Fever

Bottom line recommendations for the treatment and management of fever in neonates and infants (French). Published online: June 2019, Version 2.0.

Bottom line recommendations for the treatment and management of fever in neonates and infants. Published online: June 2019, Version 2.0.

Bottom line recommendations for the treatment and management of fever in neonates and infants (French). Published online: June 2019, Version 2.0.

The clinical pathway for treating and evaluating febrile infants is built upon publicly available medical evidence and/or a consensus of medical practitioners at The Childrens Hospital of Philadelphia.

These pathways and guidelines contain information on the assessment and management of febrile infants (0-30 days old, 31-60 days old) as inpatients and in the ED, with and without bronchiolitis.

This guideline is for fever in infants 7 to 60 days of life is elevation of central temperature to 38.0°C or higher. 

To identify and evaluate guidelines for the symptomatic management of fever in children.

This clinical policy from the American College of Emergency Physicians addresses key issues for well-appearing infants and children younger than 2 years presenting to the emergency department with fever.

To review new scientific evidence to update the Italian guidelines for managing fever in children as drafted by the panel of the Italian Pediatric Society.

The cause of fever in a child can often be determined from history, physical examination, and laboratory tests; infections account for the majority of cases. Yet in 20%, no apparent cause can be found, designated as fever without source (FWS). The yield of chest radiography in children with FWS is low, and it is usually not appropriate. However, in children with respiratory signs, high fever (>39C), or marked leukocytosis (20,000/mm(3)), chest radiography is usually appropriate, as it has a higher yield in detecting clinically occult pneumonia. In newborns with FWS, there is higher risk for serious bacterial infection, and the routine use of chest radiography is controversial. In children with neutropenia, fever is a major concern. In some clinical circumstances, such as after hematopoietic stem cell transplantation, chest CT scan may be appropriate even if the results of chest radiography are negative or nonspecific, as it has higher sensitivity and can demonstrate specific findings (such as lung nodule and "halo sign") that can guide management. In a child with prolonged fever of unknown origin despite extensive medical workup (fever of unknown origin), diagnosis is usually dependent on clinical and laboratory studies, and imaging tests have low yield. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel.

This quality standard covers the assessment and early management of fever with no obvious cause in babies and children (from birth to 5 years).

The National Institute for Health and Care Excellence (NICE) guideline for feverish illness in children (assessment and initial management in children younger than 5years) was partially updated in May 2013.1 Not all sections were reviewed, but the following were: the signs and symptoms of serious illness; the predictive value of tachycardia; the use of inflammatory markers; and the role of paracetamol and ibuprofen. The aim of the guideline is to optimise the management of young children with fever, and in particular to guide health professionals to recognise the signs of serious infection. The update made new recommendations based on current evidence. This guideline was developed by the National Collaborating Centre for Women's and Children's Health. They worked with the Guideline Development Group to review the evidence and write the recommendations.

To investigate whether doctors' and nurses' knowledge, perceptions, and attitudes toward fever influence how this sign is managed. Furthermore, it intends to evaluate whether educational programs increase knowledge and change attitudes and/or perceptions of nurses about children's fever.

Divergent attitudes towards fever have led to a high level of inconsistency in approaches to its management. In an attempt to overcome this, clinical practice guidelines (CPGs) for the symptomatic management of fever in children have been produced by several healthcare organizations. To date, a comprehensive assessment of the evidence level of the recommendations made in these CPGs has not been carried out.

Early identification of children at risk of severe febrile illness can optimise referral, admission and treatment decisions, particularly in resource-limited settings. We aimed to identify prognostic clinical and laboratory factors that predict progression to severe disease in febrile children presenting from the community.

It is not clear if children with high fever are at increased risk for serious bacterial infection (SBI). Our aim was to systematically review if children suffering from high fever are at high risk for SBI.

To compare the efficacy and safety of combined or alternating use of ibuprofen and paracetamol in children.

To collect and examine peer-reviewed literature for active educational interventions aimed at improving fever management in children and profile them based on: who provided the training, training location, how the intervention was delivered, outcomes of training, and how it was measured.

