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Child health

Feverish children - risk assessment and management

Last revised in June 2023

A child is considered to have a fever if his or her temperature is 38°C or higher.

Feverish children - risk assessment and management: Summary

  • Fever is an elevation of body temperature above the normal daily variation — an infant or child is generally considered to have a fever if their temperature is 38°C or higher. 
  • Fever is one of the most common clinical symptoms managed by healthcare professionals — it is very common in young children, with 20-40% of parents reporting an episode each year. 
  • Assessment of an infant or child with fever should include asking about:
    • The height and duration of fever, and method of temperature measurement.
    • Any associated symptoms suggesting an underlying cause of fever.
    • Any perinatal complications such as maternal fever and/or premature delivery.
    • Any significant medical conditions, such as known immunosuppression or immunodeficiency.
    • Any recent antipyretic drug and/or antibiotic use.
    • Current medication, immunization history, and immunization status.
    • Any recent foreign travel.
    • Any recent contact with people with serious infectious diseases.
  • The National Institute for Health and Care Excellence (NICE) traffic light system should be used to assess the child's risk of serious illness.
  • If there are any red features suggesting a serious or life-threatening cause of febrile illness, emergency ambulance transfer to Accident and Emergency should be arranged.
  • If there are any other non-life-threatening red features, an urgent face-to-face assessment within 2 hours should be arranged if the infant or child was initially assessed by telephone. 
  • If there are any amber features (but no red features), a face-to-face assessment should be arranged (the urgency depending on clinical judgement) if the infant or child was initially assessed by telephone.
  • If there are green features (but no amber/red features), the child can usually be managed at home.
  • Management of an infant or child with fever should include advice to parents/carers to: 
    • Look for signs of dehydration. 
    • Offer regular fluids and encourage a higher fluid intake if signs of dehydration develop. 
    • Continue breastfeeding as normal (if appropriate).
    • Dress the child appropriately for the surrounding environment by not underdressing or over-wrapping, to prevent overcooling or overheating. 
    • Avoid using tepid sponging (using cool water) to lower the child's temperature. 
    • Check the child regularly, including during the night (the frequency depending on the clinical situation). 
    • Keep the child away from nursery or school until they are recovered.
  • Advice on the use of antipyretic drug treatment should include advice to:
    • Use either paracetamol or ibuprofen initially, and consider switching to ibuprofen if paracetamol alone is ineffective, and vice versa.
    • Consider alternating these agents if paracetamol monotherapy and ibuprofen monotherapy are ineffective.
  • Safety-netting advice to parents/carers should be provided on warning symptoms and signs of when to arrange urgent medical review:
    • The child develops a non-blanching rash or other signs of central nervous system infection.
    • The child has a seizure.
    • The child is becoming dehydrated.
    • The fever lasts longer than 5 days.
    • The child is becoming more unwell.
    • They are distressed or concerned that they are unable to look after the infant or child at home.

Have I got the right topic?

From birth to 5 years.

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guideline Fever in under 5s: assessment and initial management [NICE, 2021].

This CKS topic covers the assessment and management of infants and children up to 5 years of age who have a feverish illness, including assessing the risk of a serious or life-threatening illness such as sepsis, bacterial meningitis/meningococcal disease, or pneumonia.

This CKS topic does not cover the diagnosis of other underlying causes of fever, or their management.

There are separate CKS topics on Acute childhood limp, Cellulitis - acute, Childhood cancers - recognition and referral, Cough - acute with chest signs in children, Febrile seizure, Gastroenteritis, Influenza - seasonal, Meningitis - bacterial meningitis and meningococcal disease, Otitis media - acute, Parvovirus B19 infection, Scarlet fever, Sinusitis, Sore throat - acute, Tuberculosis, and Urinary tract infection - children.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

June 2023 — reviewed. A literature search was conducted in June 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. This topic has been merged with the topic Feverish children - management, with a new scenario created covering the management of fever in children aged up to 5 years. A section on specific illnesses to consider when assessing fever has also been added.     

Previous changes

August 2022 — minor update. This topic has been updated with the NICE quality standards covering Fever in under 5s. 

