About this course:
This course reviews the assessment, triage, and management of a pediatric patient with a fever.
An Overview of Pediatric Fever for RNs and LPNs
This course reviews the assessment, triage, and management of a pediatric patient with a fever.
At the end of this module, learners should be able to:
- define pediatric fever and its most common causes
- utilize appropriate screenings and exam components when evaluating a child with a fever
- incorporate appropriate treatment for pediatric fever
- identify when pediatric fever is an emergency
Body temperature can vary based on the time of day and the site of measurement, by as much as 0.6°Celsius (°C or 1.0°Fahrenheit; Bush, 2022). The standard "normal" body temperature has been defined as 37°C (98.6°F) since the extensive research conducted by Dr. Wunderlich in the 1860s (McElroy & McElroy, 2020). Analysis of this point is ongoing, but for this course, it remains adequate. A fever is defined the same for school-aged children (4+) and adults and is at least one standard deviation higher than the average body temperature, i.e., over 37.8°C or 100.0°F if measured orally. A fever of concern is defined as greater than 39.5°C (103.1°F). In infants between 3 and 36 months old, a fever is defined as a rectal temperature above 38.0°C (100.4°F). A fever of concern in this age group is defined as greater than 39.0°C (102.2°F) if taken rectally. A newborn’s normal body temperature is between 37.5°C and 38°C, but a fever of concern is still defined as a rectal temperature over 38°C (100.4°F; Ward, 2022). This may also be further broken down by the time of day, as a fever is defined as anything above 37.2°C early in the morning and above 37.8°C any other time of day if measured orally. Rectal and tympanic measurements should be adjusted by 0.6°C, with a fever defined as above 38.4°C if taken during the day. The broad and general physiology of fever is explained as resetting the hypothalamic set point. This triggers vasoconstriction and shunts blood from the periphery to the core, resulting in heat conservation and, thus, the elevation of body temperature (Bush, 2022).
Pathophysiology and Etiology
Please note that hyperthermia in the setting of heat stroke or heat illnesses will not be discussed here and are managed differently, as these occur in the environment of a normal hypothalamic set-point. As a fever is considered a symptom of disease and not a disease unto itself, the pathophysiology of fever is manifold. Most fevers are caused by an exogenous pyrogen (i.e., substances that induce fever), such as bacteria or viruses. Fevers can also be caused by heat, some medications (e.g., levothyroxine, interferons, some inhaled anesthetics or antipsychotics, amphetamines, cocaine), immunizations, cancers, and autoimmune processes (Bush, 2022). First, a peripheral release of interleukin-1 (IL-1), tumor necrosis factor, and other cytokines by phagocytic cells in the blood or tissues trigger the anterior hypothalamus to synthesize prostaglandins such as PGE2. This increases the set point for overall body temperature and may also be responsible for the myalgias and arthralgias experienced during a fever. This temperature is maintained by an increased metabolic rate, increased muscle tone/activity, and limitation of heat loss through skin perfusion. Unless a fever is recurrent, the most common cause of fever in children is infection (Ward, 2022). Viral pathogens are the most common cause of infections in children, otitis media is the most common bacterial infection, and the most common cause of serious bacterial infections in children is a urinary tract infection (UTI). The most common bacterial infections in neonates are group B streptococcus (strep), Escherichia (E. coli), and Listeria monocytogenes (Joseph et al., 2018). While research demonstrates that there are potential protective and harmful effects of a fever, the actual protective effects of a fever in humans have not been confirmed. These conclusions were drawn from animal studies suggesting that a fever may help stall bacterial growth, but this finding has not been replicated in human studies. The initial cytokines released increase acute-phase proteins produced by the liver, reduce zinc and iron serum levels, provoke leukocytosis, and induce slow-wave sleep. Further, the familiar adage that a fever over 40°C (104°F) causes brain damage or is associated with worse outcomes has also not been demonstrated outside of animal studies. Most benefits of fever appear to dissipate above 40°C (104°F; Ward, 2022).
