Fever Management in Children

Introduction

Fever is one of the most common phenomena in children that doctors and alternative practitioners are confronted with, although it is rarely caused by a serious illness. Given the often considerable concerns of parents (especially with their first child), advising parents, examining the child and making a differential diagnosis requires a great deal of sensitivity, diagnostic competence and knowledge of the so-called "red flags" for recognising a "potentially dangerous condition (PDC)".

The first guideline on fever management in children and adolescents issued by the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) now provides important guidance (see: https://register.awmf.org/de/leitlinien/detail/027-074

Fortunately, the recommendations mark a departure from the long-standing medical tradition of rapid fever reduction and teach a relaxed approach to this symptom, which in most cases is a natural reaction of the organism. The guideline representative of the German Society for Paediatrics and Adolescent Medicine (Deutschen Gesellschaft für Kinder und Jugendliche DGKJ) says:

"The new guideline emphasises a fundamentally changed understanding of fever: it is not considered a symptom that requires priority treatment, but rather a physiological and usually helpful defence reaction of the body." (Prof. Dr Tim Niehues, German Society for Paediatrics and Adolescent Medicine e. V. 2025; transl. by the author)

The following section provides a detailed overview of the key content of the new guideline on fever management in children and adolescents.

The 10 most important points of the new guideline

1. Information on age-dependent measurement methods for reliable temperature measurement.
2. Fever should always be assessed in conjunction with the child's clinical condition.
3. It is important to observe clinical warning signs when assessing the risk of fever.
4. There is no temperature threshold that indicates the need for antipyretic treatment.
5. Non-medicinal measures are of primary importance, such as sufficient fluids, a calm environment, undisturbed sleep and loving care.
6. Ibuprofen is the first choice for drug-based antipyresis.
7. There is no evidence that medication-based fever reduction prevents febrile seizures.
8. The main focus of measures should be on the child's well-being.
9. Parents should ensure that the child has sufficient time to recover (convalescence).
10. Fever alone is not an indication for antibiotics.

The following sections explain these aspects in detail.

1) Temperature measurement

There are now a variety of different methods for measuring body temperature. In addition to invasive methods, which are only used in intensive care (e.g. via a central venous catheter or urinary catheter), various non-invasive methods are in use. Digital thermometers have been the standard for years, replacing the analogue mercury thermometers that were common decades ago. These are available for different measurement locations (rectal, oral, axillary, ear canal, forehead).

Rectal measurement continues to be considered the gold standard and reference method. Here, the guideline provides specific information and recommendations based, among other things, on a large meta-analysis by Pecoraro et al. (Pecoraro et al., 2021).

• In newborns and infants, temperature should be measured rectally. (Note: In the presence of fever, the temperature measured in the ear canal is only about 0.5°C lower than the rectal measurement. The level of evidence for this recommendation is low.)
• In children aged one year and older, measurement with an infrared tympanic thermometer is considered sufficiently accurate.
• Measurement with a forehead/temple thermometer is inaccurate but may be considered.

Tab. 1 - Recommendations on types of temperature measurement

Location of temperature measurement	Thermometer	Age group	Restrictions
Rectal	Digital termometer	All	Partial undressing necessary
Oral	Digital termometer	Adolescents	Closing the mouth is essential
Axillary		Not recommended
Ear canal	Infrared thermometer	From 1 year	Pathological tympanic membrane processes
Forehead	Infrared thermometer	Children, adolescents	Low measurement validity

2) Clinical condition assessment

The guideline emphasises that fever should initially be regarded as a symptom rather than a disease. Parents should also be informed of this. Furthermore, the severity of the fever does not necessarily correlate with the danger of an underlying disease and therefore has a low predictive value.

When considering the consequences of temperature measurement (further diagnostics, antipyretics), the general condition of the child in relation to their age must be taken into account. A child with a high fever > 40°C can be kept under observation if their general condition is acceptable, whereas a child who appears seriously ill should be taken to see a doctor even at 38°C, where appropriate measures should then be taken.

Criteria and algorithms are also presented for risk assessment.

3) Risk assessment and clinical warning signs

Clinical warning signs

The expert consensus, which is not supported by external scientific evidence, is as follows:

"If a child is found to have a fever after a correctly performed measurement, this should always be interpreted in conjunction with the child's general condition, well-being, warning signs and the uncertainty and concern of the caregivers.