July 2020 — minor update. A link to the topic on Sepsis was added to the section on management. 

November 2019 — minor update. Information about when to suspect Kawasaki disease added.

November 2018 — reviewed. A literature search was conducted in November 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring to improve navigation, clarity, and transparency. A section on Prevalence has been added to the Background information section. The management recommendations have been updated in line with the current literature including the updated National Institute for Health and Care Excellence (NICE) clinical guideline Feverish illness in children: assessment and initial management in children younger than 5 years (2017).

September 2013 — revised. A literature search was conducted in July 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Minor changes have been made to the National Institute for Health and Care Excellence (NICE) 'traffic light' system for fever risk assessment, and the evidence-base has been updated to reflect the latest evidence.

June 2011 — minor update. Information regarding the management of children with suspected meningococcal disease has been updated in line with the clinical guideline Bacterial meningitis and meningococcal septicaemia published by the National Institute for Health and Care Excellence (NICE). 

April 2009 — minor update. The Have I got the right topic? section has been updated. 

November 2008 — minor update. Text updated for children being assessed face to face with 'amber' features, to be aligned with primary care practice and 'safety net' information provided.

June to September 2008 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 June 2023.

HTAs (Health Technology Assessments)

No new HTAs since 1 June 2023.

Economic appraisals

No new economic appraisals relevant to England since 1 June 2023.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 June 2023.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 June 2023.

New policies

No new national policies or guidelines since 1 June 2023.

New safety alerts

No new safety alerts since 1 June 2023.

Changes in product availability

No changes in product availability since 1 June 2023.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make an accurate assessment of an infant or child with a febrile illness during a telephone or face-to-face consultation using the National Institute for Health and Care Excellence (NICE) traffic light system.
  • Arrange admission to secondary care if appropriate, the urgency depending on clinical judgement.
  • Advise parents/carers on the use of antipyretic drug treatment.
  • Provide self-care advice to parents/carers on how to manage a child with fever.
  • Provide advice on sources of information and support.
  • Provide safety-netting advice on warning symptoms and signs and when medical review is needed.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

The following NICE Quality Statements are relevant to this CKS topic:

  • Infants and children under 5 years with unexplained fever have their risk of serious illness assessed and recorded using the traffic light system.
  • Infants and children under 5 years who are seen in person by a healthcare professional have their temperature, heart rate, respiratory rate, and capillary refill time measured and recorded if fever is suspected.
  • Parents and carers who are advised that they can care for an infant or child under 5 years with unexplained fever at home are given safety net advice, including information on when to seek further help.

[NICE, 2022a]

Background information

What is fever?

  • Fever is an elevation of body temperature above the normal daily variation — an infant or child is generally considered to have a fever if their temperature is 38°C or higher. 
    • Normal body temperature varies within and between individuals as well as the body site where the temperature is measured, the time of day (body temperature is normally lowest in the early morning and highest in the early evening), degree of physical exertion, and ambient temperature.
  • Measured and reported parental perception of fever should be accepted as a valid indicator of fever.
  • Feverish illness in young children usually indicates an underlying infection, and fever is part of the body's natural response to this. 
    • Fever in itself is not harmful, it is the underlying infection that has the potential to cause harm. 
  • In a minority of children fever may be due to a non-infectious condition such as Kawasaki disease or malignancy. 

[Mace, 2016; NICE, 2021; BMJ, 2023]

How common is it?

  • Fever is one of the most common clinical symptoms managed by healthcare professionals — it is very common in young children, with 20-40% of parents reporting an episode each year.  
    • In a study of 1% of the national child population, the mean GP consultation rate was 3.7 per child per year and almost double that rate for children aged under 4 years.
  • It is the second most common cause of admission to children's wards, after breathing difficulties. 

[NICE, 2021; BMJ, 2023]

Management

Scenario: Feverish children - risk assessment

From birth to 5 years.

How should I assess an infant or child with fever?

