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Pediatric fever

Last updated: September 4, 2023

Summarytoggle arrow icon

Fever, which is defined as a core body temperature ≥ 100.4°F or 38°C, is one of the most common causes of pediatric health care visits. Fever is the body's normal response to an underlying infection and/or inflammatory process (e.g., rheumatologic conditions, malignancy). Following the introduction of routine childhood pneumococcal vaccines and H. influenzae type b (Hib) vaccines, acute pediatric fevers in children aged > 60 days are most commonly caused by self-limited viral infections. Diagnostic studies are not usually required but should be performed if any red flags for pediatric fever are present to identify serious bacterial infections. Children who have risk factors for life-threatening pediatric infection require additional evaluation, even if they appear well on examination, and may require antibiotics and hospital admission. Supportive care is the mainstay of treatment for children with fever and should include adequate hydration and antipyretics for discomfort. Education for caregivers is important to reduce anxiety over fever in children and help manage future episodes at home.

Fever in infants ≤ 60 days s more often caused by serious bacterial infections; diagnostics and management therefore differ from in older infants and children and is covered in a separate article “Fever in infants ≤ 60 days.”

Epidemiologytoggle arrow icon

Fever is the presenting concern in:

  • ∼ 30% of pediatric primary care visits [1]
  • 15% of emergency room visits in children < 15 years of age [2]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Fever is a symptom of an underlying infection, disease, and/or inflammatory process. Suspected causes of fever differ according to each system (see also “Differential diagnoses of fever by affected system”). [3]

Infectious causes of pediatric fever [4]

Noninfectious causes of pediatric fever [4][8]

Clinical featurestoggle arrow icon

Common findings [1]

Rectal temperature is the best indicator of core temperature. [5]

Red flags for pediatric fever [5]

Febrile seizures are common, affecting 2–5% of young children. Simple febrile seizures in a well-appearing child are not concerning, but all other febrile seizures should prompt consideration of CSF analysis and/or neuroimaging. [9][10][11]

Diagnosticstoggle arrow icon

The following information pertains to infants > 60 days of age; for diagnostics for younger infants, see “Fever in infants ≤ 60 days of age.”

General principles

Initiate treatment without awaiting the results of diagnostic studies in children with suspected serious bacterial infections.

Evaluations for suspected etiology

Unclear source [5][6][12]

Initial investigations for acute fever focus on infectious causes; if test results are negative consider noninfectious causes of pediatric fever.

Children with red flags for pediatric fever

When possible, obtain cultures before initiating empiric antibiotic therapy.

Well-appearing children

Managementtoggle arrow icon

The following information pertains to infants > 60 days of age; for management in younger infants, see “Fever in infants ≤ 60 days of age.”

Approach [2][5]

In children with red flags for pediatric fever, do not delay treatment for diagnostic studies.

Treatment

Supportive care for pediatric fever [15][16]

To prevent Reye syndrome, avoid aspirin and medications that contain salicylate in children. [16]

Antipyretics do not prevent febrile seizures. [10][17]

Do not administer ice baths or rubbing alcohol to reduce fever. [15][18]

Preventiontoggle arrow icon

Fever is part of the normal immune response to illness; to prevent infections encourage parents to:

Anticipatory guidancetoggle arrow icon

Educate caregivers on the following information regarding pediatric fever for children > 60 days of age. All febrile infants ≤ 60 days of age must be assessed.

When the child needs an assessment for fever

Indications for immediate evaluation [5]

Children with any of the following should be evaluated immediately, typically in an emergency department setting.

Indications for outpatient evaluation

An outpatient evaluation is recommended for children with:

Home management of fever [1][5][16]

The following information pertains to otherwise healthy infants and children > 60 days old.

For infants and children < 2 years of age, provide written dosing instructions for antipyretics. [20]

Ibuprofen is not approved for infants < 6 months of age.

