Introduction
Physicians have recognized fever the abnormal elevation of body temperature for
centuries as a sign of disease. Furthermore, the problem of the febrile child is one of
the most frequently encountered in clinical pediatrics, accounting for as many as 20
percent of pediatric emergency department visits. The problem of determining an
appropriate clinical and laboratory evaluation of febrile children, however, remains a
major challenge to the pediatrician and emergency room physician.
Definition
It is difficult to pinpoint the lowest temperature elevation that is definitely
abnormal for all children under all circumstances. Some children normally have a rectal
temperature as low as 36.2°C (97°F) or as high as 38° C (100.4°F). Children, like
adults, also normally have diurnal variations in temperature with the peak usually
occurring between 5:00 and 7:00 PM. Factors such as excessive clothing, physical activity,
hot weather, digestion of food, and ovulation can all raise temperature in the absence of
disease. Generally, a rectal temperature of 38°C (100.4°) or higher is considered as a
fever.
Physicians have a role in educating parents about fever phobia. Fever seldom is
harmful. It does cause an individual to feel uncomfortable. On the other hand fever does
many positive things, such as interfering with viral replication and increasing leukocyte
chemotaxis. Rarely an extreme fever (temperature greater than 41.1°C or 106°F) may pose
a risk to a child in and of itself, and demand immediate management. Fever is a symptom
(sign), not a diagnosis in and of itself. The main task facing the physician is to make a
diagnosis and to treat the underlying disease causing the fever.
History and Physical exam
The evaluation and clinical decision-making process begins with a good history and
complete physical examination. Include questions about compromised normal host defenses
(sickle cell disease, asplenia, malignancy, or immunosuppression). The physical
examination should focus on alertness, responsiveness to parents, examiner, and objects,
irritability or lethargy, respiratory status, color, feeding activity, and age-related
appropriate motor activity.
Management: a three-pronged approach
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Treat the underlying disease.
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Ensure the child is comfortable.
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Demystify the situation for parents (who think that the fever will cause brain damage
and death).
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Unless the patient is experiencing heat stroke, there is absolutely no indication for
giving a child an alcohol bath or tepid bath.
Medications
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Acetaminophen in a dosage of 15 mg/kg/dose every 4 hours with a maximum dose of 650 mg
every 4 hours.
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Ibuprofen 5-10 mg/kg/dose every 6 hours, maximum 20 mg/kg/day.
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ASA is no longer used as a routine antipyretic medication in children because of the
association with Reye's syndrome.
Thoughts on antipyretics
Parents should give their children antipyretic medicine with the understanding that
it is based more on how the child looks, acts, and feels than on the absolute number on
the thermometer.
Practical Hints
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For children below the age of 3 months with fever, always obtain a consultation from a
pediatrician. Children between 3 months and 24 months should have individualized management.
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Do not forget UTI as a cause of fever or GI symptoms especially in younger children. Routine
urinalysis is not enough; always get a culture.
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Children under 12 months of age (perhaps even under 24 months of age) do not generally
have meningeal signs. Be vigilant in evaluating for meningitis.
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Otitis media by itself is a very rare cause of temperature elevation > 102°F. Look
for associated bacteremia.
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There is no 100 percent reliable screening test for fever. Look at overall picture and
all potential sources of infection.
The gold standard is the rectal temperature. An axillary temperature is completely
unreliable. Thus far, data regarding tympanic membrane temperature is insufficient.
Reviewed by CDR Wendy Bailey, MC, USN, Pediatric Specialty Leader, Department of
Pediatrics, Naval Medical Center San Diego, San Diego, CA (1999).