History, Exam Findings, and Tests
When a child presents with a fever, one of the first history questions should be immunization status. Children who are not immunized or not up to date on their immunizations are at much higher risk for bacteremia and sepsis. The duration and severity of the fever should also be noted. Fevers lasting longer than 7 days are known as fevers of unknown origin; these require a different approach than standard acute fevers and will be discussed separately below (Allen, 2022). Providers should also include questions about the patient’s recent activity level and tolerance, feeding and elimination patterns, and if the caregiver has witnessed any seizures. The presence and severity of lethargy; irritability; weak, high pitched, or continuous crying; decreased or increased urination with pain; or seizures have been correlated with intermediate to severe risk of serious illness (National Institute for Health and Care Excellence [NICE], 2021). In the neonate, the risk of maternally transmitted infection should also be considered; the history should be expanded to include a history of premature rupture of membranes, group B strep status, and history of genital herpes. It should also be determined if the patient has received antibiotics in the last 7 days, as the risk of invasive bacterial infection (IBI) is significantly increased in infants who have recently had antibiotics (Smitherman & Macias, 2023).
In patients over 36 months, evaluation of an initial fever should be symptom-focused, as most fevers in children of this age group are self-limiting and viral. The history should also focus on associated symptoms to narrow the differential diagnoses. Associated symptoms may include cough, rash, pain (including location), restriction of motion in any extremity, known exposures, and recent travel to endemic areas. In a phenotypically male patient, circumcision status should also be assessed, as UTIs are more prevalent in uncircumcised male patients under two years of age than in their circumcised counterparts. The presence of underlying conditions should also be assessed during the history. Diseases such as sickle cell disease, cystic fibrosis, structural abnormalities, and others may predispose patients to certain infections or place them at a higher risk of rarer infection etiologies. Fevers in children 3-36 months old that were previously healthy, are currently well appearing, and cannot be linked to a specific source are termed “fever without a source”. This definition applies up to the five-day mark and can occur in up to 40% of cases. As stated above, it is essential to remember that the localization of the infectious source may be difficult and warrants further study in this age group compared to the presence of a simple fever in an older child (Allen, 2022; Barbi, 2017; Palazzi, 2023). Further testing and management of fever without a source will be discussed below.
When examining a patient with a fever, the body temperature must be accurately measured to characterize the fever. Body temperature for outpatient clinical purposes in infants and very young children (£ 3) is generally measured rectally. Oral thermometers can be used in children able to cooperate (Ward, 2022). According to the American Academy of Pediatrics (AAP, 2020), rectal temperatures are more accurate, but caution should be exercised to
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Digital multiuse thermometer
A comprehensive physical exam should also be performed to determine possible sources of infection and accompanying symptoms. Vital signs should be assessed, noting any tachycardia or tachypnea. The nasal passages and oropharynx should be observed for lesions indicating herpes gingivostomatitis or Coxsackie virus. The patient should be evaluated for suprapubic or costovertebral angle (CVA) tenderness. A skin survey should identify and characterize rashes, lesions, cellulitis, petechiae, or other unexpected findings. A complete head-to-toe musculoskeletal exam focusing on infection, including the spine, is essential, as is a thorough scan for any lymphadenopathy or pain with palpation or passive range of motion (Allen, 2022; Oakes, 2017).
