In this case-based module, GPSI in paediatrics Dr David Capehorn discusses four scenarios involving fever in children and advises on the appropriate management approaches.
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Learning objectives
This module will enhance your knowledge of the management of childhood fever in general practice, including:
· The significance of home-taken temperature and best use of thermometers in children.
· The relationship between height of fever and likelihood of serious disease.
· Use of antipyretics and analgesics in children with fever.
· Management of febrile convulsions and likelihood of recurrence.
· Red flags for serious infection in children with fever of several days duration.
Note that all cases in this module are hypothetical scenarios developed for illustrative purposes only
Case 1. Anxious parents present with ‘high temperature’ toddler
Some very anxious-looking parents attend with their 2-year-old toddler. ‘He’s had a high temperature for two days,’ they say. By this they mean that he has felt hot and flushed on and off – and since they managed to procure a thermometer the previous day, they’ve been checking his temperature every hour or so. ‘We just can’t get it below 38◦C,’ they explain. He seems well and is afebrile when you measure his temperature in the surgery.
1. How much weight should we give to parental reports of their child ‘feeling hot’ or having a temperature on home measuring, especially when the temperature is normal in the surgery? What actually constitutes ‘a fever’?
Fever in children is usually defined as a body temperature of 38°C (100.4°F) or higher. Anything below this threshold is not considered a fever, even if the child feels warm. Body temperature fluctuates naturally throughout the day, and mild increases can occur due to activity, ambient temperature, or mild illness without constituting a concerning fever.1 While it is important to acknowledge parental reports of their child ‘feeling hot’ or ‘having a temperature’, these should be interpreted with caution.
Research shows that parental concern about fever is often influenced by ‘fever phobia’, which refers to the disproportionate fear many parents have about fever and its potential complications.2,3 Studies suggest that parental assessment of fever by touch alone is not always accurate, though it is generally correct in identifying an elevated temperature when the fever is high (>39°C).1
However, a child may still feel warm or flushed without having a true fever at the time of the clinical examination. It is crucial to consider the clinical context, including the history provided by parents and the child’s behaviour and appearance, to form an accurate assessment.
The key message in this case is that, when the child’s temperature is normal in the clinic, but the parents report intermittent high temperatures at home, reassurance is important. It is essential to assess the child holistically, focusing on their overall well-being.
2. What types of thermometer should parents – and GPs – be using to measure temperatures in children?
Accurate temperature measurement is vital in paediatric practice, and the type of thermometer used can affect the reliability of readings. Using age-appropriate methods of temperature measurement ensures reliable assessments and appropriate clinical decisions.
Rectal thermometers provide the most reliable temperature readings due to their core body temperature accuracy, but they are not recommended for routine use in infants and children under 5 years of age due to discomfort, invasiveness, and the risk of injury or infection. The advice, especially in younger children, is to measure temperature using an electronic or chemical dot thermometer in the axilla.1 This method tends to slightly underestimate core body temperature and can be influenced by environmental factors.1
Tympanic methods are suitable for children aged 4 weeks and older. These thermometers are popular due to their speed and ease of use. However, accuracy depends on proper technique, including correct positioning and ensuring the ear canal is free of obstructions like earwax. They may be less accurate in younger age groups and NICE does not recommend their use in babies under 4 weeks of age.4
As children grow, tympanic or oral methods can become more reliable, but each has limitations based on the child’s ability to cooperate and anatomical differences. Oral thermometers, typically digital, are more commonly used in older children and adults and can provide reliable readings if used correctly. However, factors such as recent eating, drinking, or mouth breathing can affect accuracy, and proper placement under the tongue with the mouth closed is crucial.1 Forehead chemical thermometers are not routinely advised by NICE as they are less accurate.4
In summary:
· Under 4 weeks of age: use electronic thermometers in the axilla.
· Over 4 weeks of age: use axillary thermometry as above or infrared tympanic thermometers.
The key message for GPs is to explain the limitations of each method to parents and ensure parents understand the importance of using the thermometer appropriately.1
3. What advice would you give to parents who seem to be checking their child’s temperature excessively, especially when the child seems otherwise well?
Parents who check their child’s temperature excessively may be experiencing anxiety, often rooted in misconceptions about fever. Fever itself is a natural immune response and not inherently harmful in itself.2,3
It is important to educate and reassure parents that fever is a natural part of fighting infections and, in most cases, is not dangerous. Mild-to-moderate fevers (38-39°C) are usually not harmful.5 High fevers (>39.5-40°C), while more concerning, are still not necessarily dangerous unless other signs of serious illness are present.6
Advise parents to focus on symptoms, not just numbers on the thermometer. Reassuring parents that they should focus more on their child’s overall well-being rather than the exact temperature reading can relieve anxiety.2 Advise parents that ‘alert symptoms’ that would warrant urgent care include persistent high fever (lasting more than 5 days), difficulty breathing, seizures, poor fluid intake, reduced urine output, or lethargy.6
Of course, fever can alter a child’s mental status, causing irritability, lethargy, or reduced responsiveness, which might be mistaken for more severe neurological issues. These behavioural changes can complicate the assessment of the child’s level of distress or discomfort.
Distress from fever can also exacerbate symptoms like tachypnoea and tachycardia, leading clinicians to overestimate the severity of respiratory or cardiac conditions during a physical examination. This could result in unnecessary investigations or treatments based on a misinterpretation of fever-related signs.3
Reassuring parents about the use of antipyretics to ease distress rather than worrying about the ‘level’ of fever is therefore helpful for both the parent (reducing focus on ‘numbers’) and the clinician (potentially removing fever as a confounder of assessment).3,7
For those parents who continue to worry, it might be useful to suggest that parents measure their child’s temperature no more than a couple of times a day, unless they notice concerning symptoms.2 Excessive temperature checking can increase anxiety without providing useful information. Most importantly, reassure parents that if a child has a fever but is otherwise active and comfortable, medication such as paracetamol or ibuprofen is only necessary for discomfort, not to ‘normalise’ temperature. Overuse of antipyretics is unnecessary and can contribute to misconceptions about fever management.2,3 If clinicians stress that children need analgesia and antipyretics only if they are distressed and their appearance is the key factor, then ‘fever phobia’ may diminish.2,6
To complete the full module and log 2 CPD hours towards revalidation visit Pulse 365
Dr David Capehorn is a GPwER Paediatrics, founder and former clinical director of the Paediatric Primary Care service, Bristol and South Gloucestershire, honorary associate specialist and GP Lead, Bristol Children’s Hospital Emergency Department.
References
1. NICE. Fever in under 5s: assessment and initial management. [NG143] Last updated 26 November 2021
2. Crocetti M, Moghbeli N, Serwint J. Fever phobia revisited: have parental misconceptions about fever changed in 20 years? Pediatrics 2001;107:1241-6
3. Schmidt H. Fever phobia. Am J Dis Child 1980;134:176-81
4. Chiappini E, Venturini E, Remaschi G et al. 2016 Update of the Italian Pediatric Society Guidelines for Management of Fever in Children. J Pediatr 2017;180:177-183.e1
5. American Academy of Pediatrics. Fever and your child: How to treat a child’s fever
6. El-Radhi ASM. Why is the evidence not affecting the practice of fever management? Arch Dis Childhood 2008;93,918-20
7. Kelly M, Sahm LJ, McCarthy S. Parental knowledge, attitudes, and beliefs on fever: a cross-sectional study in Ireland. Br J Gen Pr 2016;66:e323-9
