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Fever in children

Fever in children is defined as a rectal temperature of >38°C, oral temperature of >37.5°C or an axillary temperature of >37.2°C. Fever less than 41.7°C does not cause brain damage. Only 4% of children with fever develop febrile seizure. Hyperpyrexia

Fever above 41.5°C is called hyperpyrexia and warrants aggressive antipyretic therapy because of risk of irreversible organ damage.

Fever of unknown origin (FUO). It is defined as fever of more than three weeks duration, documented fevers above 38.3°C on multiple occasions, and lack of specific diagnosis after 1 week of admission and investigation in a hospital setting. Nosocomial FUO. This refers to hospitalized patients receiving acute care in whom infection or fever was absent on admission but in whom a fever of 38.3°C or more occurs on several occasions. Multiple readings of more than 38.3°C in a patient with less than 500 neutrophils/mm3 are labelled as neutropenic FUO. Treatment

Documentation of fever

Oral temperature is accurate provided no hot/cold drinks have been consumed in preceding 20 minutes. Axillary temperatures are least accurate and rectal thermometers are uncomfortable, especially in older children. Their use should be restricted to children < 6 months. Ear tympanic membrane thermometers are accurate reflection of inner body temperature, are safer than mercury ones.

Thermometer must be left in place for 2 minutes for rectal, 3 minutes for oral and 5-6 minutes for recording axillary temperature. Digital thermometers may measure temperature within 2 seconds and are accurate but expensive. Liquid crystal strips applied to forehead for recording temperature are not accurate. Find a cause

Try to find a focus of infection by careful history and physical examination.

Short duration fevers (less than 2 weeks) are usually due to infections. Look for any characteristic feature suggesting involvement of a particular system. Character of the fever (such as relapsing, Pel Ebstein, step ladder, etc.) may give a clue to the cause. Heat hyperpyrexia, dehydration fever, allergy to drug (drug fever), and haemolytic crisis are less common causes of short fevers.

Long duration fevers lasting more than 2 weeks should be investigated for infections, malignancies, connective tissue disorders, autoimmune diseases and metabolic causes.

Appropriate laboratory inv

estigations such as total and differential leucocyte count, peripheral smear, urinalysis,serological tests, radiological investigations, and cultures of blood and body fluids are carried out as indicated by the signs and symptoms related with fever.

Children with any one of the following conditions must be seen immediately: Age < 3 months old, fever >40.6°C, crying inconsolably, crying when moved/touched, difficult to awaken, neck is stiff, purple/red spots are present on skin, breathing is difficult and does not get better even after clearing of nasal passages, drooling of saliva and inability to swallow, convulsions and

looks or acts very sick.

Children with any one of the following should be seen as early as possible: Child is 3-6 months old (unless fever occurs within 48 hours after a DPT vaccination and has no other serious symptom), fever >40°C, burning/pain occurs during micturition, fever has been present for >24 hours and then returned, and in case of fever present for more than 72 hours.


Assure parents and explain that low grade fever need not be treated with antipyretics.

Give more fluids.

Dress in only one layer of light clothing. Place in a cool and airy environment.

Sponging: Sponge with lukewarm water (never alcohol) inchildren with febrile delirium, febrile seizure, and fever > 41.1°C. Give paracetamol 30 minutes before sponging. Until paracetamol has taken effect, sponging will cause shivering, which may ultimately increa

se the temperature.

Heat stroke requires immediate and aggressive cold water sponging.

The body may be massaged gently so that the cutaneous vessels dilate and body heat is dissipated.

For children less than 3 months of age: Identify the low-risk febrile infant. These children

can be managed on outpatient basis. Hospitalize, if child appears toxic or does not fulfill the criteria in Table

In children more than 3 months of age: Rectal temperatures less than 39°C need not be treated. Temperatures higher than 39°C need administration of antipyretics. Pharmacological

Tab/syr. Paracetamol 15 mg/kg/dose, dose can be repeated at 4 hourly interval

(Paracetamol reduces fever by 1-2°C within 2 hours).

(Caution: IV paracetamol is NOT recommended in children with age <6 months and <5 kg weight)


Tab/syr. Ibuprofen 10 mg/kg/dose, dose can be repeated at 8 hourly intervals. (Note: Efficacy is similar to paracetamol. Effect lasts for 6-8 hours as compared to 4-6 hours for paracetamol).

(Caution: Aspirin should NOT be used for the risk of Reye’s syndrome). Specific treatment for the cause of fever should be simultaneously undertaken.

Monitoring: Close monitoring of all children, especially young febrile infants, is essential.



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