eMedicine Specialties > Emergency Medicine > Pediatric
Pediatrics, Fever: Treatment & Medication
Updated: Aug 6, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
Prehospital care provided by emergency medical technicians (EMTs) and paramedics may vary from region to region on the basis of regional differences in education, training, and transport times.
- Children with fever alone may require no specific intervention in the EMS setting, except for those other conditions that exist in the presence of fever.
- Assessment of and attention to airway, breathing, and circulation is recommended first for all ill children.
- Those children who have had prolonged, or very high, fever may become dehydrated, and assessment of the hydration status is indicated.
- Some children may be prone to febrile seizures and seizure precautions should be followed in those with a history of febrile seizures.
Emergency Department Care
Vital signs recorded in triage should routinely include a temperature in young children. This should be recorded on all neonates and infants presenting with fever or other potentially infectious complaints (eg, not eating well, not breathing well, color changes, behavior changes). A rectal temperature is the most accurate for infants.
The nursing triage includes an accurate assessment of the patient's weight to ascertain the correct dose of an antipyretic or other medications.
- An antipyretic should be given as early as possible during the ED visit. Reduction of fever is used to help comfort the child as well as provide for the optimal examination conditions. Triage protocols are developed to facilitate this.
- The ED staff should be educated that a positive response to antipyretics (evidenced by a drop in the measured temperature) is not predictive of the absence of a potentially serious bacterial disease.27,28
- Criteria for discharge from the ED do not necessarily include reduction of the child's fever to a certain level before discharge. No evidence indicates that fever reduction is necessary for the child to be discharged from the ED.29
- Neonates with fever who undergo the previously described routine workup to rule out sepsis should then receive 2 antibiotics as treatment for their potential septicemia: an aminopenicillin (eg, ampicillin) and a cephalosporin (eg, cefotaxime). Neonates may also receive antiviral treatment with acyclovir if they are at risk for neonatal herpes infection.
- Older children with a low-grade fever, no risk factors, no localized signs of infection, a good appearance, and no irritability may require only symptomatic treatment and close follow-up care. These patients do not routinely need laboratory evaluation, radiography, or empiric antibiotics.
Consultations
Contact with the patient's primary care provider or designee helps ensure a continuum of care and enables effective follow-up care.
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Antipyretics
These agents provide patient comfort during the ED visit and are used liberally in febrile children. A child whose temperature has been reduced is more comfortable and more likely to have an optimal examination.
Acetaminophen and ibuprofen have both been used for fever control.9
- These drugs are sometimes alternated to achieve an overlapping period of fever control. However, no data support the safety of this practice of alternating medications.29,28
- Some studies have shown that acetaminophen works faster by initially lowering elevations in temperature.27
- Some studies have shown that ibuprofen takes longer to initially result in fever reduction but that its effect may last longer than that of acetaminophen.8
- Hay et al studied whether administering a combination of acetaminophen and ibuprofen for fever in children was superior to administration of acetaminophen alone or ibuprofen alone.30 Dosage was calculated as acetaminophen 15 mg/kg/dose and ibuprofen 10 mg/kg/dose. Children aged 6 months to 6 years whose fever could be managed at home (37.5-41ºC) were included. Use of acetaminophen and ibuprofen improved time without fever during the first 4 hours and was superior to acetaminophen alone, but not ibuprofen alone. The combination also decreased fever 23 minutes faster than acetaminophen alone, but no faster than ibuprofen alone. Time without fever during the first 24 hours was improved with the combination compared with either acetaminophen or ibuprofen.
Acetaminophen (Tylenol, Feverall, Panadol)
Reduces fever by directly acting on hypothalamic heat-regulating centers, increasing dissipation of body-heat via vasodilation and sweating.
Adult
Pediatric
10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; liver failure; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible following various dose levels in persons with chronic alcoholism; severe or recurrent pain or high or continued fever may indicate serious illness; contained in many OTC products and combined use may result in cumulative doses exceeding recommended maximum
Ibuprofen (Advil, Motrin)
One of few NSAIDs indicated for reduction of fever. Inhibits prostaglandin formation.
Adult
Pediatric
5-10 mg/kg/dose PO q6-8h prn; not to exceed 40 mg/kg/d or 2.4 g/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Antimicrobial agents
Antibiotics are used to treat occult bacterial infection. Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting. Whenever feasible, select antibiotics based upon blood culture sensitivity. Consider initiating acyclovir for suspected HSV or VSV infections.
Cefotaxime (Claforan)
Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.
Adult
Pediatric
Infants and children: 150-200 mg/kg/d IV/IM divided q4-6h
Probenecid may increase levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal impairment; has been associated with severe colitis
Ampicillin (Omnipen, Marcillin, Principen)
Bactericidal activity against susceptible organisms.
Adult
Pediatric
50-100 mg/kg/d PO divided q4-6h or 100-400 mg/kg/d IV/IM divided q4-6h
Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms; arrests bacterial growth by binding to 1 or more penicillin-binding proteins.