  • Use the National Institute for Health and Care Excellence (NICE) traffic light system, to assess the child's risk of serious illness. 
    • Assess the general appearance, temperature, heart rate, respiratory rate, capillary refill time (CRT), and fluid status if the child is seen face-to-face. 
    • Measure the child's blood pressure if the heart rate or CRT are abnormal, if appropriate equipment is available. 
  • Ask about:
    • The height and duration of fever, and method of temperature measurement. Reported parental perception of fever should be accepted as a valid indicator of fever.
      • Be aware of the possibility of Kawasaki disease in children with fever that has lasted 5 days or longer. 
      • Ask parents or carers about the presence of features of Kawasaki disease since the onset of fever, because they may have resolved by the time of assessment. Be aware that children under 1 year may present with fewer clinical features of Kawasaki disease in addition to fever, but may be at higher risk of coronary artery abnormalities than older children.
    • Any associated signs or symptoms suggesting an underlying cause of fever (for example, pain, nausea, cough, breathlessness, itch, rash, swelling, confusion). 
    • Any perinatal complications such as maternal fever and/or premature delivery. 
      • Perinatal complications are risk factors for serious bacterial infection in neonates and infants aged up to 3 months. 
    • Any significant medical conditions (such as known immunosuppression or immunodeficiency). 
      • Sepsis or other serious bacterial infection in children with immunodeficiency is associated with an increased risk of complications and significant morbidity or mortality. 
    • Any recent antipyretic drug and/or antibiotic use.
      • Recent antipyretic use may result in a febrile child presenting with a normal or lower temperature when assessed. 
      • Children who have recently taken a course of antibiotics may have an incompletely treated bacterial infection and may not present with typical clinical features.
    • Current medication, immunization history and immunization status. See the CKS topic on Immunizations - childhood for more information.
    • Any recent foreign travel, including to areas with a high risk of endemic infectious disease such as malaria, or contact with a person from a disease-endemic area. See the CKS topic on Malaria for more information.
    • Any recent contact with people with serious infectious diseases. 
  • To measure body temperature in children aged: 
    • Less than 4 weeks, use an electronic thermometer in the axilla. 
    • 4 weeks to 5 years, use either an electronic thermometer or a chemical dot thermometer in the axilla, or an infra-red tympanic thermometer.
  • Do not routinely use the oral and rectal routes to measure body temperature in children aged 5 years or under. 
  • Do not use a forehead chemical thermometer. 

The NICE traffic light system

Table 1. The NICE traffic light system for identifying the risk of serious illness in children. Note: an infant or child will fall into the amber or red risk category if they have any of the relevant clinical features.

 

Green (low risk)

Amber (intermediate risk)

Red (high risk)

Colour (of skin, lips or tongue)Normal colour.

Pallor reported by parent or carer.

Pale, mottled, ashen, or blue.
Activity

Responds normally to social cues.

Content or smiles.

Stays awake or awakens quickly.

Strong normal cry or not crying.

Does not respond normally to social cues.

No smile.

Wakes only with prolonged stimulation.

Decreased activity.

No response to social cues.

Appears ill to a healthcare professional.

Does not wake, or if roused does not stay awake.

Weak, high-pitched, or continuous crying.

Respiratory—

Nasal flaring.

Tachypnoea:

Aged 6–12 months RR* > 50 breaths/minute.

Aged over 12 months RR* > 40 breaths/minute.

Oxygen saturation ≤ 95% in air.

Crackles on chest auscultation.

Grunting.

Tachypnoea: RR* >60 breaths/minute or more.

Moderate or severe chest indrawing.

Circulation and hydration 

Normal skin and eyes.

Moist mucous membranes.

Tachycardia: 

Aged under 12 months, >160 beats/minute.

Aged 12–24 months, >150 beats/minute.

Aged 2–5 years, >140 beats/minute.

Poor feeding in infants.

Dry mucous membranes.

Capillary refill time of 3 seconds or more.

Reduced urine output (in infants ask about wet nappies).

 

Reduced skin turgor.
OtherNone of the amber or red symptoms or signs.

 

Temperature ≥ 39°C in children aged 3–6 months.

 

Temperature ≥ 38°C in infants aged under 3 months.

Fever for 5 days or more.

Rigors.

Swelling of a limb or joint.

Non-weight bearing limb or not using an extremity.

Non-blanching rash†.

Bulging fontanelle†.