Warning signs include, in particular, impaired consciousness, sensitivity to touch, severe pain, shrill crying, skin haemorrhages (rash that cannot be pressed away), dehydration, very rapid breathing, recapillarisation time > 3 s, very pale, grey or blue skin, a seriously ill child or fever lasting longer than 3 days." (DGKJ, 2025, p. 22; transl. by the author)

Important warning signs that may indicate a serious illness:

• Impaired consciousness
• Sensitivity to touch
• Severe pain
• Shrill crying
• Skin haemorrhages
• Exsiccosis
• Difficulty breathing rapidly
• Pale grey skin colour with prolonged recapillarisation time
• Severely ill child
• Fever lasting longer than 3 days

Risk assessment tools

Various tools for assessing the risk of serious illness are presented. Two of these tools are cited here as examples:

Traffic light system

Tab. 2 - Traffic light system for assessing the risk of serious illness in children with fever (DGKJ, 2025, p. 23 f.)

Risk assessment for serious illness in children and adolescents with fever Medical assessment is not necessary for green, recommended for yellow, and urgent for red
Risk of serious illness	Green – Low risk :)	Yellow – Medium risk :|	Red – High risk :(
General condition	Hardly impaired	Reduced	Severely reduced
Colour of skin, conjunctiva, lips, tongue	Normal colour	Pale/marbled	very pale/grey/irregular discolouration/shiny/blue
Activity	• Smiles and communicates • Plays • awake or can be woken up • cries normally	reduced	• Does not respond or does not respond normally when spoken to • appears seriously ill • Does not wake up or remain awake when woken up • cries noticeably weakly, shrill or without interruption
Breathing		• Nostrils move noticeably when breathing ("flaring") • Rapid breathing: up to 1 year > 40 breaths/minute 1-5 years > 30 breaths/minute 6-18 years > 20 breaths/minute • Rattling sounds when breathing • Oxygen saturation ≤ 95% at room temperature	• Groans when breathing • Breathing faster than once per second (> 60 breaths/minute) • Chest retracts significantly when breathing • Oxygen saturation ≤ 90% at room temperature
Circulation	• Skin and eyes appear normal • Mucous membranes moist	• Rapid heartbeat: up to 1 year > 160 beats/minute 1-5 years > 140 beats/minute 6-12 years > 120 beats/minute 13-18 years > 100 beats/minute • Mucous membranes (inside of the lips) appear dry • Infants cannot be breastfed/fed • Urinates little or not at all (dry nappies) • Recapillarisation time ≥ 3 seconds (the skin in the centre of the chest remains white for more than 3 seconds after being pressed with a finger)	• Very dry lips and mouth, no tears when crying • Sunken eyes • No urination for a long time • Flaccid skin (e.g. a skin fold created on the back of the hand remains after release, reduced skin turgor)
Other abnormalities	No yellow or red signs	• Fever lasting more than 3 days • Swelling of an arm/leg or joint • Unable to put weight on an arm/leg or is resting it • Pain when urinating • Severe abdominal pain • Heart problems • Throbbing pain above the kidneys	• Age under 3 months and core body temperature ≥ 38 °C or below 36.5 °C • Rash that cannot be pressed away • Fontanelle is bulging and pulsating even when sitting • Unable to bend head forward • Seizure • Focal neurological signs (certain movements or senses are not functioning)

The Paediatric Assessment Triangle

The Paediatric Assessment Triangle (PAT) is used in the initial assessment of children and adolescents with fever to quickly evaluate their general condition and identify potentially life-threatening deterioration. Formal validation is not yet available. (DGKJ, 2025, p. 92)

The paediatric assessment triangle from the DGKJ guideline is shown below. An English version of the graphic, based on Dieckmann et al. (2010), can be found, for example, in Horeczko et al. (2013) at the following link: https://pubmed.ncbi.nlm.nih.gov/22831826/#&gid=article-figures&pid=figure-1-uid-0

Specific risk factors

In addition to the general assessment tools described in the previous section, specific risk factors are highlighted which, if present, mean that the occurrence of fever should always be considered a warning sign.

• Prematurity
• Congenital heart defects
• Immunodeficiency (e.g. immune disorders, leukaemia, etc.)

Age as a risk factor?