This guideline covers the assessment and early management of fever with no obvious cause in children aged under 5. It aims to improve clinical assessment and help healthcare professionals diagnose serious illness among young children who present with fever in primary and secondary care. This guideline should be read in conjunction with the NICE guidelines on sepsis, neonatal infection, meningitis (bacterial) and meningococcal septicaemia in under 16s, urinary tract infection in under 16s, diarrhoea and vomiting caused by gastroenteritis in under 5s and antimicrobial prescribing for common infections.

This review aimed to identify when to initiate testing and treatment for herpes simplex virus infection.

The authors highlight the historical context of febrile infant management, review important definitions and terminology, discuss the most clinically relevant viral and bacterial causes of fever in the young infant, describe current risk stratification tools guiding medicaldecision making, and outline research and clinical practice improvement priorities for improving the management of the febrile young infant.

Newer laboratory investigations such as C-reactive protein and procalcitonin have favorable test characteristics compared with traditional laboratory studies such as a white blood cell count. These novel biomarkers have not gained widespread acceptance because of lack of robust prospectively collected data, varying thresholds to define positivity, and differing inclusion criteria across studies. However, C-reactive protein and procalcitonin, when combined with other patient characteristics in the step-by-step approach, have a high sensitivity for detection of serious bacterial infection.

Fever in children is a common concern for parents and one of the most frequent presenting complaints in emergency department visits, often involving non-pediatric emergency physicians. Although the incidence of serious infections has decreased after the introduction of conjugate vaccines, fever remains a major cause of laboratory investigation and hospital admissions. Furthermore, antipyretics are the most common medications administered to children. We review the epidemiology and measurement of fever, the meaning of fever and associated clinical signs in children of different ages and under special conditions, including fever in children with cognitive impairment, recurrent fevers, and fever of unknown origin.

This study aimed to analyze a large group of febrile neonates 28 days or younger who received outpatient sepsis evaluation and nasopharyngeal aspirate antigen testing (NPAT) for respiratory syncytial viral (RSV) infection to determine whether there is a clinically significant association between viral study results and risk for serious bacterial infection (SBI: bacterial meningitis, bacteremia, urinary tract infection, bacterial enteritis).

The aim of this review was to synthesise qualitative and quantitative evidence on the knowledge, attitudes and beliefs of parents regarding fever and febrile illness in children.

Management of febrile children is an intrinsic aspect of pediatric practice. Febrile children account for 15% of emergency department visits and outcomes range from the presence of serious bacterial infection to benign self-limited illness.

The objective of the study was to systematically evaluate existing evidence of the diagnostic utility of biomarkers for prediction of sepsis in neonates.

This review describes diagnostic and therapeutic advances for infants with herpes simplex virus 1 (HSV-1) and 2 (HSV-2).

The objectives of this systematic review and meta-analysis were to determine: 1) the ability of serum procalcitonin concentrations to identify febrile infants < 91 days of age at high and low risk for serious bacterial infections, and 2) to compare its utility with available clinical prediction rules.

To assess the effects and side effects of combining paracetamol and ibuprofen, or alternating them on consecutive treatments, compared with monotherapy for treating fever in children.

Febrile young children present frequently to the emergency department. While most febrile children recover uneventfully, certain subgroups are at higher risk of serious infection. Febrile neonates require extensive diagnostic testing, antibiotic therapy, and hospital admission. Diagnostic testing can be utilized in older patients to identify children at low risk and high risk for serious infection. This information may assist in determining the treatment and disposition of these febrile children.

Fever is one of the most common reasons for a visit to the primary care provider or the emergency department. Traditionally, clinicians have used various risk-stratification strategies to identify serious bacterial infections (SBI) without an obvious source in febrile children, because missed bacterial infections in such children can result in meningitis, sepsis, and death; therefore, early and accurate identification of SBIs is critical. Infants aged less than 60 to 90 days are at greatest risk of SBI. The epidemiology of SBI continues to evolve, especially after the successful introduction of conjugate vaccines against Streptococcus pneumoniae and Haemophilus influenzae.

Objectives: To review the evidence for diagnostic accuracy of screening for serious bacterial illness (SBI) and invasive herpes simplex virus (HSV) infection in febrile infants 3 months or younger; ascertain harms and benefits of various management strategies; compare prevalence of SBI and HSV between different clinical settings; determine how well the presence of viral infection predicts against SBI; and review evidence on parental compliance to return for followup assessments (infants less than 6 months).