Neck stiffness†.

Focal neurological signs†.

Focal seizures.

Status epilepticus‡.

*RR: respiratory rate.

†: signs of meningeal irritation may be subtle or absent in children less than 12–24 months of age [Waruiru and Appleton, 2004; Leung, 2018].

‡: traditionally defined as a seizure that lasts for 30 minutes or longer, or a series of seizures without full recovery in between that last for 30 minutes or longer [ILAE, 1993].

NICE notes that some vaccinations may induce fever in children younger than 3 months.

Data from: [NICE, 2021]

 

Specific illnesses

Underlying illnesses to consider in children with fever include: 

  • Meningococcal disease — consider this in any child with fever and a non-blanching rash, particularly if any of the following features are present:
    • An ill-looking child.
    • Lesions larger than 2 mm in diameter (purpura).
    • A capillary refill time of 3 seconds or longer.
    • Neck stiffness.
  • For more information, see the CKS topic on Meningitis - bacterial meningitis and meningococcal disease.
  • Bacterial meningitis — consider in a child with fever and any of the following features:
    • Neck stiffness.
    • Bulging fontanelle.
    • Decreased level of consciousness.
    • Convulsive status epilepticus.
  • For more information, see the CKS topic on Meningitis - bacterial meningitis and meningococcal disease.
  • Herpes simplex encephalitis — consider herpes simplex encephalitis in children with fever and any of the following features:
    • Focal neurological signs.
    • Focal seizures.
    • Decreased level of consciousness.
  • Pneumonia — consider pneumonia in children with fever and any of the following signs:
    • Tachypnoea (respiratory rate greater than 60 breaths per minute, age 0 to 5 months; greater than 50 breaths per minute, age 6 to 12 months; greater than 40 breaths per minute, age older than 12 months).
    • Crackles in the chest.
    • Nasal flaring.
    • Chest indrawing.
    • Cyanosis.
    • Oxygen saturation of 95% or less when breathing air.
  • For more information, see the CKS topic on Cough - acute with chest signs in children.
  • Urinary tract infection — consider urinary tract infection in a baby or child under 5 with fever. For more information, see the CKS topic on Urinary tract infection - children.
  • Septic arthritis or osteomyelitis — consider septic arthritis or osteomyelitis in children with fever and any of the following signs:
    • Swelling of a limb or joint.
    • Not using an extremity.
    • Non-weight bearing.
  • Kawasaki disease — be aware of the possibility of Kawasaki disease in children with fever that has lasted 5 days or longer. Additional features of Kawasaki disease may include:
    • Bilateral conjunctival injection without exudate.
    • Erythema and cracking of lips, strawberry tongue, or erythema of oral and pharyngeal mucosa.
    • Oedema and erythema in the hands and feet.
    • Polymorphous rash.
    • Cervical lymphadenopathy. 

[NICE, 2021]

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guidelines Fever in under 5s: assessment and initial management [NICE, 2021] and Urinary tract infection in under 16s: diagnosis and management [NICE, 2022b], a US emergency medicine policy document Clinical policy for well-appearing infants and children younger than 2 years of age presenting to the emergency department with fever [Mace, 2016], the Resuscitation Council (UK) guideline Paediatric basic life support [Resuscitation Council (UK), 2021, Paediatric basic life support guidelines], the BMJ Best Practice guide Assessment of fever in children [BMJ, 2023] and expert opinion in a review Risk stratification and management of the febrile young child [Ishimine, 2013].

