The febrile child is a common paediatric presentation in both primary care and the emergency department. Studies from the UK show that over one-third of contacts with out-of-hours services are about children under five years of age, and 52% of these calls are due to a febrile child.¹

Despite being so common, the febrile child still remains diagnostically challenging as distinguishing a routine, self-limiting viral illness from a serious bacterial infection is not always straightforward. 

Fever has a reputation of being a sign that needs urgent medical attention, whereas in reality, the vast majority of children will have a mild, self-limiting illness and close observation for specific signs of serious infection is all that is required. The notable exception to this is infants under three months of age, whose risk of having a serious bacterial infection if presenting with a fever is significantly higher than in older children. 

Diagnosis of fever

The diagnosis of fever often begins with the parent’s perception that the child feels warm or hot. Subjective detection of fever by parents and carers has been relatively well studied and the sensitivity of palpation for the detection of fever ranges from 74% to 97%.^2-5 Hence, parental perception of fever should be taken seriously. 

Mercury thermometers are no longer recommended for use in children, and for children under five years of age, oral and rectal thermometers are also not advised. The accuracy of forehead strips is questionable. Three methods for taking temperatures in this age group are currently recommended:

• Infrared tympanic thermometer
• Electronic thermometer in the axilla
• Chemical dot thermometer in the axilla.

Once fever is established, the vast majority of parents will make contact with the health service. One study showed that 85% of parents made contact with a healthcare professional within 24 hours of their child having a temperature. Once this contact is made, the child will undergo a clinical assessment. 

For the vast majority of these children, a condition that can be diagnosed, assessed and treated appropriately there and then or with simple follow-up arrangements will be found. However, many will have fever where no source can be identified. Assessing these children’s needs can be more difficult. 

Healthcare professionals need to be fully conversant with the norm or near norm to recognise the ill child with a possible serious bacterial illness. 

Examination

In infants over three months of age, a careful history, observation of the child and a complete physical examination should be able to identify those needing further evaluation or referral to hospital. One should have a low threshold for obtaining a urine sample for urinalysis and if the urinalysis is abnormal, a urine culture should be sent and empirical antibiotics commenced.

Examination for rashes is important if one wishes to pick up early invasive meningococcal disease (IMD). Up to 20% of meningococcal disease cases do not have a rash and in some patients the rash may be macular and later evolve into a non-blanching or petechial rash. 

Look in the nappy area and the feet, as a petechial rash may only be present at these sites. In general terms, a rash which is present only in the distribution of the superior vena cava (head, neck and thorax) is most unlikely to be due to IMD.

‘Eyeballing’ the child is not enough and the child should be stripped down for a complete examination. Early meningococcal disease or other serious bacterial infection may be quite indistinguishable from a viral illness.

Key clinical questions

The clinical questions one should ask to help identify the serious ill child are as follows:

• What is the infant’s cry like? Is it strong or weak, is it a high-pitched cry or a moan?
• How does the infant react to his/her parents? Enquire also if the infant perks up once the fever settles
• Ask about the state of arousal of the infant and whether he/she awakens quickly
• Assess the infant’s colour looking for signs of pallor, cyanosis or mottling
• Assess the hydration status of the child
• Assess the social responses of the infant. Does he/she smile?

Serious bacterial illness is most unlikely in a smiling infant. The NICE guidelines on the febrile child established the ‘traffic light’ system for risk stratifying children.⁷ They divide them into high, intermediate or low risk of having a serious bacterial infection and suggest recommendations on appropriate management of children in each category. Table 1 lists the signs and symptoms to look out for.

 (click to enlarge)

Children with any ‘red’ features should be referred urgently to the care of a paediatric specialist. If any ‘amber’ features are present and no diagnosis has been reached, healthcare professionals should provide parents or carers with a ‘safety net’ or refer to specialist paediatric care for further assessment. The safety net should be one or more of the following:

• Providing the parent or carer with verbal and/or written information on warning symptoms and how further healthcare can be accessed
• Arranging further follow-up at a specified time and place
• Liaising with other healthcare professionals, including out-of-hours providers, to ensure direct access for the child if further assessment is required.