We systematically identified clinical features and laboratory tests which identify serious infection in children attending the ED and primary care. We also identified clinical prediction rules and validated those using existing data sets.

This review discusses challenges and new approaches to assessment and management of febrile children with suspected serious bacterial infections.

To collate all available evidence on the diagnostic value of laboratory tests for the diagnosis of serious infections in febrile children in ambulatory settings.

The objective of this systematic review was to determine the accuracy of C-reactive protein (CRP) for diagnosing serious bacterial and bacterial infections in infants and children presenting with fever.

This paper reports a review which draws together findings from studies targeting parents' temperature-taking, antipyretic administration, attitudes, practices and information-seeking behaviours.

A practice guideline for the management of febrile infants and children younger than three years of age sparked controversy when it was published in 1993. Surveys indicate that many office-based physicians do not agree with recommendations for venipuncture and bladder catheterization in nontoxic febrile children, and that many employ watchful waiting rather than empiric antibiotic therapy. Surveys of parents note a preference for less testing and treatment.

The objective of this systematic review was to evaluate the agreement between temperature measured at the axilla and rectum in children and young people.

Nearly 40% of parents with children aged 6 to 17 months consult a healthcare professional when their child has a high temperature. Clinical guidelines recommend temperature measurement in these children, but little is known about parents' experiences of and beliefs about temperature measurement. This study aimed to explore parents' concerns and beliefs about temperature measurement in children.

Fever in childhood is a common acute presentation requiring clinical triage to identify the few children who have serious underlying infection. Clinical practice guidelines (CPGs) have been developed to assist clinicians with this task. This study aimed to assess the proportion of care provided in accordance with CPG recommendations for the management of fever in Australian children.

We know that parents require resources which can assist them to improve fever knowledge and management practices. The purpose of this study, using an RCT, was to examine the effectiveness of an information leaflet at increasing parental knowledge of fever, specifically temperature definition.

Fever is responsible for 30% of pediatric consultations at primary care services. The aim of this study was to explore the parental approach to fever in children aged between 0 and 12 years old by both health professional and non-health professional parents. A qualitative study based on grounded theory was performed. Focus groups were conducted, segmented by sex, place of residence, and healthcare training, using a triangulated sample (theoretical and snowball sampling) of parents of children aged between 0 and 12 years who were treated for fever at primary care emergency services. The constant comparative method and a process of coding was used for the analysis. The study findings reveal that the health training of parents, their former experience, family pressures, the age of the child, and the parents' work outside the home, all influenced how they approached fever management. These findings could be incorporated into clinical practice to improve care and compliance with fever treatment.

This prospective study aimed to develop improved tools to assess children attending ambulatory hospital care, integrating clinical features with point-of-care C reactive protein (CRP).

The objective of this study was to assess the diagnostic value of existing clinical prediction models in febrile young infants at risk for serious bacterial infections.

The objective of this study was to estimate the accuracy of individual complete blood cell count parameters to identify febrile infants with invasive bacterial infections.

The objective of this study was to evaluate the impact of a febrile young infant clinical pathway implemented in a large, urban children's hospital ED on the timeliness and consistency of care.

The objectives of this study were to assess the performance of the Yale Observation Scale score and unstructured clinician suspicion to identify febrile infants 60 days of age with and without serious bacterial infections.

The objectives of this study were to determine the incidence of bacterial meningitis among all febrile infants 29-56 days old undergoing a lumbar puncture in the emergency department of a tertiary care children's hospital and the number of low-risk febrile infants with bacterial meningitis to reassess the need for routine lumbar puncture in these infants.

The objective of this study was to describe the frequency of concomitant acute bacterial meningitis in neonates with febrile urinary tract infection.

Our objective was to assess the effect of alternating acetaminophen and ibuprofen therapy on distress and refractory fever compared with acetaminophen or ibuprofen as monotherapy in febrile children.

The objective of this study was to inform the decision to test and empirically treat for herpes simplex virus (HSV) by describing the initial clinical presentation and laboratory findings of infants with a confirmed diagnosis of neonatal HSV.

The aim of this study was to analyze the usefulness of physical examination, C-reactive protein, procalcitonin, white blood cell count, and absolute neutrophils counts for the diagnosis of invasive bacterial infections and potentially serious bacterial infections in infants younger than the age of 3 months presenting with fever without source to the emergency department.