NICE traffic light system
  • NICE recommends using the traffic light system to assess and predict a child's risk of serious illness and the need for further investigation and/or monitoring. This recommendation is based on evidence-based reviews, clinical features in the Yale Observation Scale (a pre-existing scoring system), and the clinical experience of the NICE guideline development group [NICE, 2021].
    • NICE assessed multiple heterogeneous studies of variable quality which used different methodologies, temperature cut-offs for study inclusion, study populations, clinical settings, and outcomes. As a result, the data could not be pooled, and it was difficult for the guideline development group to compare evidence from multiple studies for a particular symptom or sign.
    • It identified two scoring systems, the Yale Observational Scale and the Young Infant Observation Score, however, neither scale was considered sensitive for the detection of serious bacterial infection. It concluded that the Yale Observation Scale was good at excluding serious illness but was less good at identifying serious illness, and was most useful when combined with a clinical history and examination. Although it was designed for use with children aged under 3 years, the GDG agreed it was reasonable to extrapolate the signs and symptoms to children aged up to 5 years.
    • NICE conducted an initial systematic review of the relationship between the height of fever and the risk of serious illness, and found the predictive value of a high temperature was poor in general, however, a higher predictive value was noted in children aged under 6 months.
  • An Australian retrospective analysis of the same study data found the NICE traffic light system had a test sensitivity of 85.5% and specificity of 28.5% for the detection of any serious bacterial infection (specifically urinary tract infection, pneumonia, and bacteraemia). In particular, it failed to detect 13.8% of serious infections (children classified in the green zone), particularly urinary tract infections. It found that adding urine analysis to the scoring system significantly improved the traffic light system test performance and sensitivity [De, 2013].
    • CKS notes that NICE recommends considering urine analysis on all children with fever with no apparent focus of infection.
  • A European study of the predictive value of the red features of the NICE traffic light system in identifying serious infection in children presenting with acute illness in various settings in primary care, emergency and paediatric departments (n = 6260), found that the presence of three or more red features improved the predictive value of serious infection, however, the results were not consistent in multiple settings [Kerkhof, 2014].
  • A recent retrospective cohort study which analysed data from the Diagnosis of Urinary Tract infection in Young children (DUTY) study (which evaluated the presenting signs and symptoms of urinary tract infections), mapped clinical features at the time of GP presentation to equivalent variables in the traffic light system, categorised them into one of the 3 categories (green, amber, or red) and also identified hospital admissions for this cohort [Clark, 2022].
    • Of the 6703 acutely unwell children, 31.6% were classified as red, 62.7% as amber, and 5.7% as green.
    • Of the 75.1% of children (5032) who were febrile at presentation, 2.4% were admitted to hospital within 7 days of presentation to GP practice, and 0.3% were diagnosed with a serious illness. 
    • The traffic light tool had a sensitivity of 58.8% and specificity of 68.5% for the identification of children admitted to hospital with a serious illness, when comparing red with amber and green categories. Changing the threshold to include red and amber categories combined, compared with green, improved the sensitivity to 100% but worsened specificity to 5.7%.
    • While there were limitations to the study, the authors concluded that the NICE traffic light system is not able to accurately detect or exclude serious illness in acutely unwell children presenting to GP practice. If the red category had been used as a positive threshold, around one-third of children in the study would have been urgently referred to hospital, and potentially 41.2% of children with a serious illness in the amber category would have been missed. 

Scenario: Feverish children - management

From birth to 5 years.

How should I manage an infant or child with fever?

