Fever
Consultation guide for UK community pharmacy: clinical features, referral criteria, time frame to resolution and management strategy.
Clinical features
- Body temperature above normal (≥38°C). In children under 5 years of age, forehead chemical (strip) thermometers should not be used, and the oral and rectal routes should not be used routinely. NICE recommends an electronic or chemical dot thermometer in the axilla, or an infra-red tympanic thermometer
- Parent/carer states child has a fever
- The NICE traffic light system includes information about the child’s general appearance, temperature, heart rate, respiratory rate, capillary refill time
(CRT) and fluid status
- Quantification of a 'fever' is secondary to parent/carer concerns and the clinical profile. The NICE traffic light system (or equivalent) should be used to assess the likelihood of serious or life-threatening illness such a bacterial infection/dehydration/sepsis
Referral criteria
- Any infant under 3 months of age with a temperature of 38°C or higher — refer urgently, regardless of how well the infant appears (NICE red-risk criterion)
- Any 'amber' and/or 'red' features as defined by the NICE traffic light system. For example, the child is becoming dehydrated/is dehydrated, has had a seizure, has reduced consciousness, has a non-blanching rash or any other signs of meningitis, septicaemia, sepsis, pneumonia
- remember a fever could be due to COVID-19 (see separate COVID-19 entry)
- compromise to ABC (airway, breathing, circulation)
- Fever lasting longer than 5 days
- Symptoms worsening/child is deteriorating
- Parents distressed or worried
Time frame to resolution
- Depending on the cause, fever should resolve within a few days and certainly last no longer than 5 days
Management strategy
Non-pharmacological advice
- As previously mentioned, NICE has a traffic light system which ideally should be used (or an equivalent) to assess the likelihood of serious or life-threatening illness such a bacterial infection/dehydration/sepsis. Being familiar with this will help ensure the appropriate action is taken. Typically, if the child has green features (but no amber or red features) they can be managed at home with appropriate advice and safety netting. If applicable, signpost to the NHS leaflet ‘Fever in children’
- NICE does not advocate the use of tepid sponging to reduce temperature
- Dress child appropriately to avoid overheating or shivering
- Give regular fluids
- Explain how to identify a non-blanching rash (glass test)
- NICE suggests that the child is checked regularly, including during the night
- Seek further medical advice if any referral criteria develop (see referral criteria). See updated NICE guidance (Nov 2021). NICE warns NOT to use a response to antipyretic therapy alone as a means to differentiate between serious and non-serious infection
Pharmacological advice
- NICE states that if the child appears distressed or is unwell give either paracetamol or ibuprofen (depending on co-morbidities, cautions or contraindications, and preference). Paracetamol has a better safety profile. Continue only as long as the child appears distressed
- If the chosen analgesic is ineffective, consider switching to the other
- Do not give both antipyretic drugs together; if monotherapy with both has been ineffective, consider alternating if the child remains distressed or symptoms recur before the next dose is due
- Encourage adherence to manufacturer's dosing instructions and recording of when (and how much of) the particular analgesic has been given to minimise the risk of overdosing
- NICE advises not to routinely give antipyretic medicines with the sole aim of reducing body temperature of a child who is otherwise well or for preventing febrile convulsions