The question of the extent to which the level of fever depending on age is a decisive criterion for a serious bacterial infection (SBI) is examined.

With reference to the work of Michelson et al., the following statistical correlations are cited, which then led to the expert consensus listed below: Children with a body temperature >39°C have a higher probability of invasive bacterial infection (Michelson et al., 2021).

• However, in 30.4% of infections, the temperature is below 38.5°C.
• Infants may be afebrile in the case of an invasive bacterial infection.
• In infants under 3 months of age, the predictive value of fever for a severe infection is higher.

The expert consensus (EC) on the topic of "Age and fever level" is as follows:

Tab. 3 - Consensus-based recommendation: Age and fever level (DGKJ, 2025, p. 27, Table 3.3.1.1 EK)

	Consensus-based recommendation (status 2024)
EC	Children under 3 months of age with a (rectal) temperature of ≥ 38 °C should be carefully examined by a doctor for a severe bacterial infection. Fever may often be absent in this age group, even though a severe bacterial infection is present. The clinical findings are always decisive.
This recommendation is consensus-based, supported by only partially relevant literature and expert experience. Evidence for: Odds ratio for SBI from 38 °C	Literature: Rosenfeld-Yehoshua et al., 2018, PMID: 29387980
Very low ⊕⊝⊝⊝	Consensus strength: 100% (strong) consensus

4) No threshold value for antipyresis

In addition to the low correlations between fever level and severe illness already shown, the guideline states, with reference to a meta-analysis by Green et al., that there is no generally applicable threshold value above which the temperature should be lowered (Green et al., 2021).

5) Non-pharmacological antipyresis

The following behaviours and measures are recommended for the non-medicinal treatment of children with fever:

• A calming environment and loving care are important for children with fever.
• Parents should be informed about the positive effects of fever on the immune system.
• Undisturbed sleep is an important factor in supporting recovery.
• The child should be offered sufficient fluids, preferably warm drinks, so as not to induce additional energy expenditure for warming up.
• External cooling methods such as cold compresses are obsolete because they place additional strain on the body due to the increased energy expenditure.
• Physical heat dissipation, for example through calf wraps, is recommended. However, it is important to emphasise that the wraps should be at body temperature.

6) Medicinal antipyresis

The information on medicinal fever reduction is much more extensive than that on non-medicinal fever reduction and contains important information for the therapeutic use of common antipyretics:

• The two most commonly used medicines for reducing fever are paracetamol (PCM) and ibuprofen. Both have antipyretic and analgesic effects, with ibuprofen having a greater anti-inflammatory effect.

Ibuprofen

Like other non-steroidal anti-inflammatory drugs (NSAIDs) (e.g. diclofenac, acetylsalicylic acid), ibuprofen works by inhibiting cyclooxygenases 1 and 2, which are key enzymes in arachidonic acid metabolism (see supplementary figure below).

The desired main effect is the inhibition of prostaglandin (PG) synthesis, resulting in temperature downregulation in the hypothalamus and pain reduction.

Adverse drug reactions (ADRs) include gastric ulcers and kidney damage due to PG inhibition with regular use.

Paracetamol

In contrast, the mechanism of action of paracetamol (PCM) is still not fully understood and is significantly more complex. Due to the conjugation of PCM in the liver, the conjugation capacity of the liver is decisive for toxicity. In their review, Green et al. therefore even discuss classifying PCM as a second-line drug for fever only. (Green et al., 2021)

It is emphasised that the threshold for overdose can be quickly exceeded, especially by concerned parents. It is therefore particularly important to provide parents with detailed information.

Acetylsalicylic acid (ASA)

Acetylsalicylic acid (ASA) is not recommended for children under 12 years of age. Although the possibility of Reye's syndrome as a serious side effect of ASA administration in children under 12 years of age is no longer considered scientifically proven, it cannot be ruled out with certainty. (DGKJ, 2025, p. 51)

7) No drug-based prevention of febrile seizures

It is still common practice to administer prophylactic medication at a temperature of 38.5 °C or higher after a first febrile seizure. However, both the study by Green et al. (2021) and the current S3 guideline on fever management (Deutsche Gesellschaft für Kinder- und Jugendmedizin e. V. DGKJ, 2025) point out that there is no evidence for the effectiveness of this measure and that it should therefore be discontinued. A Cochrane review (Offringa et al., 2017) was also unable to demonstrate a preventive effect on the occurrence of febrile seizures for either ibuprofen or various anticonvulsants.