Adult
Pediatric
Neonates >7 days: 25-50 mg/kg/d IV/IM; not to exceed 125 mg/d
Infants and children: 50-75 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and patients with penicillin allergy
Oxacillin (Bactocill, Prostaphlin)
Bactericidal antibiotic that inhibits cell wall synthesis. Used in the treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when a staphylococcal infection is suspected.
Adult
Pediatric
50-100 mg/kg/d PO divided q6h or 150-200 mg/kg/d IV/IM divided q6h; not to exceed 12 g/d
Oxacillin decreases effects of contraceptives and tetracycline; administered concomitantly with disulfiram and probenecid, may increase oxacillin levels; effect of anticoagulants increase when large IV doses of oxacillin given
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal impairment
Acyclovir (Zovirax)
Prodrug activated by phosphorylation by virus-specific thymidine kinase (TK) that inhibits viral replication. Herpes virus TK, but not host cells TK, uses acyclovir as a purine nucleoside, converting it into acyclovir monophosphate, a nucleotide analogue. Guanylate kinase converts the monophosphate form into diphosphate and triphosphate analogues that inhibit viral DNA replication.
Has affinity for viral TK and once phosphorylated causes DNA chain termination when acted on by DNA polymerase. Inhibits activity of both HSV-1 and HSV-2. Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h from rash onset. May prevent recurrent outbreaks. Early initiation of therapy is imperative.
IV therapy is treatment of choice for neonatal HSV infection regardless of clinical presentation.
Also used in VZV meningitis. Activated by herpes-specific TK; prevents viral replication by inhibiting viral DNA polymerase. Excreted primarily by kidneys; modify dose in patients with renal impairment.
Adult
Pediatric
1500 mg/m2/d divided q8h or 10 mg/kg/dose IV q8h for 14-28 d; typically infused over 1 h (smaller doses may be appropriate in very premature infants)
Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity of acyclovir
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure or when using nephrotoxic drugs
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| Differential Diagnoses & Workup: Pediatrics, Fever |
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References
Schweich PJ, Smith KM, Dowd MD, et al. Pediatric emergency medicine practice patterns: a comparison of pediatric and general emergency physicians. Pediatr Emerg Care. Apr 1998;14(2):89-94. [Medline].
Poirier MP, Davis PH, Gonzalez-del Rey JA, Monroe KW. Pediatric emergency department nurses' perspectives on fever in children. Pediatr Emerg Care. Feb 2000;16(1):9-12. [Medline].
Seow VK, Lin AC, Lin IY, Chen CC, Chen KC, Wang TL, et al. Comparing different patterns for managing febrile children in the ED between emergency and pediatric physicians: impact on patient outcome. Am J Emerg Med. Nov 2007;25(9):1004-8. [Medline].
Myers MG, Wright PF, Smith AL, et al. Complications of occult pneumococcal bacteremia in children. J Pediatr. May 1974;84(5):656-60. [Medline].
Bratton L, Teele DW, Klein JO. Outcome of unsuspected pneumococcemia in children not initially admitted to the hospital. J Pediatr. May 1977;90(5):703-6. [Medline].
Stoll ML, Rubin LG. Incidence of occult bacteremia among highly febrile young children in the era of the pneumococcal conjugate vaccine: a study from a Children's Hospital Emergency Department and Urgent Care Center. Arch Pediatr Adolesc Med. Jul 2004;158(7):671-5. [Medline].
Graneto JW, Soglin DF. Maternal screening of childhood fever by palpation. Pediatr Emerg Care. Jun 1996;12(3):183-4. [Medline].
Noyola DE, Fernandez M, Kaplan SL. Reevaluation of antipyretics in children with enteric fever. Pediatr Infect Dis J. Aug 1998;17(8):691-5. [Medline].
Carson SM. Alternating acetaminophen and ibuprofen in the febrile child: examination of the evidence regarding efficacy and safety. Pediatr Nurs. Sep-Oct 2003;29(5):379-82. [Medline].
McCarthy PL, Lembo RM, Fink HD, et al. Observation, history, and physical examination in diagnosis of serious illnesses in febrile children less than or equal to 24 months. J Pediatr. Jan 1987;110(1):26-30. [Medline].
Baker MD, Avner JR, Bell LM. Failure of infant observation scales in detecting serious illness in febrile, 4- to 8-week-old infants. Pediatrics. Jun 1990;85(6):1040-3. [Medline].
Colletti JE, Homme JL, Woodridge DP. Unsuspected neonatal killers in emergency medicine. Emerg Med Clin North Am. Nov 2004;22(4):929-60. [Medline].
Crocetti M, Moghbeli N, Serwint J. Fever phobia revisited: have parental misconceptions about fever changed in 20 years?. Pediatrics. Jun 2001;107(6):1241-6. [Medline].
Bonsu BK, Chb M, Harper MB. Identifying febrile young infants with bacteremia: is the peripheral white blood cell count an accurate screen?. Ann Emerg Med. Aug 2003;42(2):216-25. [Medline].
