Fever

Fever is defined as an axillary temperature higher than or equal to 37.5 °C.

Fever is frequently due to infection. In a febrile patient, first look for signs of serious illness then, try to establish a diagnosis.

Signs of severity

• Severe tachycardia, tachypnoea, respiratory distress, SpO₂ ≤ 90%.
• Shock, altered mental status, petechial or purpuric rash, meningeal signs, seizures, heart murmur, severe abdominal pain, dehydration, critically ill appearance a Citation a. Critically ill appearing child: weak grunting or crying, drowsiness, difficult to arrouse, does not smile, unconjugate or anxious gaze, pallor or cyanosis, general hypotonia. ; a bulging fontanel in young children.

Infectious causes of fever according to localizing symptoms

• In endemic area, always consider malaria.
• If the patient is ill appearing a Citation a. Critically ill appearing child: weak grunting or crying, drowsiness, difficult to arrouse, does not smile, unconjugate or anxious gaze, pallor or cyanosis, general hypotonia. and has a persistent fever, consider HIV infection and tuberculosis, according to clinical presentation.

Laboratory and other examinations

• Children less than 2 months with a temperature higher than or equal to 37.5 °C without a focus:
  • Urinary dipstick;
  • Lumbar puncture (LP) if child less than 1 month or if any of the following: meningeal signs, coma, seizures, critically ill appearance a Citation a. Critically ill appearing child: weak grunting or crying, drowsiness, difficult to arrouse, does not smile, unconjugate or anxious gaze, pallor or cyanosis, general hypotonia. , failure of prior antibiotic therapy, suspicion of staphylococcal infection;
  • Chest X-Ray (if available) in case of signs of respiratory disease.
• Children 2 months to 3 years with a temperature higher than or equal to 38 °C without a focus:
  • Urine dipstick;
  • White blood cell count (WBC) if available;
  • LP if meningeal signs.
• Children over 3 years and adults with a temperature higher than or equal to 39 °C:

According to clinical presentation.

Aetiological treatment

• Antibiotherapy according to the cause of fever.
• For patients with sickle cell disease, see Sickle cell disease, Chapter 12.
• If no source of infection is found, hospitalise and treat the following children with empiric antibiotics:
  • Children less than 1 month;
  • Children 1 month to 3 years with WBC ≥ 15000 or ≤ 5000 cells/mm³;
  • All critically ill appearing a Citation a. Critically ill appearing child: weak grunting or crying, drowsiness, difficult to arrouse, does not smile, unconjugate or anxious gaze, pallor or cyanosis, general hypotonia.  patients or those with signs of serious illness;

For antibiotic doses according to age, see Acute pneumonia, Chapter 2.

Symptomatic treatment

• Undress the patient. Do not wrap children in wet towels or cloths (not effective, increases discomfort, risk of hypothermia).
• Antipyretics may increase the patient’s comfort but they do not prevent febrile convulsions. Do not treat for more than 3 days with antipyretics.

paracetamol PO 
Children less than 1 month: 10 mg/kg 3 to 4 times daily (max. 40 mg/kg daily)
Children 1 month and over: 15 mg/kg 3 to 4 times daily (max. 60 mg/kg daily)
Adults: 1 g 3 to 4 times daily (max. 4 g daily)
or
ibuprofen PO
Children over 3 months and < 12 years: 5 to 10 mg/kg 3 to 4 times daily (max. 30 mg/kg daily)
Children 12 years and over and adults: 200 to 400 mg 3 to 4 times daily (max. 1200 mg daily)
or
acetylsalicylic acid (ASA) PO
Children over 16 years and adults: 500 mg to 1 g 3 to 4 times daily (max. 4 g daily)

Prevention of complications

• Encourage oral hydration. Continue frequent breastfeeding in infants.
• Look for signs of dehydration.
• Monitor urine output.

Notes:

• In pregnant or breast-feeding women use paracetamol only.
• In case of haemorrhagic fever and dengue: acetylsalicylic acid and ibuprofen are contraindicated; use paracetamol with caution in the presence of hepatic dysfunction.