Infants 90 days or Less
Previously, the testing and hospitalization of children, especially children under 90 days old, were determined mainly by the severity of the fever. In the 1980s, infants younger than 90 days old who presented with a fever were hospitalized and underwent lumbar puncture (LP) and a full sepsis workup. Until recently, little consideration was given to the potential risks involved with such invasive testing in this age group, even when there was a low risk for sepsis (Joseph et al., 2018). Patients under 3 months old should be evaluated by a provider for any temperature over 38°C or 100.4°F (NICE, 2021; Smitherman & Macias, 2023). However, current guidelines suggest that risk stratification should be done carefully in infants with a fever, and the infant's appearance should be seriously considered, along with the temperature level. In infants 30 to 60 days old, risk stratification both in the UK and US recommend taking a urinalysis (UA), urine culture (UC), complete blood count (CBC), blood cultures, cerebrospinal fluid (CSF), and chest x-ray (CXR). A C-reactive protein (CRP) and procalcitonin (PCT) level should be drawn to determine if the infant is at high or low risk for IBI. If the child appears well, has a reliable caregiver, and the white blood cell count (WBC), CBC, UA, CSF, and CXR are negative, and they are considered low risk (PCT and CRP are within normal limits, or only one is mildly elevated), they may be discharged under the observation of a caregiver with a follow-up appointment within 24 hours. Further treatment should be initiated premised on the results of the blood cultures (Joseph et al., 2018; NICE, 2021). The AAP (2021) published a clinical practice guideline to help providers manage fever in infants under 90 days old. If febrile, they recommend that infants between 8 and 21 days old obtain a UA, blood culture, LP, and potentially inflammatory markers (IM). If at risk, herpes simplex virus (HSV) testing should also be considered. At 22 days, the UA and IM results should be obtained before the LP. If positive, the LP may be avoided, and the patient should be treated presumptively for UTI. If the IMs are elevated, UC and LP may be considered (Pantell et al., 2021).
Infants from 60 to 90 days old are now considered low risk for bacteremia and meningitis; therefore, their evaluation can be slightly more focused. It is still necessary to get a UA/UC, CBC, and blood cultures; however, a CXR is only recommended if the infant has tachypnea, tachycardia, wheezing, or a cough, and a lumbar puncture is only indicated if the infant appears toxic or is irritable. If these tests are negative and the patient’s PCT and CRP levels are within normal limits, they may also be discharged home with a caregiver and a follow-up in 24 hours. Empiric antibiotics and hospitalization are only indicated in high-risk infants, such as those with an elevated CRP and/ or PCT level (Joseph et al., 2018).
Various methods have been developed to standardize this stratification process for infants. The “Step by Step” method was validated by Gomez and colleagues (2016) based on infants who were 90 days old or younger across 11 pediatric emergency centers in Europe. This method places patients into the category of high risk, requiring hospitalization and empiric antibiotics if any of the following conditions are met:
- Is the child ill-appearing? The Pediatric Assessment Triangle may be useful to determine ill versus well-appearing, based on the following:
- Appearance: the patient's tone, interactiveness, consolability, look or gaze, and speech or cry
- Work of breathing: the degree to which the patient is working to oxygenate and ventilate, such as stridor, grunting, wheezing, abnormal positioning, retractions, or flaring of the nostrils on inspiration
- Circulation to the skin: the color and color pattern of the skin and mucous membranes, noting pallor, cyanosis, or mottling (Fernandez et al., 2017; Gomez et al., 2016)
- Is the patient 21 days old or less?
- Does the patient have leukocyturia (urine test positive for WBCs)?
- Is the patient's PCT above or equal to 0.5 ng/mL?
If the answer to any of the above questions is “yes”, then the child should be considered high risk, and appropriate management steps should be taken immediately. If all of the above questions are negative, but the child has a CRP greater than 20 mg/L or an absolute neutrophil count (ANC) above 10,000 cells/mm3, they can be considered intermediate risk. Otherwise, if the answers to all of the above are “no”, then the child can be categorized as low risk with relatively little chance of IBI underlying the fever (Gomez et al., 2016).