Children with ‘green’ features and none of the ‘amber’ or ‘red’ features can be managed at home with appropriate advice for parents and carers, always including advice on when to seek further attention from the healthcare services.

The concept of safety-netting is not a new one but its importance cannot be overstated. It has been shown to significantly decrease the rate of re-presentation in the incidence of a febrile child,¹ but more importantly, it gives parents the information to recognise that their child’s illness has deteriorated and the need to seek further medical help. 

Going through the list of ‘red’ features is helpful. The quality of the information given and whether or not written information is given also impacts on how well parents retain the information.

Investigation 

Urinalysis is crucial in the assessment of every infant with a fever and in any older child who has fever with a definite source.

Important advice which parents should be given is how best to manage pyrexia at home. There are many old wives’ tales as to how best to manage temperature with anything from cold baths to warm blankets. There is a lack of evidence about opening windows or fanning as methods of reducing temperature, but tepid sponging offers no significant benefit over antipyretic agents alone.⁸ In studies looking at combinations of sponging techniques and drugs, sponging seemed to have no or only short-lived additive effects on the reduction in temperature. Adverse effects in some children included crying and shivering in those treated with sponging. Undressing alone had little effect on temperature. A small study in adult volunteers with artificially induced fever showed that, during active external cooling, shivering was common, and both heat production and blood pressure were raised.⁹ Discomfort was also significant, a finding that is supported by some studies of tepid sponging in children.¹⁰

Pharmacological management of fever

Paracetamol and/or ibuprofen are the mainstay of pharmacological management of fever. Unlike physical methods of cooling, these medications act to lower the hypothalamic set-point rather than simply cooling the body. 

There is a perception that fever needs to be controlled to safeguard the health of the child or ward off febrile convulsions. In reality, there is no evidence that fever causes any neurological or other damage to the health of a child and there is also no evidence that medication reduces the incidence of febrile convulsions.^11,12

Fever can, however, be a distressing symptom, causing pain, lethargy, rigors and irritability. In this setting it is very reasonable to want to control the temperature. Advice given to parents about the use of antipyrexials varies considerably. Both ibuprofen and paracetamol have been shown to be effective at managing temperature. Their use in combination is a little more controversial. Currently, there is no evidence that the combination of the two taken at the same time is of any benefit.^13,14 However, there is limited data to suggest that using both drugs in alternation is more effective then monotherapy.¹⁵ A sensible approach would be to use monotherapy as first-line as the use of two medications comes with a higher risk of medication error. If monotherapy fails to control the temperature one should attempt alternate-dose therapy.

Dosage guidelines 

The child’s weight should be measured and the medications should be dosed per kilogram. To a greater extent, doses per age are under-treating children, as the average weight of children is increasing.

Paracetamol¹⁶

• By mouth: 15mg/kg four to six hourly to a maximum of four doses in 24 hours
• By rectum: 20mg/kg six hourly to a maximum of four doses in 24 hours.

Ibuprofen¹⁶

• By mouth in > one month: 7.5mg/kg eight hourly
• By rectum in one month to two years: 60mg (one suppository) eight hourly
• By rectum in > two years: 60mg (one suppository) six hourly.

Other considerations

What other advice should be given to parents for further management of a febrile child? The parents need to consider: 

• Hydration
• Feeding
• When to attend nursery or school
• How long will the fever last
• Appearance of non-blanching rash.

Fluid intake is very important and parents should be advised that fluids containing sugar are preferable to plain water as the child’s calorie intake is likely to be reduced and hypoglycaemia can occur in infants, especially if there are ongoing losses such as vomiting or diarrhoea. If a child is breastfeeding, breast milk is best for them to continue taking. Parents should be informed of signs of dehydration to look out for, including: sunken fontanel, dry mouth, sunken eyes, absence of tears and poor overall appearance.

