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
Signs or symptoms |
Possible aetiology |
---|---|
Meningeal signs, seizures |
Meningitis/meningoencephalitis/severe malaria |
Abdominal pain or peritoneal signs |
Appendicitis/peritonitis/typhoid fever |
Diarrhoea, vomiting |
Gastroenteritis/typhoid fever |
Jaundice, enlarged liver |
Viral hepatitis |
Cough |
Pneumonia/measles/tuberculosis if persistent |
Ear pain, red tympanic membrane |
Otitis media |
Sore throat, enlarged lymph nodes |
Streptococcal pharyngitis, diphtheria |
Dysuria, urinary frequency, back pain |
Urinary tract infection |
Red, warm, painful skin |
Erysipelas, cellulitis, abscess |
Limp, difficulty walking |
Osteomyelitis/septic arthritis |
Rash |
Measles/dengue/haemorrhagic fever/chikungunya |
Bleeding (petechiae, epistaxis, etc.) |
Dengue/haemorrhagic fever |
Joint pain |
Rheumatic fever/chikungunya/dengue |
- 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.
- (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.