Treatment of Fever in Children
The primary goal of treating fever in children should be to improve the child's overall comfort rather than normalizing body temperature, using paracetamol (acetaminophen) or ibuprofen only when fever causes discomfort, while avoiding combined or alternating antipyretic therapy. 1, 2
Age-Stratified Management Approach
Neonates (0-28 days)
- Hospitalization and empirical antibiotics are mandatory for all febrile neonates due to extremely high risk of severe bacterial infection and immature immune function 1, 2
- Perform complete sepsis evaluation including blood cultures, urine culture via catheterization (never bag collection), and lumbar puncture before initiating antibiotics 1
- The reduced activity of opsonins, macrophages, and neutrophils in this age group significantly increases infection risk 1
Young Infants (29-90 days)
- Infants in the second month of life may be risk-stratified, with low-risk infants potentially managed as outpatients with close 24-hour follow-up 3
- Perform urine culture via catheterization in females, fever >24 hours, temperature ≥39°C, and uncircumcised males 1
- Consider chest radiography if cough, hypoxia, wheezing, high fever (≥39°C), or fever >48 hours duration is present 1
- Avoid chest radiography in children with wheezing or high probability of bronchiolitis 1
Children >90 Days
- Clinical evaluation for focal signs of bacterial infection guides management 3
- Urinary tract infections account for >90% of serious bacterial illness in this age group 3
- Most febrile children will have benign, self-limiting viral infections 2
Antipyretic Therapy
Medication Selection
- Use only paracetamol (acetaminophen) or ibuprofen as antipyretics, and only when fever is associated with discomfort 1, 2
- Paracetamol is recommended as the first-line agent 2
- No substantial difference exists in safety and effectiveness between acetaminophen and ibuprofen in generally healthy children 4
- Combined or alternating use of antipyretics is discouraged due to concerns about complicated dosing and unsafe use 1, 4
Non-Pharmacological Measures
- Encourage adequate fluid intake to prevent dehydration 2, 5
- Unwrap or remove excess clothing 5
- Avoid tepid sponging, cold bathing, and fanning as these cause discomfort without lasting benefit 2, 5
Antibiotic Therapy Indications
- Initiate antibiotics when bacterial infection is suspected, obtaining appropriate cultures first 1
- Discontinue antibiotics in 24-36 hours if cultures are negative and the child is clinically improved 1
Hospitalization Criteria
Admit if any of the following are present: 1, 2
- Age 0-28 days (mandatory)
- Toxic or severely ill appearance
- Oxygen saturation ≤92%
- Severe dehydration
- Abnormal cerebrospinal fluid analysis
- Difficulty feeding, vomiting, or decreased urine output
Safe Discharge Criteria
Discharge is appropriate when: 1, 2
- Well-appearing child with all negative tests
- Normal oxygen saturation
- Adequate hydration
- Guaranteed follow-up within 24 hours
- Parents able to monitor and recognize warning signs
Critical Pitfalls to Avoid
- Do not rely solely on clinical appearance as many children with severe bacterial infections may appear well initially 1
- Do not use response to antipyretics as an indicator of disease severity 1
- Do not ignore the impact of recent antipyretic use on measured temperature 1
- Avoid unnecessary radiographic studies in children with probable viral illnesses 1
- Never use bag collection for urine culture due to high contamination rates 1
Parent Education and Follow-Up
- Provide verbal and written information on fever management and warning signs 2
- Instruct parents on red flags requiring immediate return: worsening general condition, skin spots/rash, respiratory distress, feeding refusal, excessive irritability or somnolence 2
- Emphasize that fever itself is a beneficial physiologic response to infection and rarely causes harm below 41.7°C 4, 6
- Reevaluate all outpatient-managed children within 24 hours 2