Levine DA, Platt SL, Dayan PS, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics. Jun 2004;113(6):1728-34. [Medline].
Teele DW, Pelton SI, Grant MJ, et al. Bacteremia in febrile children under 2 years of age: results of cultures of blood of 600 consecutive febrile children seen in a "walk- in" clinic. J Pediatr. Aug 1975;87(2):227-30. [Medline].
Carstairs KL, Tanen DA, Johnson AS, Kailes SB, Riffenburgh RH. Pneumococcal bacteremia in febrile infants presenting to the emergency department before and after the introduction of the heptavalent pneumococcal vaccine. Ann Emerg Med. Jun 2007;49(6):772-7. [Medline].
Herz AM, Greenhow TL, Alcantara J, Hansen J, Baxter RP, Black SB, et al. Changing epidemiology of outpatient bacteremia in 3- to 36-month-old children after the introduction of the heptavalent-conjugated pneumococcal vaccine. Pediatr Infect Dis J. Apr 2006;25(4):293-300. [Medline].
Brown ZA, Wald A, Morrow RA, Selke S, Zeh J, Corey L. Effect of serologic status and cesarean delivery on transmission rates of herpes simplex virus from mother to infant. JAMA. Jan 8 2003;289(2):203-9. [Medline].
Yee-Guardino S, Kumar D, Abughali N, Tuohy M, Hall GS, Kumar ML. Recognition and treatment of neonatal community-associated MRSA pneumonia and bacteremia. Pediatr Pulmonol. Feb 2008;43(2):203-5. [Medline].
Pitetti RD, Choi S. Utility of blood cultures in febrile children with UTI. Am J Emerg Med. Jul 2002;20(4):271-4. [Medline].
Downs SM. Technical report: urinary tract infections in febrile infants and young children. The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement. Pediatrics. Apr 1999;103(4):e54. [Medline].
Kuppermann N, Bank DE, Walton EA, et al. Risks for bacteremia and urinary tract infections in young febrile children with bronchiolitis. Arch Pediatr Adolesc Med. Dec 1997;151(12):1207-14. [Medline].
Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research. Ann Emerg Med. Jul 1993;22(7):1198-210. [Medline].
Downs SM, McNutt RA, Margolis PA. Management of infants at risk for occult bacteremia: a decision analysis. J Pediatr. Jan 1991;118(1):11-20. [Medline].
[Best Evidence] Trautner BW, Caviness AC, Gerlacher GR, Demmler G, Macias CG. Prospective evaluation of the risk of serious bacterial infection in children who present to the emergency department with hyperpyrexia (temperature of 106 degrees F or higher). Pediatrics. Jul 2006;118(1):34-40. [Medline].
Torrey SB, Henretig F, Fleisher G, et al. Temperature response to antipyretic therapy in children: relationship to occult bacteremia. Am J Emerg Med. May 1985;3(3):190-2. [Medline].
Wahba H. The antipyretic effect of ibuprofen and acetaminophen in children. Pharmacotherapy. Feb 2004;24(2):280-4. [Medline].
Weisse ME, Miller G, Brien JH. Fever response to acetaminophen in viral vs. bacterial infections. Pediatr Infect Dis J. Dec 1987;6(12):1091-4. [Medline].
[Best Evidence] Hay AD, Redmond NM, Costelloe C, Montgomery AA, Fletcher M, Hollinghurst S, et al. Paracetamol and ibuprofen for the treatment of fever in children: the PITCH randomised controlled trial. Health Technol Assess. May 2009;13(27):iii-iv, ix-x, 1-163. [Medline].
Yamamoto LG, Worthley RG, Melish ME, et al. A revised decision analysis of strategies in the management of febrile children at risk for occult bacteremia. Am J Emerg Med. Mar 1998;16(2):193-207. [Medline].
Baker MD, Bell LM, Avner JR. The efficacy of noninvasive in hospital and outpatient management of febrile infants: a four year experience. Ann Emerg Med. 1991;20:445.
AAP. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Pediatrics. Apr 1999;103(4 Pt 1):843-52. [Medline].
Shah SS, Alpern ER, Zwerling L, et al. Low risk of bacteremia in children with febrile seizures. Arch Pediatr Adolesc Med. May 2002;156(5):469-72. [Medline].
Ammann RA, Hirt A, Luthy AR, Aebi C. Predicting bacteremia in children with fever and chemotherapy-induced neutropenia. Pediatr Infect Dis J. Jan 2004;23(1):61-7. [Medline].
Further Reading
Keywords
fever in children, fever in kids, high temperature, febrile, pyrexia, feverish, febrile child, febrile infant, infant with fever, child with fever, infection, meningitis, bacteremia or sepsis, enteritis, pneumonia, pericarditis, osteomyelitis, septic arthritis, cellulitis, otitis media, pharyngitis, sinusitis, urinary tract infections, enteritis, appendicitis, viral illnesses, upper respiratory infections, bronchiolitis, enteroviral exanthems, gastroenteritis, flulike illnesses
