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MarjoRenko

Fever in a Child

Essentials

  • Diseases that require immediate care (septicaemia, meningitis; see Meningitis in Children) or urgent care (within the next 24 hours; urinary tract infection Urinary Tract Infection in a Child, pneumonia Pneumonia in Children) must be identified. If the child's general condition has deteriorated or he/she is irritable, an emergency referral to a hospital is indicated.
  • Infants under the age of 3 months with fever should always be referred to specialist care.
  • If fever is the only presenting symptom, CRP determination should be used to rule out bacterial infection in a child whose general condition does not warrant immediate hospital investigations. However, the CRP concentration may also be increased in viral infections and, on the other hand, it may be normal in the initial phases of a bacterial infection.
  • If the child's general condition is poor, laboratory investigations are omitted and the child is referred immediately to specialist care.
  • The child's condition must be monitored as necessary; for example, the parents should have the possibility to contact the same physician by phone should the symptoms persist.

Particular situations Tonsillectomy for Periodic Fever, Aphthous Stomatitis, Pharyngitis and Cervical Adenitis Syndrome (Pfapa)

  • Fever with no clearly localizing symptoms or focal findings
    • Keep the possibility of pneumococcal or other septicaemia in mind.
    • The most common innocent condition presenting with fever as the only symptom is exanthema subitum (roseola infantum, sixth disease; Exanthema Subitum), and the most common condition requiring treatment is urinary tract infection Urinary Tract Infection in a Child.
  • Fever in a child below 3 months of age is investigated in specialized care.
  • Fever in a child over 3 months of age
    • Consider the possibility of a serious fulminant disease.
    • Pay attention to the child's general condition, neurological symptoms and alertness.
    • The parents' concern about and perception of an exceptionally difficult situation is associated with the risk of a serious infection. A physician's intuition also works similarly.
    • If the general condition is good and the CRP concentration is low, only observation is needed.
  • Fever and rash
    • Remember, in particular, meningococcal septicaemia and Kawasaki disease Kawasaki Disease.
  • Fever, abdominal pain and vomiting
    • Remember appendicitis, urinary tract infection.
  • Fever and headache or neck pain
    • Remember the possibility of a central nervous system infection.
  • Fever and joint pains
    • Remember suppurative arthritis.
  • Persistent fever
    • Investigate whether the fever is caused by successive viral infections causing fever episodes that only seem to form a single prolonged episode or is the fever really persistent.
    • Mild rise in the body temperature in the evenings is common in children after a viral infection and does not require further investigations if the child is in good condition.
    • Arrange for further investigations as necessary.
  • Periodically recurring fever
    • If the child has episodes of high fever recurring regularly at intervals of some weeks without a clear explanation he/she may have the PFAPA (periodic fever, aphtous stomatitis, pharyngitis, adenitis) syndrome and may benefit from tonsillectomy.

Fever and rash in a child: diagnostic clues. Legends: 1) = requires emergency hospital admission; 2) = can usually be treated in primary care.