Older Infants and Toddlers
In children 3 to 36 months old, evaluation becomes less stratified, as even a severely elevated temperature in children of this age range may not indicate a severe infection. Children between 3 and 36 months of age with a fever over 39°C (102.2°F) should be evaluated by a provider and managed based on their appearance. In fully immunized children, the incidence of bacteremia is less than 1%; despite this statistic, a toxic-appearing child, or a child with unstable vital signs, should be managed as if they have sepsis. In well-appearing children, immunization status is the determining factor for the intensity of the workup required. CBC with differential and serum PCT levels should be drawn in a febrile child that is unimmunized or partially immunized without an obvious source of infection. UA and/or culture should also be done. If urine testing indicates a probable UTI, empiric antibiotics should be initiated. Patients in this demographic group with an elevated PCT level or WBC should have blood cultures drawn. A CXR should also be performed. If infiltrates are present on CXR, blood cultures and empiric antibiotics are recommended (Allen, 2022).
Fully immunized children between 3 and 36 months typically do not require these tests due to the lower risk of occult bacteremia. However, they are still at risk for UTI. All children should have a UA/UC done if they have a prolonged (> 48 hours) fever, symptoms of a UTI, have had a recent UTI, have genital abnormalities, are uncircumcised males under the age of 12 months (or circumcised but under 6 months), or are females under the age of 24 months. If not toilet trained, toddlers may require catheterization to obtain a sample (Allen, 2022). A child may be categorized as low-risk if they have average or expected coloring in their skin, lips, and tongue, are occasionally smiling, are reacting as expected to others socially, are awake/alert, are either not crying or crying forcefully, and appear well-hydrated with moist mucous membranes, a brisk capillary refill, and good skin turgor (NICE, 2021).
A provider should also evaluate patients older than 36 months with a fever and focal symptoms or who do not appear otherwise well (Allen, 2022). Lab values and tests should be ordered in these children based on exam findings and correlated symptoms (Ward, 2022). Systemic inflammatory response syndrome (SIRS) and sepsis should be considered when a child over 36 months has a fever over 38.5°C (101.3°F) with tachycardia, tachypnea, or leukocytosis. Of note, SIRS and sepsis may also be considered in the absence of fever if the child has any combination of tachycardia, tachypnea, or leukocytosis (Pomerantz & Weiss, 2022). A non-blanching rash with larger lesions ( > 2mm) and/or neck pain or stiffness should raise suspicion for meningitis. Other signs may include prolonged capillary refill, bulging fontanelle, decreased level of consciousness, a high-pitched cry, an overall ill appearance, or seizure activity (NICE, 2021).
Treatment of fever has not been shown to decrease adverse events or worsen the illness in otherwise healthy children. Treating fever in an otherwise healthy child should be based on the caregiver and child’s wishes to reduce discomfort. A downside of treating fever with antipyretic agents is that it affects the provider's ability to assess the temperature duration and may delay the identification of the underlying etiology. The ultimate goal of fever treatment in these patients is simply to increase the child’s comfort level and potentially prevent fluid loss. Therefore, the initial therapy for fever should consist of rest and additional oral fluid intake. The treatment of fever is recommended if over 40°C (104°F) or in children who have underlying conditions that increase metabolism and limit their ability to tolerate the increased metabolic demands, have had significant head trauma, are post-cardiac arrest, are in shock, or have fluid or electrolyte alterations. If the child is uncomfortable or exhibits decreased activity level or intake, the fever may be treated with an antipyretic agent, such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin; Ward, 2022). Ibuprofen (Advil, Motrin) is slightly more effective as an antipyretic in children and may reduce pain better in children under 2 (Perrott et al., 2004; Tony et al., 2020). Many providers recommend acetaminophen (Tylenol) as the first-line antipyretic for children due to its longer and more researched safety history (Ward, 2022).
Antibiotics and Other Treatment Measures
Empiric antibiotics are indicated for fever alone in children under 60 days old who are determined to be at high risk based on the criteria discussed above. In infants 8 to 21 days old, recommended empiric antibiotics include ampicillin (Unasyn) and either ceftazidime (Fortaz) or gentamycin (Garamycin). If bacterial meningitis is suspected, the ampicillin (Unasyn) dose should be increased and the ceftazidime (Fortaz) should be used (not gentamycin; Pantell et al., 2021).
