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Fever in infants and children: Pathophysiology and management

INTRODUCTION

Fever is an abnormal elevation of body temperature that occurs as part of a specific biologic response that is mediated and controlled by the central nervous system.  

The pathophysiology and treatment of fever in infants and children will be reviewed here. Other causes of elevated body temperature in children and the evaluation and management of fever in specific populations of infants and children are discussed separately:

(See "Heat stroke in children" and "Heat illness (other than heat stroke) in children".)

(See "Evaluation and management of fever in the neonate and young infant (younger than three months of age)" and "Fever without a source in children 3 to 36 months of age".)

(See "Management of fever in sickle cell disease".)

                           

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Literature review current through: Sep 2014. | This topic last updated: Oct 27, 2014.
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References
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  1. Ward MA. Fever: Pathogenesis and treatment. In: Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 7th, Cherry JD, Harrison GJ, Kaplan SL, et al. (Eds), Elsevier Saunders, Philadelphia 2014. p.83.
  2. Health supervision: First week visit. In: Bright Futures Guidelines for Health Supervision, 3rd ed, Hagan JF, Shaw JS, Duncan PM. (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2008. p.289.
  3. National Institute for Health and Care Excellence. Feverish illness in children (CG160). May 2013. http://guidance.nice.org.uk/CG160 (Accessed on June 14, 2013).
  4. Paes BF, Vermeulen K, Brohet RM, et al. Accuracy of tympanic and infrared skin thermometers in children. Arch Dis Child 2010; 95:974.
  5. Schmitt BD. Fever in childhood. Pediatrics 1984; 74:929.
  6. Anagnostakis D, Matsaniotis N, Grafakos S, Sarafidou E. Rectal-axillary temperature difference in febrile and afebrile infants and children. Clin Pediatr (Phila) 1993; 32:268.
  7. Freed GL, Fraley JK. Lack of agreement of tympanic membrane temperature assessments with conventional methods in a private practice setting. Pediatrics 1992; 89:384.
  8. Webb GE. Comparison of esophageal and tympanic temperature monitoring during cardiopulmonary bypass. Anesth Analg 1973; 52:729.
  9. Moran JL, Peter JV, Solomon PJ, et al. Tympanic temperature measurements: are they reliable in the critically ill? A clinical study of measures of agreement. Crit Care Med 2007; 35:155.
  10. Devrim I, Kara A, Ceyhan M, et al. Measurement accuracy of fever by tympanic and axillary thermometry. Pediatr Emerg Care 2007; 23:16.
  11. Nimah MM, Bshesh K, Callahan JD, Jacobs BR. Infrared tympanic thermometry in comparison with other temperature measurement techniques in febrile children. Pediatr Crit Care Med 2006; 7:48.
  12. El-Radhi AS, Patel S. An evaluation of tympanic thermometry in a paediatric emergency department. Emerg Med J 2006; 23:40.
  13. Sehgal A, Dubey NK, Jyothi MC, Jain S. Comparison of tympanic and rectal temperature in febrile patients. Indian J Pediatr 2002; 69:305.
  14. Brennan DF, Falk JL, Rothrock SG, Kerr RB. Reliability of infrared tympanic thermometry in the detection of rectal fever in children. Ann Emerg Med 1995; 25:21.
  15. Hay AD, Peters TJ, Wilson A, Fahey T. The use of infrared thermometry for the detection of fever. Br J Gen Pract 2004; 54:448.
  16. Dodd SR, Lancaster GA, Craig JV, et al. In a systematic review, infrared ear thermometry for fever diagnosis in children finds poor sensitivity. J Clin Epidemiol 2006; 59:354.