  • If there is any compromise of the airway, breathing, circulation, or consciousness level, telephone 999 to arrange emergency ambulance transfer to Accident and Emergency.
  • If there are red features suggesting a serious or life-threatening cause of febrile illness, arrange emergency ambulance transfer to Accident and Emergency. These include:
  • If there are other non life-threatening red features, arrange an urgent (within 2 hours) face-to-face assessment if the infant or child was initially assessed by telephone, to help guide whether urgent hospital admission is needed. 
  • If there are amber features (but no red features), arrange a face-to-face assessment if the infant or child was initially assessed by telephone, the urgency depending on clinical judgement, to help guide whether hospital admission is needed. 
    • Arrange immediate referral to a paediatric specialist for infants aged under 3 months with a suspected urinary tract infection (UTI) and no alternative focus of infection, to obtain a reliable urine specimen and initiate treatment. See the CKS topic on Urinary tract infection - children for more information. 
    • Consider arranging hospital admission if:
      • The parent or carer's concern for their child's current illness has caused them to seek healthcare advice repeatedly.
      • The feverish illness has no obvious underlying cause, and the infant or child is unwell for longer than expected for a self-limiting illness. 
      • The family has experienced a previous serious illness or death due to feverish illness which has increased their anxiety levels.
    • If the child can be managed at home, provide the parents/carers with one or more of the following safety nets, depending on clinical judgement: 
      • Provide verbal and/or written information on warning signs and symptoms and how further healthcare advice can be accessed. 
      • Arrange a follow-up appointment in primary care for review.
      • Liaise with other healthcare professionals, including out-of-hours providers, to ensure direct access for the child if further assessment is required.
  • If there are green features (but no amber/red features), the child can usually be managed at home. 
  • If the child can be managed at home:
    • Assess for and manage any underlying cause of fever, if appropriate. 
      • Consider urine dipstick analysis and urine microscopy and culture if there is unexplained fever and no apparent focus of infection to exclude a UTI. See the CKS topic on Urinary tract infection - children for more information. 
    • Advise on the use of paracetamol or ibuprofen to reduce fever if the child is uncomfortable or distressed, and on measures to prevent dehydration. See the section on  Antipyretic drug dosage regimens. Also advise:
      • Switching to ibuprofen if paracetamol is ineffective, and vice versa, and alternating ibuprofen and paracetamol treatment if monotherapy is ineffective. 
      • That both drugs should not be taken simultaneously and a treatment diary (to record the drug and the time it was given) may help to avoid medication errors.
      • That routine administration of prophylactic antipyretic drugs does not prevent recurrent febrile seizures. See the CKS topic on Febrile seizure for more information.
      • That they should not rely on a decrease (or lack of decrease) in the child's temperature after 1–2 hours following the use of antipyretic therapy, to differentiate between serious and non-serious illness. 
    • Provide advice on sources of information and support, such as: 
    • Provide the parents/carers with safety netting advice on warning symptoms and signs and when medical review is needed. 
  • Advise on other measures to self-manage fever and prevent dehydration. See the section on self-care advice for more information. 

Antipyretic drug dosage regimes

Paracetamol

  • For children aged:
    • 1 to 2 months: 30–60 mg every 8 hours as required, maximum daily dose to be given in divided doses; maximum 60 mg/kg per day (off-label indication).
    • 3 months to 5 years, see the section on paracetamol doses in the CKS topic on Analgesia - mild-to-moderate pain.

Ibuprofen

  • For children aged: 
    • 1 to 2 months: 5 mg/kg 3–4 times a day (off-label indication under 3 months of age or body weight less than 5 kg).
    • 3 to 5 months: 50 mg three times a day.
    • 6 to 11 months: 50 mg three to four times a day.
    • 1 to 3 years: 100 mg three times a day.  
    • 4 to 5 years: 150 mg three times a day. 
  • Note: for children aged 3 months to 5 years the maximum daily dose is 30 mg/kg per day which should be given in 3–4 divided doses.

[BNFC, 2023]

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guidelines Fever in under 5s: assessment and initial management [NICE, 2021], and Urinary tract infection in under 16s: diagnosis and management [NICE, 2022b], and what CKS considers good medical practice.  

