Fever


– Fever is defined as a rectal temperature higher than or equal to 38 °C.

– In practice, axillary route is easier, more accepted and more hygienic. An axillary temperature higher than or equal to 37.5 °C is considered a fever. In a child under 3 years, if the axillary temperature is higher than or equal to 37.5 °C, take the temperature rectally if possible.
Record the temperature as measured and if taken using the rectal or axillary route. Do not add 0.5 °C to the axillary temperature. Use an electronic thermometer.

– Fever is frequently due to infection. In a febrile patient, first look for signs of serious illness then, try to establish a diagnosis. There is an increased risk of severe bacterial infection1  if the rectal temperature is ≥ 38 °C in children 0 to 2 months; ≥ 38.5 °C in children 2 months to 3 years; ≥ 39 °C in children older than 3 years and adults.

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 appearance2 ; 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 appearing2  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 rectal temperature higher than or equal to 38 °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 appearance2 , 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 rectal temperature higher than or equal to 38.5 °C without a focus:
• Urine dipstick;
• White blood cell count (WBC) if available;
• LP if meningeal signs.

– Children over 3 years and adults with an axillary or rectal temperature higher than or equal to 39 °C:
According to clinical presentation.

Treatment

– Treat 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 appearing2  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.



Footnotes
Ref Notes
1

Malnourished or immune-depressed children may have a bacterial infection without a fever.

2 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 b c d ]