  17. Zhen C, Xia Z, Long L, Pu Y. Accuracy of infrared ear thermometry in children: a meta-analysis and systematic review. Clin Pediatr (Phila) 2014; 53:1158.
  18. Titus MO, Hulsey T, Heckman J, Losek JD. Temporal artery thermometry utilization in pediatric emergency care. Clin Pediatr (Phila) 2009; 48:190.
  19. Hebbar K, Fortenberry JD, Rogers K, et al. Comparison of temporal artery thermometer to standard temperature measurements in pediatric intensive care unit patients. Pediatr Crit Care Med 2005; 6:557.
  20. Schuh S, Komar L, Stephens D, et al. Comparison of the temporal artery and rectal thermometry in children in the emergency department. Pediatr Emerg Care 2004; 20:736.
  21. Al-Mukhaizeem F, Allen U, Komar L, et al. Comparison of temporal artery, rectal and esophageal core temperatures in children: Results of a pilot study. Paediatr Child Health 2004; 9:461.
  22. Callanan D. Detecting fever in young infants: reliability of perceived, pacifier, and temporal artery temperatures in infants younger than 3 months of age. Pediatr Emerg Care 2003; 19:240.
  23. De Curtis M, Calzolari F, Marciano A, et al. Comparison between rectal and infrared skin temperature in the newborn. Arch Dis Child Fetal Neonatal Ed 2008; 93:F55.
  24. Greenes DS, Fleisher GR. Accuracy of a noninvasive temporal artery thermometer for use in infants. Arch Pediatr Adolesc Med 2001; 155:376.
  25. Siberry GK, Diener-West M, Schappell E, Karron RA. Comparison of temple temperatures with rectal temperatures in children under two years of age. Clin Pediatr (Phila) 2002; 41:405.
  26. Hoffman RJ, Etwaru K, Dreisinger N, et al. Comparison of temporal artery thermometry and rectal thermometry in febrile pediatric emergency department patients. Pediatr Emerg Care 2013; 29:301.
  27. Teller J, Ragazzi M, Simonetti GD, Lava SA. Accuracy of tympanic and forehead thermometers in private paediatric practice. Acta Paediatr 2014; 103:e80.
  28. Mackowiak PA, Wasserman SS. Physicians' perceptions regarding body temperature in health and disease. South Med J 1995; 88:934.
  29. Mackowiak PA, Wasserman SS, Levine MM. A critical appraisal of 98.6 degrees F, the upper limit of the normal body temperature, and other legacies of Carl Reinhold August Wunderlich. JAMA 1992; 268:1578.
  30. Herzog LW, Coyne LJ. What is fever? Normal temperature in infants less than 3 months old. Clin Pediatr (Phila) 1993; 32:142.
  31. Baraff LJ. Management of the febrile child: a survey of pediatric and emergency medicine residency directors. Pediatr Infect Dis J 1991; 10:795.
  32. Dagan R, Sofer S, Phillip M, Shachak E. Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serious bacterial infections. J Pediatr 1988; 112:355.
  33. 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 1993; 22:1198.
  34. Herzog L, Phillips SG. Addressing concerns about fever. Clin Pediatr (Phila) 2011; 50:383.
  35. Dinarello CA. Cytokines as endogenous pyrogens. J Infect Dis 1999; 179 Suppl 2:S294.
  36. Trautner BW, Caviness AC, Gerlacher GR, et al. 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 2006; 118:34.
  37. El-Radhi AS. Why is the evidence not affecting the practice of fever management? Arch Dis Child 2008; 93:918.
  38. Klastersky J, Kass EH. Is suppression of fever or hypothermia useful in experimental and clinical infectious diseases? J Infect Dis 1970; 121:81.
  39. Mackowiak PA. Fever: blessing or curse? A unifying hypothesis. Ann Intern Med 1994; 120:1037.
  40. Section on Clinical Pharmacology and Therapeutics, Committee on Drugs, Sullivan JE, Farrar HC. Fever and antipyretic use in children. Pediatrics 2011; 127:580.