Antipyretic treatment 
  • The recommendation to consider switching antipyretic treatment is based on the expert opinion of the NICE guideline development group, which found evidence that both ibuprofen and paracetamol reduce fever and improve some aspects of quality of life [NICE, 2021]. This approach is also pragmatic, based on what CKS considers to be good clinical practice if monotherapy with one antipyretic agent has not reduced a child's distress or discomfort.
    • A recent systematic review and meta-analysis which compared the antipyretic, analgesic and safety profiles of paracetamol with ibuprofen for short-term fever in children aged under 2 years found moderate quality evidence that ibuprofen was associated with reduced temperature at less than 4 hours (4 studies, n = 435) and 4 to 24 hours (5 studies n = 879), and less pain at 4 to 24 hours (2 studies n = 535) compared to paracetamol. However, the superiority of ibuprofen as an antipyretic did not continue beyond 24 hours [Tan, 2020].    
  • The recommendation to consider alternating ibuprofen and paracetamol is based on limited evidence in the NICE guideline which showed a greater improvement in quality of life and temperature reduction outcomes when these agents were alternated compared with either treatment alone. The guideline development group considered alternating drugs to be a reasonable option if monotherapy has been unsuccessful, but advised that this should only be used while the child appears distressed [NICE, 2021].
  • A Cochrane systematic review that assessed six randomized controlled trials (RCTs, n = 915) to examine the effects and adverse effects of alternating or combined paracetamol and ibuprofen regimens compared with monotherapy in the management of febrile children found [Wong, 2013]:
    • Moderate-quality evidence that compared with a single antipyretic alone, giving combined paracetamol and ibuprofen may result in a lower mean temperature one hour after treatment.
    • The difference in temperature reduction was very small (0.27°C at one hour) so unlikely to be of clinical significance. If no further antipyretics are given, combined treatment probably also results in a lower mean temperature at 4 hours, and in fewer children remaining or becoming febrile for at least 4 hours after treatment.
    • Low-quality evidence that alternating treatment may result in a lower mean temperature one hour after the second dose and may also result in fewer children remaining or becoming febrile for up to three hours after it is given. In addition, one trial assessing child discomfort found mean scores were lower with alternating therapy, despite fewer doses of antipyretic being given overall.
    • That in one small trial which compared alternating therapy with combined therapy there was very low-quality evidence of no statistically significant differences in mean temperature or the number of febrile children at one, four or six hours between the different regimens.
    • Overall, there was some evidence that both alternating and combined antipyretic therapy may be more effective at reducing temperatures than monotherapy alone, but there was insufficient evidence to determine which of the two methods was more beneficial.
  • The NICE guideline advises that paracetamol and ibuprofen should not be taken simultaneously [NICE, 2021].
    • Evidence showed little difference between paracetamol and ibuprofen given alone or simultaneously to reduce temperature. The guideline development group recognised that some of the evidence showed a small benefit in reducing temperature when both drugs were given together compared with paracetamol monotherapy, but no evidence of a reduction in distress or discomfort, which was the primary outcome. Each antipyretic drug is known to be effective as a single agent, and the potential for confusion and drug administration errors is increased by using more than one drug.
  • The recommendation to use ibuprofen with caution if a child is dehydrated is based on the monograph in the British National Formulary (BNF) for Children [BNFC, 2023].
  • The recommendation not to use prophylactic antipyretic drugs to prevent febrile seizures is based on the NICE guideline [NICE, 2021] and a Cochrane review of 32 randomized trials (n = 4431) which found there was insufficient evidence to support the use of antipyretic drugs prophylactically to treat children with febrile seizures [Offringa, 2021].   

What self-care advice should I give?

  • Provide parents/carers with advice on sources of information and support, such as:
  • Advise parents/carers to:
    • Look for signs of dehydration including poor urine output, dry mouth, sunken anterior fontanelle (usually closed by 18 months), absence of tears, sunken eyes, and ill appearance. 
    • Offer regular fluids and encourage a higher fluid intake if signs of dehydration develop. 
      • If the infant is breastfeeding, advise continuing this as normal.
    • Dress the child appropriately for the surrounding environment by not underdressing or over-wrapping, to prevent overcooling or overheating. 
    • Avoid using tepid sponging (using cool water) to lower the child's temperature. 
    • Check the child regularly, including during the night (the frequency depending on the clinical situation). 
    • Keep the child away from nursery or school until they are recovered, depending on the underlying cause of fever, and notify nursery or school about the illness. See the Public Health England (PHE) guidance Health protection in schools and other childcare facilities for more information.
  • Provide parents/carers with verbal and written safety-netting advice on warning symptoms and signs of when and how urgent medical review should be arranged:
    • The child develops a non-blanching rash or other signs of central nervous system infection. See the CKS topic on Meningitis - bacterial meningitis and meningococcal disease for more information.
    • The child has a seizure. See the CKS topic on Febrile seizure for more information. 
    • The child is becoming dehydrated and self-management measures are not helping. 
    • The fever lasts longer than 5 days (may indicate Kawasaki disease or other serious illness if there are associated symptoms and signs). 
    • The child is becoming more unwell. 
    • They are distressed or concerned that they are unable to look after the infant or child at home. 

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guidelines Fever in under 5s: assessment and initial management [NICE, 2021], and the UK Health Security Agency (UKHSA) publication Health protection in children and young people settings, including education [UKHSA, 2023].