Dominant symptom, diseaseTypical featuresLaboratory findings
Petechiae (pinpoint haemorrhages that do not blanch when pressed)
Meningococcal septicaemia 1) Irritability, floppiness, poor general conditionCRP increased
Henoch-Schönlein purpura 1) Henoch-Schönlein Purpura (IgA vasculitis)Petechiae on the buttocks and lower extremities, joint and abdominal painCRP low, platelets normal
Check urine sample
Idiopathic thrombocytopenic purpura (ITP) 1) Bruises and Purpura in ChildrenGeneral condition usually good, often normal temperaturePlatelets decreased
Leukaemia 1) Patient often tired, pale, occasionally bone painPlatelets decreased, leucocyte count often abnormal, haemoglobin often decreased
Enlarged lymph nodes, conjunctival erythema, oral or pharyngeal symptoms
Kawasaki disease 1) Kawasaki DiseaseIrritability, other specific disease criteriaCRP increased, leucocytosis
MIS-C, multisystem inflammatory syndrome following a COVID-19 infection1) Multisystem Inflammatory Syndrome in Children (Mis-C) with Covid-19 InfectionImpaired general condition, sepsis-like condition, other specific disease criteriaCRP increased, lymphocytopenia, heart enzymes often increased
Scarlet fever 2) Scarlet FeverTonsillitisStreptococcal culture or antigen test positive
Infectious mononucleosis 2) MononucleosisOften tonsillitis, sometimes hepatosplenomegaly, a rash may follow a course of amoxicillinOften lymphocytosis; mononucleosis rapid test positive (in children above 4 years of age)
Rash with small spots (< 3 mm)
Exanthema subitum 2) Exanthema SubitumFever precedes the rash by 2-4 daysCRP low
Other viral exanthema 2) CRP low
Drug reaction 2) Hypersensitivity to DrugsPreceding medication (may have already been stopped)
Kawasaki disease 1) Kawasaki DiseaseIrritability, other specific disease criteriaCRP increased, leucocytosis
MIS-C, multisystem inflammatory syndrome following a COVID-19 infection1) Multisystem Inflammatory Syndrome in Children (Mis-C) with Covid-19 InfectionImpaired general condition, sepsis-like condition, other specific disease criteriaCRP increased, lymphocytopenia, heart enzymes often increased
Red blotches on the cheeks
Erythema infectiosum 2) Erythema InfectiosumMild fever, pharyngitis, headache, good general conditionCRP low
Vesicles on the skin or mucosa
Chickenpox 2) ChickenpoxOften a known infectious contact
Hand, foot and mouth disease 2) Enterovirus InfectionsBlisters on the hands, feet and often on the oral mucosa
Stevens-Johnson syndrome 1) Erythema MultiformeAlso mucosal symptoms, erythema multiforme
Primary herpes infection 2) If the patient has stomatitis both the oral mucosa and the skin on the lips are affected.
Obvious cough and rhinitis
Adenovirus 2) 2-8% of the patients have a rash.
COVID-19 Covid-19 and other Coronavirus Infections5-20% of the patients have a rash.
Measles (rubeola) 1) Measles, Mumps and Rubella (Mmr)Ocular symptoms, Koplik spots; blotches on the skin merge as the skin rash progresses to form larger areas of rash.
Urticaria
Viral infection 2) Other local symptoms of infectionCRP low
Type I drug reaction 2) Preceding medicationCRP low
Urticaria and arthritis 2) Arthritis in ChildrenJoint swelling and erythema; preceding antimicrobial treatment (often penicillin or cefaclor)CRP low
Remittent fever, with red macular rash during fever
Kawasaki disease 1) Kawasaki DiseaseImpaired general condition, other specific disease criteriaCRP increased, leucocytosis
MIS-C, multisystem inflammatory syndrome following a COVID-19 infection1) Multisystem Inflammatory Syndrome in Children (Mis-C) with Covid-19 InfectionImpaired general condition, sepsis-like condition, other specific disease criteriaCRP increased, lymphocytopenia, heart enzymes often increased
Systemic juvenile rheumatoid arthritis (juvenile idiopathic arthritis) 1) Juvenile Idiopathic Arthritis (Juvenile Rheumatoid Arthritis)A rash often on the upper part of the bodyCRP and ESR increased, leucocytosis

Assessment of the general condition

Investigations Rapid Viral Diagnosis for Acute Febrile Respiratory Illness in Children

Management of fever

Indications for symptomatic treatment

General care

  • Adequate fluid intake. It is advisable to continue breastfeeding. In theory, the fluid requirement in a child weighing 10 kg is 1 000 ml in 24 h, and in a child weighing 20 kg it is 1 500 ml in 24 h Diarrhoea and Vomiting in Children. Note the increase in the need for fluids caused by fever, vomiting and diarrhoea.
  • Light food that the child finds tasty. Appetite is often suppressed which is not a cause for concern.
  • Avoidance of excessive physical activity (for example sports)

Drug treatment Combined and Alternating Paracetamol and Ibuprofen for Febrile Children

  • Antipyretic drugs should only be used if necessary.
  • The first-line drug is paracetamol.
    • A single dose is 15 mg/kg, maximum dose 60 mg/kg/24 hours. This will reduce the temperature by approximately 1.5 °C within 1-2 hours of administering the medicine. The duration of action is 5-6 hours.
  • Other antipyretics suitable for use in children are ibuprofen (> 6 kg) and naproxen (> 12 months). The antipyretic effect of these is at least as good as that of paracetamol and their duration of action longer.
    • The single dose of ibuprofen is 10 mg/kg, maximum dose 40 mg/kg/24 hours.
    • The single dose of naproxen is 5 mg/kg, maximum dose 10 mg/kg/24 hours.
  • Aspirin (acetylsalicylic acid) should not be used as an antipyretic drug in children because its use is associated with the risk of Reye's syndrome.
  • The advantages of paracetamol as compared with other antipyretic drugs
    • Well tolerated
    • Has only a few or hardly any serious adverse effects when used in recommended doses.
    • Has no effect on bleeding or clotting factors.
    • Allergies are rare.
    • Antipyretic effect is proven and well documented.

Evidence Summaries ⬆