What is the best way to manage fever in children?

Managing Fever in Children

Use paracetamol (acetaminophen) to improve the child's comfort, not to normalize temperature, and avoid physical cooling methods like tepid sponging or cold bathing, which cause discomfort without proven benefit. 1, 2, 3

Primary Goal of Fever Management

The fundamental objective is to enhance the child's overall comfort rather than focusing on achieving a normal body temperature. 2, 4 Fever itself is a beneficial physiologic mechanism that aids in fighting infection and does not worsen illness outcomes or cause long-term neurological complications. 4

Pharmacologic Management

• Paracetamol (acetaminophen) is the preferred first-line antipyretic for symptomatic relief in febrile children. 1, 2, 5, 3
• Administer antipyretics to promote comfort and prevent dehydration, not for seizure prevention, as they do not reduce febrile seizure recurrence. 1, 2, 6
• Ibuprofen is equally safe and effective as acetaminophen in otherwise healthy febrile children. 4
• Avoid aspirin in children under 16 years of age. 1

Non-Pharmacologic Management

• Ensure adequate fluid intake to prevent dehydration, which is a primary concern in febrile illness. 1, 2, 6
• Do not use physical cooling methods including fanning, cold bathing, or tepid sponging, as these cause significant discomfort without lasting benefit. 1, 2, 6, 7
• Unwrap or remove excessive clothing to allow natural heat dissipation. 7
• Encourage rest and continued feeding, including breast-feeding if applicable. 7

Critical Assessment: Identifying Serious Bacterial Infections

The key clinical task is differentiating benign viral illness from serious bacterial infections (SBIs), particularly in high-risk groups:

Age-Based Risk Stratification

• Infants under 3 months require immediate pediatric assessment due to immature immune systems and higher SBI risk, regardless of clinical appearance. 5, 8
• Children aged 3 months to 3 years with fever >38.5°C warrant evaluation for occult bacteremia and urinary tract infection. 1, 5

Red Flags Requiring Urgent Evaluation

• Toxic or ill appearance: extreme pallor, hypotension, poor feeding, floppy infant 1, 5
• Meningeal signs: altered mental status, neck stiffness, excessive drowsiness, irritability, bulging fontanelle 1, 2, 6
• Respiratory distress: markedly raised respiratory rate, grunting, intercostal recession, cyanosis 1
• Severe dehydration: absent tears, mucosal dryness, delayed capillary refill 1, 9
• Complicated or prolonged seizure (>5 minutes) 1, 2
• Petechial or purpuric rash suggesting septicemia 5

Diagnostic Workup

Essential Investigations

• Urinalysis and urine culture should be obtained in all febrile children where a clean-catch specimen is readily available, as urinary tract infection is the most common SBI (5-7% prevalence). 2, 5, 8
• Blood glucose if the child is seen during a seizure. 1, 6
• Chest radiography only if respiratory symptoms are present (tachypnea, retractions, crackles). 2, 5

Investigations to Avoid Routinely

• Do not routinely perform electroencephalography after simple febrile seizures, as it does not guide treatment or prognosis. 1, 6
• Avoid routine blood tests (complete blood count, inflammatory markers) unless specific clinical indication exists. 5

Special Consideration: Febrile Seizures

When to Perform Lumbar Puncture

• Mandatory in children under 12 months with febrile seizure to exclude meningitis, as meningeal signs may be absent in this age group. 1, 2, 6
• Consider in children 12-18 months with febrile seizure. 1, 6
• Always perform if: meningeal signs present, complex seizure features, child unduly drowsy/irritable/systemically ill, or incomplete recovery within one hour. 1, 2, 6
• A comatose child requires examination by an experienced physician before lumbar puncture due to herniation risk; brain imaging may be necessary first. 1, 6

Prognosis and Reassurance

• The prognosis for simple febrile seizures is excellent, with only 2.5% risk of subsequent epilepsy. 2, 6
• Recurrence risk is approximately 30% overall, increasing to 50% with younger age at first convulsion or positive family history. 1, 2, 6

Disposition and Follow-Up

Criteria for Hospitalization

• Age under 3 months with fever 5, 8
• Toxic appearance or signs of septicemia 1, 5
• Respiratory distress with oxygen saturation <92% 1
• Severe dehydration 1, 9
• Altered consciousness or prolonged seizure 1
• Inability to maintain oral intake 5

Outpatient Management

• Children with good general condition, normal urinalysis, and reliable parents capable of monitoring may be managed at home. 5
• Reevaluate within 24 hours if managed as outpatient. 2, 6, 5

Parent Education

Provide verbal and written instructions covering:

• Warning signs requiring immediate return: worsening general condition, skin rash/petechiae, respiratory distress, feeding refusal, excessive irritability or somnolence. 2, 5
• Fever is a normal physiologic response that helps fight infection. 4
• Focus on the child's overall comfort and activity level rather than the temperature number. 4
• Proper antipyretic dosing and safe storage to prevent accidental overdose. 4
• For febrile seizures: positioning child on side during seizure, not placing anything in mouth, seeking emergency care if seizure lasts >5 minutes. 2

Common Pitfalls to Avoid

• Do not treat fever aggressively to achieve normal temperature, as this provides no clinical benefit and may lead to excessive medication use. 2, 4
• Do not use tepid sponging, which causes immediate discomfort and only transient temperature reduction. 1, 7
• Do not delay lumbar puncture in high-risk infants based on absence of obvious meningeal signs. 1, 6
• Do not use inappropriate beverages like cola drinks for rehydration, as they contain insufficient sodium and excessive osmolarity. 9