Supporting evidence

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guideline Fever in under 5s: assessment and initial management [NICE, 2021]. The rationale for individual recommendations is outlined in the relevant basis for recommendation sections of the topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search for was conducted for guidelines and systematic reviews on risk assessment of feverish children in primary care. 

Search dates

November 2018 - June 2023

Key search terms

The terms listed below are the core search terms that were used for EBSCO MEDLINE (searched 12th November 2018). These terms were combined with search filters for systematic reviews and guidelines in EBSCO MEDLINE. The strategy was adapted for The Cochrane Library databases.

S9 S3 AND S8
S8 S4 OR S5 OR S6 OR S7
S7 AB ( (infant* or infancy or baby or babies or child* or pediatric* or paediatric* or toddler*) ) OR TI ( (infant* or infancy or baby or babies or child* or pediatric* or paediatric* or toddler*) ) 
S6 (MH "Pediatrics+") 
S5 (MH "Infant+")
S4 (MH "Child+") 
S3 S1 OR S2
S2 AB ( (fever* or febrile or pyrexia or hyperthermi* or hyperpyrexi*) ) OR TI ( (fever* or febrile or pyrexia or hyperthermi* or hyperpyrexi*) ) 
S1 (MH "Fever+") 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • BMJ (2023) Assessment of fever in children. BMJ Best Practice. BMJ Publishing. https://bestpractice.bmj.com
  • BNFC (2023) British National Formulary for Children. National Institute for Health and Care Excellence. https://bnfc.nice.org.uk
  • Clark, A., Cannings-John, R., Blyth, M. et al. (2022) Accuracy of the NICE traffic light system in children presenting to general practice: a retrospective cohort study. The British Journal of General Practice 72(719), e398-e404. [Abstract]
  • De, S., Williams, G., Hayen, A. et al. (2013) Accuracy of the 'traffic light' clinical decision rule for serious bacterial infections in young children with fever: a retrospective cohort study. British Medical Journal 346, 1-16. [Free Full-text]
  • International League Against Epilepsy (1993) Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia 34(4), 592-596. [Abstract]
  • Ishimine, P. (2013) Risk stratification and management of the febrile young child. Emerg Med Clin N Am 31(3), 601-626. [Abstract]
  • Kerkhof, E., Lakhanpaul, M., Ray, S. et al. (2014) The predictive value of the NICE red traffic lights in acutely ill children. PLoS One 9(3), 1-9. [Abstract]
  • Leung, A.K.C., Hon, K.L. and Leung, T.N.H. (2018) Febrile seizures: an overview. Drugs in Context 7, 1-12. [Abstract]
  • Mace, S.E., Gemme, S.R., Valente, J.H. et al. (2016) Clinical policy for well-appearing infants and children younger than 2 years presenting to the emergency department with fever. Ann Emerg Med 67(5), 625-639. [Abstract]
  • NICE (2021) Fever in under 5s: assessment and initial management. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2022a) Fever in under 5s (QS64). National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • NICE (2022b) Urinary tract infection in under 16s: diagnosis and management. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • Offringa, M., Newton, R., Nevitt, S.J. and Vraka, K. (2021) Prophylactic drug management for febrile seizures in children (Cochrane Review). Issue 6. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Resuscitation Council (UK) (2021) Paediatric basic life support guidelines. Resuscitation Council (UK). https://www.resus.org.uk [Free Full-text]
  • Tan, E., Braithwaite, I., McKinlay, C.J.D. et al. (2020) Comparison of acetaminophen (paracetamol) with ibuprofen for treatment of fever or pain in children younger than 2 years. A systematic review and meta-analysis. JAMA Network Open. https://pubmed.ncbi.nlm.nih.gov/33125495
  • UKHSA (2023) Health protection in children and young people settings, including education. UK Health Security Agency. http://www.gov.uk [Free Full-text]
  • Waruiru, C. and Appleton, R. (2004) Febrile seizures: an update. Archives of Disease in Childhood 89(8), 751-756. [Abstract]
  • Wong, T., Stang, A.S., Ganshorn, H. et al. (2013) (Cochrane Review). Issue 10. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
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