Clinical update

Assessment and management of fever in young children

Updated National Institute for Health and Care Excellence guidance aims to help nurses assess and manage fever in children aged under five

Updated National Institute for Health and Care Excellence guidance aims to help nurses assess and manage fever in children aged under five

Picture of a mother with child who has fever
Picture: Alamy

Essential information

Feverish illness is common in young children, with up to 40% of parents reporting such illnesses each year, according to the National Institute for Health and Care Excellence (NICE) (2019).

Fever is probably the most common reason for a child to be taken to a doctor and feverish illness is the second most common reason for a child being admitted to hospital.

Feverish illness in young children usually indicates an underlying infection and is a cause of concern for parents. Infections remain the leading cause of death in children under the age of five years (NICE 2019).

What’s new?

Updated guidance to help health professionals assess and manage fever in children aged under five has been published by NICE (2019).

Fever in young children can be a diagnostic challenge because it is often difficult to identify the cause. In most cases, the illness is due to a self-limiting viral infection, but may also be the presenting feature of serious bacterial infection, such as meningitis or pneumonia.

A significant number of children have no obvious cause of fever despite careful assessment and these cases are of particular concern to healthcare professionals.

Signs and symptoms

Children with fever; pale, mottled, ashen or blue skin, lips or tongue; no response to social cues; appearing ill; do not wake; weak, high-pitched or continuous cry; grunting; respiratory rate greater than 60 breaths per minute; chest indrawing; reduced skin turgor; and bulging fontanelle are at high risk of serious illness.

A list of symptoms that puts a child at intermediate risk is also listed by NICE (2019).

Causes and risk factors

Conditions to consider as the source of the temperature when treating a feverish child include meningococcal disease and bacterial meningitis, herpes simplex encephalitis, pneumonia, urinary tract infections, septic arthritis or osteomyelitis and Kawasaki disease (in children with a high temperature for five days or longer).

How you can help your patient

  • Consider reported parental perception of a fever to be valid and take it seriously.
  • Look for a source of fever, and check for the presence of symptoms and signs associated with specific disease.
  • If a child presents with fever and symptoms or signs that indicate the condition, think: ‘Could this be sepsis?’. 
  • When deciding whether a child should be admitted to hospital, consider parental anxiety and instinct based on their knowledge of the child alongside the child’s clinical condition.
  • In children with fever who appear distressed, consider using either paracetamol or ibuprofen. 
  • Do not use antipyretic agents, such as paracetamol or ibuprofen, with the sole aim of reducing body temperature in children with fever if they are otherwise well. 

Expert comment

Picture of Coral Rees

Coral Rees, advanced paediatric nurse practitioner at Noah’s Ark Children’s Hospital for Wales in Cardiff

‘The majority of children presenting to primary and secondary care with an acute illness will have a fever because this is the body’s way of naturally trying to fight an infection.

‘Fever in children aged under three months is worrying and their parents should seek medical attention immediately because the risk of serious bacterial infection is more likely in this age group.

‘As nurses, we should not be treating a fever if the child is otherwise well, and we should use antipyretics only if the child is uncomfortable or distressed.

‘Reassuring parents can sometimes be challenging because they often see fever as being dangerous. 

‘This NICE guideline (NICE 2019) gives clear recommendations for the assessment and early management of fever with no obvious cause in children aged under five. It aims to improve clinical assessment and help healthcare professionals diagnose serious illness in primary and secondary care.’


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