What is the first line treatment for fever in children?

First-Line Treatment for Fever in Children

Acetaminophen (paracetamol) is the first-line antipyretic for treating fever in children, with the primary goal being to improve the child's overall comfort rather than normalizing body temperature. 1, 2

Core Treatment Principles

The fundamental approach to fever management prioritizes comfort over temperature normalization. Fever itself is a physiologic mechanism with beneficial effects in fighting infection and does not worsen illness course or cause long-term neurologic complications. 2 The American Academy of Pediatrics emphasizes that antipyretics should be used to promote comfort and prevent dehydration, not to prevent febrile seizures or achieve normal temperature. 1, 2

First-Line Antipyretic: Acetaminophen

Acetaminophen is the safest and preferred first-line antipyretic agent for children. 3, 4

Dosing Guidelines

• Dose based on weight, not age: 10-15 mg/kg per dose 3, 5
• Route: Oral administration is preferable to rectal when possible 3
• Frequency: Every 4-6 hours as needed for comfort 2

Safety Profile

• Relatively free of adverse effects when dosed appropriately 4
• Safe in newborns with dose adjusted to gestational age 3
• Not contraindicated in children with asthma 3

Second-Line Antipyretic: Ibuprofen

Ibuprofen is an appropriate alternative or second-line agent, particularly when longer duration of action is desired. 1, 3

Dosing Guidelines

• Dose: 5-10 mg/kg per dose 5, 6
• Frequency: Every 6-8 hours as needed 2

Comparative Efficacy

• Pain relief: Comparable efficacy to acetaminophen at 2 and 4 hours (risk ratio 1.14 and 1.11 respectively) 5
• Fever reduction: More effective than acetaminophen at reducing temperature at 2,4, and 6 hours post-treatment (effect sizes 0.19,0.31, and 0.33 respectively) 5, 6
• Duration: Longer action makes it preferable when sustained antipyresis is needed 6

Contraindications and Cautions

• Avoid in: Children with chickenpox or dehydration 3
• Safe in: Children with asthma (not contraindicated) 3
• Age consideration: Generally recommended for children ≥6 months 2

What NOT to Do

Avoid Combined or Alternating Therapy

Do not combine or alternate acetaminophen and ibuprofen. 3 While evidence suggests combined therapy may be more effective than single agents, this approach increases complexity and risk of unsafe medication use, including potential for dosing errors and toxicity. 2, 4

Avoid Physical Cooling Methods

Physical methods of reducing fever (sponging, cooling blankets) are discouraged except in cases of true hyperthermia. 3 These methods cause discomfort without addressing the underlying fever mechanism.

Avoid Aspirin

Aspirin should not be used in children due to association with Reye's syndrome when given during viral illnesses. 4 Its use in pediatric patients has appropriately declined in the United States. 4

Age-Specific Considerations

Newborns and Young Infants (<1 month)

• Always hospitalize febrile newborns due to elevated risk of severe bacterial infection 3
• Acetaminophen may be used with dose adjusted to gestational age 3

Infants 1-3 Months

• Require careful evaluation for serious bacterial infection 7
• Acetaminophen remains first-line for comfort 1

Children ≥3 Months

• Standard acetaminophen or ibuprofen dosing applies 2, 3
• Focus on identifying fever source while treating for comfort 1

Common Pitfalls to Avoid

1. Treating fever as the disease: Remember that fever is a symptom, not the primary illness. Focus on the child's overall comfort and identifying the underlying cause. 2

2. Dosing by age instead of weight: Always calculate antipyretic doses based on the child's weight to ensure efficacy and safety. 3

3. Overzealous temperature normalization: Parents often administer antipyretics even with minimal fever. Counsel that the goal is comfort, not achieving 37°C. 2

4. Using antipyretics to prevent febrile seizures: Antipyretics do not prevent febrile seizure recurrence and should not be used for this purpose. 1, 3

5. Complicated dosing regimens: Avoid alternating medications, which increases risk of dosing errors and medication toxicity. 2, 3

Parent Counseling Points

Emphasize to parents: 2

• Monitor the child's overall well-being and activity level, not just temperature
• Observe for signs of serious illness requiring medical attention
• Encourage appropriate fluid intake to prevent dehydration
• Store antipyretics safely out of children's reach
• Fever itself does not cause brain damage or long-term complications