  41. Greisman LA, Mackowiak PA. Fever: beneficial and detrimental effects of antipyretics. Curr Opin Infect Dis 2002; 15:241.
  42. Dixon G, Booth C, Price E, et al. Fever as nature's engine. Part of beneficial host response? BMJ 2010; 340:c450.
  43. Fowler AW. A/H1N1 flu pandemic. Fever as nature's engine? BMJ 2009; 339:b3874.
  44. Kluger MJ, Kozak W, Conn CA, et al. The adaptive value of fever. Infect Dis Clin North Am 1996; 10:1.
  45. Small PM, Täuber MG, Hackbarth CJ, Sande MA. Influence of body temperature on bacterial growth rates in experimental pneumococcal meningitis in rabbits. Infect Immun 1986; 52:484.
  46. Bernheim HA, Kluger MJ. Fever: effect of drug-induced antipyresis on survival. Science 1976; 193:237.
  47. Kluger MJ, Vaughn LK. Fever and survival in rabbits infected with Pasteurella multocida. J Physiol 1978; 282:243.
  48. Banet M. Fever and survival in the rat. The effect of enhancing fever. Pflugers Arch 1979; 381:35.
  49. Clasen RA, Pandolfi S, Laing I, Casey D Jr. Experimental study of relation of fever to cerebral edema. J Neurosurg 1974; 41:576.
  50. Austin TW, Truant G. Hyperthermia, antipyretics and function of polymorphonuclear leukocytes. Can Med Assoc J 1978; 118:493.
  51. Roberts NJ Jr, Steigbigel RT. Hyperthermia and human leukocyte functions: effects on response of lymphocytes to mitogen and antigen and bactericidal capacity of monocytes and neutrophils. Infect Immun 1977; 18:673.
  52. May A, Bauchner H. Fever phobia: the pediatrician's contribution. Pediatrics 1992; 90:851.
  53. Poirier MP, Davis PH, Gonzalez-del Rey JA, Monroe KW. Pediatric emergency department nurses' perspectives on fever in children. Pediatr Emerg Care 2000; 16:9.
  54. Crocetti M, Moghbeli N, Serwint J. Fever phobia revisited: have parental misconceptions about fever changed in 20 years? Pediatrics 2001; 107:1241.
  55. Enarson MC, Ali S, Vandermeer B, et al. Beliefs and expectations of Canadian parents who bring febrile children for medical care. Pediatrics 2012; 130:e905.
  56. Teagle AR, Powell CV. Is fever phobia driving inappropriate use of antipyretics? Arch Dis Child 2014; 99:701.
  57. Yin HS, Wolf MS, Dreyer BP, et al. Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications. JAMA 2010; 304:2595.
  58. Wilson JT, Brown RD, Kearns GL, et al. Single-dose, placebo-controlled comparative study of ibuprofen and acetaminophen antipyresis in children. J Pediatr 1991; 119:803.
  59. Perrott DA, Piira T, Goodenough B, Champion GD. Efficacy and safety of acetaminophen vs ibuprofen for treating children's pain or fever: a meta-analysis. Arch Pediatr Adolesc Med 2004; 158:521.
  60. Walson PD, Galletta G, Braden NJ, Alexander L. Ibuprofen, acetaminophen, and placebo treatment of febrile children. Clin Pharmacol Ther 1989; 46:9.
  61. Sidler J, Frey B, Baerlocher K. A double-blind comparison of ibuprofen and paracetamol in juvenile pyrexia. Br J Clin Pract Suppl 1990; 70:22.
  62. Kauffman RE, Sawyer LA, Scheinbaum ML. Antipyretic efficacy of ibuprofen vs acetaminophen. Am J Dis Child 1992; 146:622.
  63. Pierce CA, Voss B. Efficacy and safety of ibuprofen and acetaminophen in children and adults: a meta-analysis and qualitative review. Ann Pharmacother 2010; 44:489.
  64. Nabulsi M. Is combining or alternating antipyretic therapy more beneficial than monotherapy for febrile children? BMJ 2009; 339:b3540.
  65. Purssell E. Systematic review of studies comparing combined treatment with paracetamol and ibuprofen, with either drug alone. Arch Dis Child 2011; 96:1175.
  66. Wong T, Stang AS, Ganshorn H, et al. Combined and alternating paracetamol and ibuprofen therapy for febrile children. Cochrane Database Syst Rev 2013; 10:CD009572.
