At what level of fever should paracetamol be considered in children?

At What Temperature Should Paracetamol Be Given to Children?

Paracetamol should be considered for children when fever (≥38°C/100.4°F) is accompanied by discomfort or pain, rather than being given based on a specific temperature threshold alone. 1, 2

Primary Indication: Symptom Relief, Not Temperature Reduction

The decision to administer paracetamol should be driven by the child's comfort level rather than the height of fever itself:

• Fever with discomfort or pain is the appropriate indication for paracetamol use 1, 2
• Fever alone does not require treatment, and clinicians should exercise caution about routinely advising paracetamol for children with fever as the only symptom 3
• Paracetamol provides symptomatic relief for discomfort associated with fever and can help manage high fevers (>38.5°C) while improving the child's comfort 1

Temperature Thresholds in Specific Clinical Contexts

While comfort is the primary driver, certain clinical situations warrant attention to specific temperature levels:

• Grade 1 cytokine-release syndrome: Acetaminophen should be given as needed for temperatures ≥38°C 4
• High fever management: Children with temperatures >38.5°C and respiratory symptoms can be managed with antipyretics and fluids when no high-risk features are present 1
• Persistent fever: Temperatures ≥39°C lasting >10 hours despite acetaminophen may warrant consideration of alternative diagnoses, though this does not change the indication for symptomatic treatment 4

Dosing Guidelines

When paracetamol is indicated:

• Standard dosing: 10-15 mg/kg every 4-6 hours, not exceeding 5 doses in 24 hours 1
• Weight-based dosing: 15 mg/kg per dose is commonly used, with maximum daily dose of 60 mg/kg/day 2
• The American Academy of Pediatrics recommends acetaminophen as first-line antipyretic therapy due to its favorable safety profile 1

What Paracetamol Does NOT Do

Critical limitations that should inform prescribing decisions:

• Does not prevent febrile seizures: Antipyretics are ineffective at preventing initial or recurrent febrile seizures and should not be used for this purpose 4, 5
• Does not alter disease course: No evidence supports using antipyretics to change the course of illness or prevent complications 1
• Does not reduce fever recurrence: Prophylactic acetaminophen during febrile episodes is ineffective at preventing fever recurrence 4

Clinical Approach Algorithm

Step 1: Assess the child's comfort level and presence of pain (headache, chest pain, arthralgia, abdominal pain) 1

Step 2: If fever is present (≥38°C) WITH discomfort or pain → Give paracetamol 1, 2

Step 3: If fever is present WITHOUT discomfort → Observation and reassurance; treatment is not necessary 3

Step 4: For children with high fever (>38.5°C) and respiratory symptoms, ensure adequate hydration and monitor for warning signs requiring hospital assessment 1

Important Safety Considerations

• Hepatotoxicity occurs with overdose; single ingestions >10 times the recommended dose are potentially toxic 2
• Chronic overdosing (>140 mg/kg/day for several days) carries risk of serious toxicity 2
• Parents should carefully record all dose times to avoid accidentally exceeding maximum recommended doses 6
• Aspirin must not be used in children under 16 years due to Reye's syndrome risk 1

Common Pitfalls to Avoid

• Treating the thermometer: Height and duration of fever are not predictive parameters for major illness 5
• Routine prophylaxis: Repeated dosing "around the clock" to prevent fever is not indicated 4
• Masking serious illness: While antipyretics may affect discomfort, repeated clinical observation remains essential regardless of treatment 5
• Alternating with ibuprofen: While combination therapy provides additional time without fever (2.5-4.4 hours over 24 hours), this must be weighed against the risk of inadvertently exceeding maximum doses 6, 7