The aim of this study was to prospectively validate a sequential approach to young febrile infants on the basis of clinical and laboratory parameters, and compare it with the Rochester criteria and the Lab-score.

The objective of this study was to assess the diagnostic characteristics of the procalcitonin assay for detecting serious bacterial infection and invasive bacterial infection in febrile infants aged 7 to 91 days.

To evaluate the diagnostic value of published CPRs for febrile children in primary care.

To determine which signs and symptoms predict a prolonged duration of fever in febrile children in primary care and evaluate whether C-reactive protein (CRP) measurement has an additive predictive value for these symptoms.

The objective of this study was to evaluate the accuracy of leukocyte count for the detection of serious bacterial infections in febrile children.

This study analyzed all cultures of blood, urine and cerebrospinal fluid obtained from full-term infants 1 week to 3 months of age, who presented during a 7-year period. Compared with earlier studies, urinary tract infections (UTIs) are now found significantly more often than bacteremia and meningitis with 92% of occult infections associated with UTIs. These data emphasize the importance of an urinalysis in febrile infants.

It is important to advise parents when to consult a doctor when their child has fever. To provide evidence-based, safety-net advice for young febrile children, we studied the risk of complications, the occurrence of alarm symptoms, the duration of fever.

The objective of this study was to assess the diagnostic accuracy of white blood cell count, absolute neutrophil count, and C-reactive protein in detecting severe bacterial infections in well-appearing neonates with early onset fever without source and in relation to fever duration.

The objectives of this study were (1) to assess the rate of bacteremia in febrile infants less than 3 months of age admitted to a pediatric emergency department at a tertiary hospital; (2) to describe the bacteria isolated; and (3) to analyze factors related to increased probability of having a positive blood culture.

The objective of this study was to determine the potential predictive power of C-reactive protein as a marker of serious bacterial infection in hospitalized febrile infants aged < or =3 months.

The objective of this study was to determine the unique clinical and laboratory features of neonates with and without herpes simplex virus infection admitted to Texas Children's Hospital during a 14-year period.

To describe short-term outcomes relevant to children and their caregivers after evaluation in the emergency department (ED) for febrile illnesses.

The management of children with fever of indefinite source still remains controversial. This study aimed to compare different practice patterns between pediatric physicians (PPs) and emergency physicians (EPs) in the management of pediatric fever in the emergency department (ED) and correlate them to existing practice guidelines. Their impact on patient outcomes was also discussed.

To compare the antipyretic benefit of acetaminophen or ibuprofen monotherapy with an alternating regimen of both drugs in young children aged 6 to 36 months.

The purpose of this study was to determine (1) the risk of serious bacterial infection in children with hyperpyrexia and (2) whether clinical presentation can identify hyperpyrexic patients at risk for serious bacterial infection.

Fever is common in children and causes misconceptions among parents. Many investigators have called for improved parental education to dispel "fever phobia." Our objectives were to assess parental and health care provider understanding of fever, its treatment, and beliefs about its consequences, as well as to identify parental sources of information about fever.

Fever is the most common complaint of children seen in a Pediatric Emergency Department (PED). Since pediatric emergency nurses commonly educate parents on fever management, this study sought to examine their knowledge base regarding fever in children.

The objective of this study was to determine whether bundling elevates rectal and/or skin temperature of young infants.

Fevers are the body’s natural response to infection. It can be scary when your child has a fever, but fevers will not hurt your child. This video provides information about how to take your child’s temperature, how to manage their symptoms, and when to seek health care.

This video was created through a collaboration between ECHO Research (University of Alberta), TREKK, and ARCHE (University of Alberta). Funding was provided by the Networks of Centres of Excellence and the Stollery Children’s Hospital Foundation through the Women and Children’s Health Research Institute.

Video on how to manage your child's fever

Fevers are the body’s natural response to infection. It can be scary when your child has a fever, but fevers will not hurt your child. This infographic provides information about how to take your child’s temperature, how to manage their symptoms, and when to seek medical care.

This infographic was created through a collaboration between ECHO Research (University of Alberta), TREKK, and ARCHE (University of Alberta). Funding was provided by the Networks of Centres of Excellence and the Stollery Children’s Hospital Foundation through the Women and Children’s Health Research Institute.