High fever ≥40°C: Increases risk of bacteremia 1
• Persistent fever >5 days: Increases likelihood of SBI 1
• Meningeal signs: Altered mental status, neck stiffness, bulging fontanelle 5, 4
• Respiratory distress: Tachypnea, retractions, crackles 1
• Feeding difficulties: Refusal to feed, vomiting, decreased urine output 1
• Incomplete immunization status: Higher risk for invasive bacterial disease 1

Critical Pitfall - Meningitis:

In up to one in six children with meningitis, seizures are the presenting sign, and in one-third of these patients, meningeal signs may be absent. 4 Lumbar puncture should be strongly considered in children <18 months (and almost certainly <12 months) who are unduly drowsy, irritable, or systemically ill, even without obvious meningeal signs. 5

Treatment of Fever

Paracetamol (acetaminophen) is the preferred antipyretic agent for symptomatic management of fever in children. 1, 5

Key Treatment Principles:

• Goal: Improve child's comfort, not normalize temperature 1
• Avoid physical cooling methods: Fanning, cold bathing, and tepid sponging cause discomfort and are not recommended 5
• Ensure adequate hydration: Maintain fluid intake to prevent dehydration 5
• Treat underlying cause: Specific treatment for identified infections (e.g., antibiotics for bacterial infections) 4

Important Caveat:

Antipyretics do NOT prevent febrile seizures. Multiple meta-analyses demonstrate no benefit of acetaminophen, ibuprofen, or paracetamol in preventing recurrent febrile seizures in the same illness or subsequent illnesses. 5 Fever treatment helps children feel better but will not prevent seizures. 5

Febrile Seizures

Febrile seizures affect 2-5% of children between 6 and 60 months of age and have an excellent prognosis for neurological development. 5

Definition and Classification:

• Simple febrile seizures: Brief (<15 minutes), generalized, occurring once in 24 hours in a febrile child without intracranial infection, metabolic disturbance, or history of afebrile seizures 5
• Complex febrile seizures: Prolonged (>15 minutes), focal, or occurring more than once in 24 hours 5

Immediate Management During Seizure:

• Help child to ground and place on their side in recovery position to reduce aspiration risk 5
• Clear area around child to minimize injury risk 5
• Stay with the child throughout the seizure 5
• Do NOT restrain the child 5
• Do NOT put anything in the mouth or give food, liquids, or oral medicines during or immediately after seizure 5

When to Activate Emergency Services:

Call emergency services if:

• Seizure lasts >5 minutes 5
• First-time seizure 5
• Seizure in infant <6 months 5
• Multiple seizures without return to baseline between episodes 5
• Child does not return to baseline within 5-10 minutes after seizure stops 5
• Associated traumatic injuries, choking, or difficulty breathing 5

Recurrence Risk and Prognosis:

• Overall recurrence risk: Approximately 30%, increasing with younger age at first convulsion 5
• Family history impact: First-degree relative with febrile seizures increases recurrence risk to nearly 50% 5
• Epilepsy risk: After a single simple febrile convulsion, risk of subsequent epilepsy is approximately 2.5% (slightly higher than general population) 5
• Complex seizures: With three or more complex features, epilepsy risk rises to nearly 50% by age 25, though only about 1% of all children with febrile convulsions will develop epilepsy 5
• Developmental prognosis: Excellent—no long-term neurological or developmental impairment from simple febrile seizures 5

Prophylactic Treatment:

Neither continuous nor intermittent anticonvulsant therapy is recommended for children with simple febrile seizures. 5 While continuous therapy with phenobarbital, primidone, or valproic acid and intermittent therapy with diazepam are effective in reducing recurrence, the potential toxicities outweigh the relatively minor risks of simple febrile seizures. 5

Many pediatricians advise rectal diazepam after onset of a convulsion for acute management, with parents receiving instructions on its use. 5

Diagnostic Evaluation

For Children >1 Year with Good General Condition:

• Urinalysis: Essential to rule out urinary tract infection (most common SBI in this age group) 1
• Chest radiography: If respiratory signs present (tachypnea, retractions, crackles) 1
• Blood tests: Complete blood count, C-reactive protein, procalcitonin based on clinical evaluation 1

For Infants <3 Months:

Extensive diagnostic evaluation is still recommended as serious bacterial infections can occur despite unremarkable physical findings. 3 These infants require pediatric assessment. 5

For Children with Febrile Seizures:

• Lumbar puncture: Should be performed if child is <18 months (especially <12 months), unduly drowsy, irritable, systemically ill, or has not completely recovered within one hour 5, 4
• Blood glucose: Should be checked if child seen during convulsion 5
• Electroencephalography: NOT helpful after a single convulsion and not a guide to treatment or prognosis 5
• Brain imaging: Only necessary in selected cases (prolonged seizure, focal features, failure to return to baseline) 5

Hospitalization vs. Outpatient Management

Outpatient Management Appropriate When:

• Good general condition 1
• Normal urinalysis 1
• Normal inflammatory markers (if performed) 1
• Parents able to monitor and return if deterioration 1
• Mandatory 24-hour follow-up 1

Hospitalization Required When:

• Toxic or ill appearance 1
• Age <3 months with fever 1, 3
• Abnormal cerebrospinal fluid analysis 1
• Elevated inflammatory markers suggesting SBI 1
• Difficulty feeding, vomiting, or decreased urine output 1
• Prolonged seizure (>20 minutes) or failure to recover within one hour 5

Parent Education

Parents should receive verbal and written information including:

• Nature and prevalence of febrile seizures with reassurance about excellent prognosis 5
• Fever management instructions (antipyretics, hydration) 5
• Rectal diazepam use if prescribed 5
• Warning signs requiring immediate return: Worsening general condition, skin spots (petechiae), respiratory distress, feeding refusal, excessive irritability or somnolence 1