In infants between 22 to 60 days old, ceftriaxone (Rocephin) is recommended in those with a suspected UTI or no identified focus. In infants able to receive oral antibiotics (over 28 days), cephalexin (Keflex) or cefixime (Suprax). If meningitis is suspected in an infant between 22 to 28 days, the regimen described above (for under 21 days) can be followed. In infants between 28 and 60 days with a fever that is suspected to be related to meningitis, the empirical antibiotics recommended include vancomycin (Vancocin) ceftriaxone (Rocephin) or ceftazidime (Fortaz; Pantell et al., 2021). Infants between 60 and 90 days should be hospitalized for additional workup as described previously and given empiric antibiotics if risk factors for IBI are present. Infants can often be managed at home with close observation if previously healthy and without any risk factors. If UTI is suspected based on UA, the oral antibiotic should cover E. coli and consider local resistance patterns (Smitherman & Macias, 2023).
Regardless of vaccination status, all young children (3 to 36 months) should receive empiric antibiotics with coverage for E. coli based on local resistance patterns if their urine testing indicates probable UTI. In young children (3 to 36 months) that are not vaccinated (or incompletely vaccinated) with infiltrates present on CXR, empiric antibiotics are recommended initially. This age child may be discharged if well-appearing with good oral intake and solid family support. Otherwise, they should be admitted for care. In young children (3 to 36 months) that are fully vaccinated without risk factors or abnormal UA results, it is most likely that a virus would cause a fever and empiric antibiotics are not advised (Allen, 2022).
Empiric antibiotics are not warranted in children over 36 months of age unless shock or sepsis is suspected. If SIRS or sepsis is suspected, children must first be fluid resuscitated and cultured (blood and UCs at least, but potentially including CSF culture per facility protocol). Further treatment of these children should be managed in a pediatric intensive care unit and is beyond the scope of this article (Pomerantz & Weiss, 2022). Initiation of antibiotic treatment not in the setting of sepsis or SIRS should be based on clinical findings. In these instances, empiric antibiotics are not warranted without an identified source of infection, as fever alone is not an indication for the prescription of antibiotics (NICE, 2021). For caregivers of children over 3 years old, extensive education should be provided that antibiotics are not indicated without an identified source of infection to help with understanding (Joseph et al., 2018; Ward, 2022)
Fever of Unknown Origin
A persistent fever over 38.3°C (101°F) that has been present for longer than 7 days with no identified source after the initial evaluation is called a fever of unknown origin (FUO). While infections are common, other potential causes include rheumatologic and neoplastic disorders, with leukemia and lymphoma cited as the top two contributing malignancies. It should also be noted that FUOs often resolve spontaneously without the causal etiology ever being identified. When evaluating a child with this type of fever, it is crucial to repeat an extensive history. FUOs are often common diseases presenting abnormally. The history should include how frequently the child’s temperature is being taken, how it is being measured, and any associated symptoms. This may be best collected via a fever diary. Possible exposures should be reviewed, including travel history, insect or animal bites or scratches, previous illnesses, sick contacts, medications, and recent laboratory tests. A comprehensive physical examination should be repeated. Labs should include CBC and peripheral smear, CXR, comprehensive metabolic panel, UA/UC, blood cultures, erythrocyte sedimentation rate, and CRP. Further testing and imaging should be determined by the history, physical exam, and accompanying symptoms. A comprehensive list of underlying etiologies for FUOs is beyond this course's scope. However, the provider should consider common neoplasms in children, Kawasaki disease, juvenile idiopathic arthritis, cat scratch fever, and autoimmune diseases. A gap of a few days without any fever may indicate two consecutive but separate viral infections. An additional option for testing a child with FUO is a viral polymerase chain reaction (PCR) panel, which can identify common viral pathogens such as adenovirus, influenza, and respiratory syncytial virus (RSV). Cytomegalovirus and Epstein-Barr virus may need to be ruled out. If the patient’s CBC indicates a high level of bands (immature WBCs), the provider may consider checking their lactate dehydrogenase, uric acid, and ferritin levels to rule out an oncologic process. A referral to a pediatric oncologist should be considered if the peripheral smear and laboratory values discussed above are abnormal or in the context of night sweats or weight loss. An antinuclear antibody, complement level, and a referral to a pediatric rheumatologist should be considered if a rheumatologic etiology is suspected. A trial of empiric antibiotics or anti-inflammatories should be avoided in these patients unless the evidence suggests juvenile arthritis or a life-threatening infection (e.g., typhoid, malaria, tuberculosis [TB]; Oakes, 2017; Palazzi, 2023).