  67. Kramer LC, Richards PA, Thompson AM, et al. Alternating antipyretics: antipyretic efficacy of acetaminophen versus acetaminophen alternated with ibuprofen in children. Clin Pediatr (Phila) 2008; 47:907.
  68. Zaffanello M, Brugnara M, Angeli S, Cuzzolin L. Acute non-oliguric kidney failure and cholestatic hepatitis induced by ibuprofen and acetaminophen: a case report. Acta Paediatr 2009; 98:903.
  69. Del Vecchio MT, Sundel ER. Alternating antipyretics: is this an alternative? Pediatrics 2001; 108:1236.
  70. Mayoral CE, Marino RV, Rosenfeld W, Greensher J. Alternating antipyretics: is this an alternative? Pediatrics 2000; 105:1009.
  71. McIntyre J, Hull D. Comparing efficacy and tolerability of ibuprofen and paracetamol in fever. Arch Dis Child 1996; 74:164.
  72. Lavonas EJ, Reynolds KM, Dart RC. Therapeutic acetaminophen is not associated with liver injury in children: a systematic review. Pediatrics 2010; 126:e1430.
  73. U.S. Food and Drug Administration. Acetaminophen: Drug safety communication - association with risk of serious skin reactions. http://www.fda.gov/Drugs/DrugSafety/ucm363041.htm (Accessed on September 04, 2013).
  74. Berezin SH, Bostwick HE, Halata MS, et al. Gastrointestinal bleeding in children following ingestion of low-dose ibuprofen. J Pediatr Gastroenterol Nutr 2007; 44:506.
  75. Lesko SM, Mitchell AA. An assessment of the safety of pediatric ibuprofen. A practitioner-based randomized clinical trial. JAMA 1995; 273:929.
  76. Misurac JM, Knoderer CA, Leiser JD, et al. Nonsteroidal anti-inflammatory drugs are an important cause of acute kidney injury in children. J Pediatr 2013; 162:1153.
  77. Zerr DM, Alexander ER, Duchin JS, et al. A case-control study of necrotizing fasciitis during primary varicella. Pediatrics 1999; 103:783.
  78. Lesko SM, O'Brien KL, Schwartz B, et al. Invasive group A streptococcal infection and nonsteroidal antiinflammatory drug use among children with primary varicella. Pediatrics 2001; 107:1108.
  79. Aronoff DM, Bloch KC. Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus. Medicine (Baltimore) 2003; 82:225.
  80. Hall AH, Smolinske SC, Conrad FL, et al. Ibuprofen overdose: 126 cases. Ann Emerg Med 1986; 15:1308.
  81. Erlewyn-Lajeunesse MD, Coppens K, Hunt LP, et al. Randomised controlled trial of combined paracetamol and ibuprofen for fever. Arch Dis Child 2006; 91:414.
  82. Sarrell EM, Wielunsky E, Cohen HA. Antipyretic treatment in young children with fever: acetaminophen, ibuprofen, or both alternating in a randomized, double-blind study. Arch Pediatr Adolesc Med 2006; 160:197.
  83. Nabulsi MM, Tamim H, Mahfoud Z, et al. Alternating ibuprofen and acetaminophen in the treatment of febrile children: a pilot study [ISRCTN30487061]. BMC Med 2006; 4:4.
  84. Hay AD, Costelloe C, Redmond NM, et al. Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial. BMJ 2008; 337:a1302.
  85. Paul IM, Sturgis SA, Yang C, et al. Efficacy of standard doses of Ibuprofen alone, alternating, and combined with acetaminophen for the treatment of febrile children. Clin Ther 2010; 32:2433.
  86. Thomas S, Vijaykumar C, Naik R, et al. Comparative effectiveness of tepid sponging and antipyretic drug versus only antipyretic drug in the management of fever among children: a randomized controlled trial. Indian Pediatr 2009; 46:133.
  87. Alves JG, Almeida ND, Almeida CD. Tepid sponging plus dipyrone versus dipyrone alone for reducing body temperature in febrile children. Sao Paulo Med J 2008; 126:107.
  88. Purssell E. Physical treatment of fever. Arch Dis Child 2000; 82:238.
  89. Moss MH. Alcohol-induced hypoglycemia and coma caused by alcohol sponging. Pediatrics 1970; 46:445.