Referencestoggle arrow icon

  1. Hamilton JL, Evans SG, Bakshi M. Management of Fever in Infants and Young Children. Am Fam Physician. 2020; 101 (12): p.721-729.
  2. Ravi Jhaveri, Eugene D. Shapiro. Fever Without Localizing Signs. Principles and Practice of Pediatric Infectious Diseases. 2018: p.115-117.e1.doi: 10.1016/b978-0-323-40181-4.00014-1 . | Open in Read by QxMD
  3. Cioffredi LA, Jhaveri R. Evaluation and Management of Febrile Children. JAMA Pediatr. 2016; 170 (8): p.794.doi: 10.1001/jamapediatrics.2016.0596 . | Open in Read by QxMD
  4. Nikolopoulou GB, Maltezou HC. COVID-19 in Children: Where do we Stand?. Arch Med Res. 2022; 53 (1): p.1-8.doi: 10.1016/j.arcmed.2021.07.002 . | Open in Read by QxMD
  5. Blaney SM, Giardino AP, Orange JS, et al. Rudolph's Pediatrics, 23rd Edition. McGraw-Hill Education / Medical ; 2018
  6. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  7. WHO. Pocket Book of Hospital Care for Children. World Health Organization ; 2013
  8. McNeil JC, Campbell JR, Crews JD. Healthcare-Associated Infections in Children. Springer ; 2018
  9. American Academy of Pediatrics. Textbook of Pediatric Care. American Academy of Pediatrics ; 2016
  10. Mace SE, Gemme SR, Valente JH, et al. Clinical Policy for Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the Emergency Department With Fever. Ann Emerg Med. 2016; 67 (5): p.625-639.e13.doi: 10.1016/j.annemergmed.2016.01.042 . | Open in Read by QxMD
  11. Subcommittee on Febrile Seizures. Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure. Pediatrics. 2011; 127 (2): p.389-394.doi: 10.1542/peds.2010-3318 . | Open in Read by QxMD
  12. Smith DK, Sadler KP, Benedum M. Febrile Seizures: Risks, Evaluation, and Prognosis.. Am Fam Physician. 2019; 99 (7): p.445-450.
  13. Eilbert W, Chan C. Febrile seizures: A review. J Am Coll Emerg Physicians Open. 2022; 3 (4).doi: 10.1002/emp2.12769 . | Open in Read by QxMD
  14. Trautner BW, Caviness AC, Gerlacher GR, Demmler G, Macias CG. Prospective Evaluation of the Risk of Serious Bacterial Infection in Children Who Present to the Emergency Department With Hyperpyrexia (Temperature of 106°F or Higher). Pediatrics. 2006; 118 (1): p.34-40.doi: 10.1542/peds.2005-2823 . | Open in Read by QxMD
  15. Fever Without Fear: Information for Parents. https://web.archive.org/web/20230814193750/https://www.healthychildren.org/English/health-issues/conditions/fever/Pages/Fever-Without-Fear.aspx. Updated: December 13, 2022. Accessed: August 14, 2023.
  16. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. 2011; 128 (3): p.595-610.doi: 10.1542/peds.2011-1330 . | Open in Read by QxMD
  17. Sullivan JE, Farrar HC. Fever and Antipyretic Use in Children. Pediatrics. 2011; 127 (3).doi: 10.1542/peds.2010-3852 . | Open in Read by QxMD
  18. Signs of Dehydration in Infants & Children. https://web.archive.org/web/20230814194101/https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/dehydration.aspx?_gl=1*1eja6id*_ga*MTY5ODgyOTM1OS4xNjc4Mzg1ODE0*_ga_FD9D3XZVQQ*MTY5MjA0MTA3OC44Ny4xLjE2OTIwNDE5ODguMC4wLjA.. Updated: September 24, 2019. Accessed: August 14, 2023.
  19. When to Keep Your Child Home From Child Care. https://web.archive.org/web/20230814184805/https://www.healthychildren.org/English/family-life/work-and-child-care/Pages/when-to-keep-your-child-home-from-child-care.aspx. Updated: December 6, 2022. Accessed: August 14, 2023.
  20. AAP Committee on Infectious Diseases. Red Book: 2021–2024 Report of the Committee on Infectious Diseases. American Academy of Pediatrics ; 2021
  21. Green C, Krafft H, Guyatt G, et al. Symptomatic fever management in children: A systematic review of national and international guidelines. PLoS ONE. 2021; 16 (6): p.e0245815.doi: 10.1371/journal.pone.0245815 . | Open in Read by QxMD
  22. El-Radhi AS. Do antipyretics prevent febrile convulsions?. Arch Dis Child. 2003; 88 (7): p.641-642.doi: 10.1136/adc.88.7.641 . | Open in Read by QxMD
  23. Treating Your Child’s Fever. https://web.archive.org/web/20230315193915/https://www.healthychildren.org/English/health-issues/conditions/fever/Pages/Medications-Used-to-Treat-Fever.aspx. Updated: December 13, 2022. Accessed: March 15, 2023.

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