Physicians have recognized fever the abnormal elevation of body temperature for centuries as a sign of disease. Furthermore, the problem of the febrile child is one of the most frequently encountered in clinical pediatrics, accounting for as many as 20 percent of pediatric emergency department visits. The problem of determining an appropriate clinical and laboratory evaluation of febrile children, however, remains a major challenge to the pediatrician and emergency room physician.

It is difficult to pinpoint the lowest temperature elevation that is definitely abnormal for all children under all circumstances. Some children normally have a rectal temperature as low as 36.2°C (97°F) or as high as 38° C (100.4°F). Children, like adults, also normally have diurnal variations in temperature with the peak usually occurring between 5:00 and 7:00 PM. Factors such as excessive clothing, physical activity, hot weather, digestion of food, and ovulation can all raise temperature in the absence of disease. Generally, a rectal temperature of 38°C (100.4°) or higher is considered as a fever.

Physicians have a role in educating parents about fever phobia. Fever seldom is harmful. It does cause an individual to feel uncomfortable. On the other hand fever does many positive things, such as interfering with viral replication and increasing leukocyte chemotaxis. Rarely an extreme fever (temperature greater than 41.1°C or 106°F) may pose a risk to a child in and of itself, and demand immediate management. Fever is a symptom (sign), not a diagnosis in and of itself. The main task facing the physician is to make a diagnosis and to treat the underlying disease causing the fever.

The evaluation and clinical decision-making process begins with a good history and complete physical examination. Include questions about compromised normal host defenses (sickle cell disease, asplenia, malignancy, or immunosuppression). The physical examination should focus on alertness, responsiveness to parents, examiner, and objects, irritability or lethargy, respiratory status, color, feeding activity, and age-related appropriate motor activity.

• Treat the underlying disease.

• Ensure the child is comfortable.

• Demystify the situation for parents (who think that the fever will cause brain damage and death).

• Unless the patient is experiencing heat stroke, there is absolutely no indication for giving a child an alcohol bath or tepid bath.

• Acetaminophen in a dosage of 15 mg/kg/dose every 4 hours with a maximum dose of 650 mg every 4 hours.

• Ibuprofen 5-10 mg/kg/dose every 6 hours, maximum 20 mg/kg/day.

• ASA is no longer used as a routine antipyretic medication in children because of the association with Reye's syndrome.

Parents should give their children antipyretic medicine with the understanding that it is based more on how the child looks, acts, and feels than on the absolute number on the thermometer.

Practical Hints

• For children below the age of 3 months with fever, always obtain a consultation from a pediatrician. Children between 3 months and 24 months should have individualized management.

• Do not forget UTI as a cause of fever or GI symptoms especially in younger children. Routine urinalysis is not enough; always get a culture.

• Children under 12 months of age (perhaps even under 24 months of age) do not generally have meningeal signs. Be vigilant in evaluating for meningitis.

• Otitis media by itself is a very rare cause of temperature elevation > 102°F. Look for associated bacteremia.

• There is no 100 percent reliable screening test for fever. Look at overall picture and all potential sources of infection.

The gold standard is the rectal temperature. An axillary temperature is completely unreliable. Thus far, data regarding tympanic membrane temperature is insufficient.