Febrile seizures are fairly common; they can occur in pediatric patients and are associated with fever without other intracranial abnormalities or infections. Children with a genetic predisposition can be more susceptible to febrile seizures. Viruses, bacteria, or vaccines can be causative agents of febrile seizures. Febrile seizures can be classified as simple, complex, or symptomatic. Simple febrile seizures last less than 15 minutes, are generalized, and occur once within 24 hours with no focal component. Complex febrile seizures last longer than 15 minutes, have a focal component, and occur more than once in 24 hours. A symptomatic febrile seizure occurs due to a fever in a child with a preexisting neurological abnormality. Acute management of a febrile seizure involves maintaining a patent airway, ensuring effective breathing, administering oxygen therapy as needed, protecting from injury, placing the patient in a semi-prone position, and loosening their clothing. The fever should be treated as noted above according to the duration and severity. Rectal diazepam (Valium) can be given for any seizure lasting over 5 minutes in length; IV diazepam (Valium), lorazepam (Ativan), or phenobarbital (Luminal) is indicated for any seizure lasting longer than 15 minutes (Victorio, 2022).
As discussed in the introduction of this course, the current definition of fever has been in use since the 1860s; however, a 2018 study by Dr. Hausmann and associates suggests that the average human body temperature may be lower than our current understanding. His research indicates that the definition of a “fever” as that of a body temperature in the 99th percentile of normal body temperatures may be closer to 37.5°C (99.5°F) or higher (Hausmann et al., 2018). Further data analysis of other studies shows that humans’ average body temperature may be steadily declining since the time of Dr. Wunderlich (McElroy & McElroy, 2020). Despite the recent study by Dr. Hausmann receiving much attention in the press, it has not been replicated, and children were excluded from the data. For these reasons, it is too early to apply it to current standards of practice or to extrapolate that there is a need to change the current guidelines for treating or evaluating fever. Dr. Hausmann’s research suggests that using smartphones may be an efficient way to measure temperature in the future. However, until this study can be replicated in children, this is still far from an appropriate way to clinically measure an accurate temperature (Hausmann et al., 2018).
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McElroy, S., & McElroy, J. (2020). Sawbones: Body temperature [Audio Podcast]. https://maximumfun.org/episodes/sawbones/sawbones-body-temperature
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Pomerantz, W. J. & Weiss, S. L. (2022). Systemic inflammatory response syndrome (SIRS) and sepsis in children: Definitions, epidemiology, clinical manifestations, and diagnosis. UpToDate. Retrieved April 21, 2023, from https://www.uptodate.com/contents/systemic-inflammatory-response-syndrome-sirs-and-sepsis-in-children-definitions-epidemiology-clinical-manifestations-and-diagnosis
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Victorio, M. C. (2022). Febrile seizures. Merck Manual Professional Version. https://www.merckmanuals.com/professional/pediatrics/neurologic-disorders-in-children/febrile-seizures
Ward, M. A. (2022). Fever in infants and children: Pathophysiology and management. UpToDate. Retrieved April 21, 2023, from https://www.uptodate.com/contents/fever-in-infants-and-children-pathophysiology-and-management