The average duration of febrile illness in children is three days, but anything from 10 minutes to 14 days can occur with a simple viral illness. Duration of fever is not a specific indicator for significant illness. In fact, a long duration of fever in a child not on antibiotics and who has not rapidly deteriorated makes a severe bacterial infection very unlikely; however, there are other conditions which are characterised by persistent fever such as Kawasaki, and hence a reassessment after five days if the illness has failed to dissipate is not an unreasonable approach, and again is likely to give parents more confidence managing at home. 

The appearance of a non-blanching rash is something all parents should be made aware of and be shown how to look for this important sign. 

In conclusion, the most important role of the healthcare professional is to identify the rare child with a serious bacterial illness who needs further medical intervention among the much more common multitude of children with benign, self-limiting conditions, who are best managed in the care of their parents at home. Table 2 offers a list of practical tips to help in this challenging task. 

 (click to enlarge)

References

1. Which urgent care services do febrile children use and why? Maguire S, Ranmal R, Komulainen S et al; RCPCH Fever Project Board. Arch Dis Child 2011 Sep; 96(9): 810-6. Epub 2011 Jun 3
2. Banco L, Veltri D. Ability of mothers to subjectively assess the presence of fever in their children. Am J Diseases of Children 1984; 138(10): 976-8
3. Hooker EA, Smith SW, Miles T, et al. Subjective assessment of fever by parents: comparison with measurement by non-contact tympanic thermometer and calibrated rectal glass mercury thermometer. Annals of Emergency Medicine 1996; 28(3): 313-7
4. Nwanyanwu OC, Ziba C, Redd SC et al. Palpation as a method of fever determination in Malawian children who are less than 5 years old: how reliable is it? Annals of Tropical Medicine & Parasitology 1997; 91(4): 359-63
5. Singhi S, Sood V. Reliability of subjective assessment of fever by mothers. Indian Pediatrics 1990; 27(8): 811-5
6. Ernst TN, Philp M. Temperature assessment by parental palpation. Am J Diseases of Children 1985;139(6): 546-7
7. Feverish illness in children assessment and initial management in children younger than 5 years. National Collaborating Centre for Women’s and Children’s Health. Commissioned by the National Institute for Health and Clinical Excellence (NICE). May 2007
8. Purssell E. Physical treatment of fever. Archives of Disease in Childhood 2000; 82(3): 238-9
9. Lenhardt R, Negishi C, Sessler DI et al. The effects of physical treatment on induced fever in humans. Am J Med 1999; 106: 550-5
10. Meremikwu M, Oyo-Ita A. Physical methods for treating fever in children. (Cochrane Review). In: Cochrane Database of Systematic Reviews, Issue 1, 2007. Oxford: Update Software
11. Andre P, Thebaud B, Guibert M et al. Maternal-fetal staphylococcal infections: A series report. Am J Perinatology 2000; 17(8): 423-8
12. Meremikwu M, Oyo-Ita A. Paracetamol for treating fever in children. (Cochrane Review). In: Cochrane Database of Systematic Reviews, Issue 3, 2005. Oxford: Update Software
13. Erlewyn-Lajeunesse MD, Coppens K, Hunt LP et al. Randomised controlled trial of combined paracetamol and ibuprofen for fever. Archives of Disease in Childhood 2006; 91(5): 414-6
14. Lal A, Gomber S, Talukdar B. Antipyretic effects of nimesulide, paracetamol and ibuprofen-paracetamol. Indian J J Pediatrics 2000; 67(12): 865-70
15. Sarrell EM, Wielunsky E, Cohen HA. Antipyretic treatment in young children with fever: acetaminophen, ibuprofen, or both alternating in a randomized, double-blind study. Archives of Pediatrics and Adolescent Medicine 2006; 160(2): 197-202
16. The Children’s University Hospital Formulary 2010