8) Well-being of the child

The main goal of all measures taken to care for a child with fever is to increase the child's well-being. This is achieved by:

• providing a calm and loving environment with a comfortable temperature,
• reducing fever as needed, and
• antipyretics not only to reduce fever, but also to relieve pain.

9) Sufficiently long convalescence

The authors of the guideline emphasise, primarily to parents, that a sufficiently long convalescence period is important for the child's recovery. The expert consensus recommends that the child should be "fit and fever-free for at least one day" before returning to nursery or school.

10) No indication for antibiotics

The expert consensus on the use of antibiotics for fever is very clear: antibiotics should only be used restrictively.

Since the majority of febrile infections are caused by viruses, there is generally no indication for antibiotic treatment. A pragmatic approach (fever as the main indication for antibiotics) is expressly rejected.

In addition, attention is drawn to the possible negative consequences of antibiotics, such as effects on the gut microbiome, allergic reactions and antibiotic resistance.

Sources and References

Deutsche Gesellschaft für Kinder- und Jugendmedizin e. V. DGKJ. (2025). S3-Leitlinie: Fiebermanagement bei Kindern und Jugendlichen. 1. Auflage 2025. AWMF-Register Nr. 027- 074. https://register.awmf.org/de/leitlinien/detail/027-074

Deutsche Gesellschaft für Kinder- und Jugendmedizin e.V. (2025, Juli 28). Pressemitteilung S3-Leitlinie „Fiebermanagement“. https://www.dgkj.de/detail/post/neu-s3-leitlinie-fiebermanagement

Dieckmann, R. A., Brownstein, D., & Gausche-Hill, M. (2010). The Paediatric Assessment Triangle: A Novel Approach for the Rapid Evaluation of Children. Paediatric Emergency Care, 26(4), 312–315. https://doi.org/10.1097/PEC.0b013e3181d6db37

Gelbe Liste—Wirkstoffe- Ibuprofen. (n.d.). Retrieved 22 October 2025, from https://www.gelbe-liste.de/wirkstoffe/Ibuprofen_289

Green, C., Krafft, H., Guyatt, G., & Martin, D. (2021). Symptomatic fever management in children: A systematic review of national and international guidelines. PLOS ONE, 16(6), e0245815. https://doi.org/10.1371/journal.pone.0245815

Horeczko, T., Enriquez, B., McGrath, N. E., Gausche-Hill, M., & Lewis, R. J. (2013). The Paediatric Assessment Triangle: Accuracy of Its Application by Nurses in the Triage of Children. Journal of Emergency Nursing, 39(2), 182–189. https://doi.org/10.1016/j.jen.2011.12.020

Michelson, K. A., Neuman, M. I., Pruitt, C. M., Desai, S., Wang, M. E., DePorre, A. G., Leazer, R. C., Sartori, L. F., Marble, R. D., Rooholamini, S. N., Woll, C., Balamuth, F., & Aronson, P. L. (2021). Height of fever and invasive bacterial infection. Archives of Disease in Childhood, 106(6), 594–596. https://doi.org/10.1136/archdischild-2019-318548

Offringa, M., Newton, R., Cozijnsen, M. A., & Nevitt, S. J. (2017). Prophylactic drug management for febrile seizures in children. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD003031.pub3

Pecoraro, V., Petri, D., Costantino, G., Squizzato, A., Moja, L., Virgili, G., & Lucenteforte, E. (2021). The diagnostic accuracy of digital, infrared and mercury-in-glass thermometers in measuring body temperature: A systematic review and network meta-analysis. Internal and Emergency Medicine, 16(4), 1071–1083. https://doi.org/10.1007/s11739-020-02556-0

Rosenfeld-Yehoshua, N., Barkan, S., Abu-Kishk, I., Booch, M., Suhami, R., & Kozer, E. (2018). Hyperpyrexia and high fever as a predictor for serious bacterial infection (SBI) in children—A systematic review. European Journal of Paediatrics, 177(3), 337–344. https://doi.org/10.1007/s00431-018-3098-x

Author: gbh | Rev.: glt | Ed.: pz | Last modified on November 6, 2025