Summary
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 is more often caused by serious bacterial infections; diagnostics and management for this age group are covered in a separate article, “Fever in infants ≤ 60 days.”
Epidemiology
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.
Etiology
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]
- Common infectious conditions include:
- Urinary tract infection in children (most common bacterial infection in children < 3 years) [5][6]
- Upper respiratory tract infections (e.g., common cold, pharyngitis, acute tonsillitis, sinusitis, croup)
- Lower respiratory tract infections (e.g., bronchiolitis, pneumonia in children,)
- Acute otitis media
- Pediatric acute gastroenteritis
- Viral exanthems
- Skin and soft tissue infections
- Bacteremia and sepsis
- Meningitis in children
- Infectious mononucleosis
- Herpetic gingivostomatitis
- Bone and joint infections (e.g., septic arthritis, pediatric osteomyelitis)
- Less common causes include: [7]
- Rickettsial infections (e.g., tick-borne diseases, typhus)
- Tropical diseases (malaria, dengue fever, zika virus, chikungunya virus)
- Tuberculosis
- Cat-scratch disease
Noninfectious causes of pediatric fever [4][8]
- Postvaccination fever
- Heat stroke
- Drug fevers
- Thyrotoxicosis
- Intracranial pathology
- Rheumatologic conditions
- Malignancy, e.g., leukemia, lymphoma
Clinical features
Common findings [1]
- Physiological adaptations to fever, e.g.:
- Tachypnea
- Tachycardia
- Flushed skin
- Shivering or sweating
- Peripheral vasoconstriction
- Associated behavioral changes, e.g.:
- Decreased activity
- Fussiness or irritability
- Clinical features of the underlying condition (see “Etiology of pediatric fever”)
Rectal temperature is the best indicator of core temperature. [5]
Red flags for pediatric fever [5]
- Ill-appearance [2]
- Signs of sepsis
- Signs of respiratory distress
- Petechial rash or other symptoms of meningitis [9]
- Prolonged capillary refill time (> 3 seconds)
- Altered mental status including reduced arousability
-
Seizures [9][10][11]
- All complex febrile seizures or febrile status epilepticus
-
Simple febrile seizures in a child who meets any of the following criteria:
- Aged 6–12 months and unvaccinated or incompletely vaccinated
- Receiving antibiotics
- Who has additional red flags for pediatric fever
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]
Diagnosis
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
- In well-appearing children, a diagnosis can often be made clinically after a thorough history and examination.
- When required, diagnostics for fever are usually evaluations for the suspected etiology.
- In fever of unknown source, consider more extensive diagnostic studies, particularly in children < 3 years of age.
- In children with red flags for pediatric fever or risk factors for life-threatening pediatric infections, give empiric antibiotic treatment without waiting for diagnostic studies.
Initiate treatment without awaiting the results of diagnostic studies in children with suspected serious bacterial infections.
Evaluations for suspected etiology
- Based on the clinical examination, evaluate for suspected conditions, e.g.:
- See also “Etiology of pediatric fever.”
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
-
Blood tests
- Blood culture
- Inflammatory markers: procalcitonin, CRP, ANC on CBC
- If CSF studies are performed, obtain serum glucose.
- Urine studies: urinalysis with reflex urine culture
-
CSF studies: if neurologic symptoms or signs of meningitis are present
- Glucose, protein
- Gram stain and culture
- Cell count
- PCR (e.g., enterovirus, HSV)
-
Other
- Signs of shock: Obtain diagnostics of shock.
- Chest x-ray: Consider if signs of pneumonia are present. [5]
When possible, obtain cultures before initiating empiric antibiotic therapy.
Well-appearing children
- 2 months–3 years of age: Obtain diagnostics for pediatric UTI. [6]
- Consider:
- Rapid influenza test during flu season (see “Diagnostics for influenza”)
- COVID-19 test [13]
- Chest x-ray if there are signs of pneumonia [5]
Management
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]
- Evaluate for red flags for pediatric fever and if present:
- Provide immediate hemodynamic support.
- Initiate immediate broad-spectrum empiric antibiotics (see “Treatment”).
- Perform diagnostic studies for pediatric fever.
- Provide supportive care for pediatric fever.
- For well-appearing children with risk factors for life-threatening pediatric infections, provide additional management. [2][5]
- Underimmunized children: Evaluate for pathogens affecting unvaccinated children.
- Children with indwelling devices: See “Management of device-related infections.”
- Children with immunosuppression
- Consult relevant specialty.
- Follow local protocols where available, e.g., for management of neutropenic fever.
- Children with sickle cell disease: Consult hematology and start empiric antibiotics for infections in SCD.
- Children with prematurity or significant congenital abnormalities: Consult pediatrics.
- Currently hospitalized children: Consult infectious disease/microbiology for advice on the management of hospital-acquired infections.
In children with red flags for pediatric fever, do not delay treatment for diagnostic studies.
Treatment
- Treat the underlying cause.
- Give empiric antibiotics to children with red flags for pediatric fever and/or risk factors for life-threatening pediatric infections.
- Tailor to the suspected source, e.g.:
- If the source is unclear, give ceftriaxone. [5][12][14]
Supportive care for pediatric fever [15][16]
- Ensure adequate fluid intake via oral or IV fluids.
- Maintain a comfortable room temperature and dress the child in light clothing.
- If fever is bothersome to the child, consider:
-
Antipyretics
- Acetaminophen enteric or IV [16]
- Ibuprofen [16]
- Lukewarm sponging or bathing [16]
-
Antipyretics
- Provide anticipatory guidance for pediatric fever.
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]
Prevention
Fever is part of the normal immune response to illness; to prevent infections encourage parents to:
- Stay up-to-date on recommended immunizations in children.
- Practice rigorous hand hygiene and respiratory hygiene.
Anticipatory guidance
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.
- Risk factors for life-threatening pediatric infections
- Clinical features of life-threatening pediatric infections
- Clinical features of dehydration
- Hyperpyrexia, i.e., temperature ≥ 106 °F (≥ 41 °C), or repeated temperatures > 104 °F (≥ 40 °C) [19][20]
Indications for outpatient evaluation
An outpatient evaluation is recommended for children with:
- Signs of bacterial infection
- Infants and children 2–36 months with unexplained fever (i.e., no localizing symptoms) [5][21]
- Rapid testing during viral outbreaks (e.g., influenza, COVID-19) [5]
- Prolonged fever, i.e.: [20]
Home management of fever [1][5][16]
The following information pertains to otherwise healthy infants and children > 60 days old.
- If viral URTI symptoms are present, recommend:
- Provide reassurance to decrease caregiver anxiety about fever (fever phobia), e.g.:
- Fever is a part of the immune system response and may help fight infections.
- Antipyretics improve the child's comfort; they do not treat infection or prevent febrile seizures.
- The child's appearance is more important than the degree of fever. [1][2]
- If antipyretic use is indicated, advise caregivers on ways to minimize dosing errors and adverse effects.
- Follow weight-based dosing for acetaminophen or ibuprofen. [16]
- Specify which concentration to use.
- Do not routinely alternate between acetaminophen and ibuprofen. [16]
- Avoid:
- Aspirin and other medications containing salicylate
- Over-the-counter cough and cold products [16]
- Stay home until afebrile, without the use of antipyretics, for at least 24 hours. [23]
For infants and children < 2 years of age, provide written dosing instructions for antipyretics. [20]