FEVER IN CHILDREN: WHEN TO TEST, TREAT AND AVOID ANTIBIOTICS

By Dr Weriwoyingipre Silver Yeibake  Paediatrics, Federal Medical Centre Yenagoa, Bayelsa State 

Email: silveryeibake@gmail.com

When a child feels hot, it is natural to worry. But fever is a symptom, not a diagnosis. It is often part of the body’s inflammatory response, so *not every fever requires an antibiotic or antimalarial medicine.

Why fever happens

Fever is a regulated component of the body’s response to infection, tissue injury or other illness—not simply a direct effect of germs.

When immune cells detect infection or tissue damage, they release inflammatory chemicals called *pyrogenic cytokines*, including interleukin-1, interleukin-6 and tumour necrosis factor-alpha. These stimulate the production of *prostaglandin E₂*, which acts on the hypothalamus—the brain’s temperature-control centre—to raise the body’s temperature set point. [1–3]

The child may then feel cold, develop cold hands and feet, or shiver while the body generates heat. When the response settles, the temperature returns to normal and sweating may occur.

Safe home care

If the child is alert, drinking and breathing comfortably:

- Measure the temperature with a reliable thermometer.

- Continue breastfeeding and offer frequent fluids.

- Give oral rehydration solution for diarrhoea or vomiting.

- Dress the child lightly and keep the room comfortably ventilated.

- Allow the child to rest and check regularly, including during the night.

- Monitor drinking, urination, breathing and alertness.

- Give paracetamol only if the child is uncomfortable, using the correct weight-based dose.

- Do not give aspirin to children.

- Do not routinely alternate paracetamol and ibuprofen unless advised by a healthcare professional.

Do not wrap a feverish child in heavy clothing or blankets, even if the hands and feet are cold or the child is shivering. Avoid ice, cold baths, alcohol rubs and cold-water sponging, which may worsen shivering and discomfort. [4–6][15–19]

Watch for dehydration, including reduced urination, dry mouth, sunken eyes, absence of tears, unusual sleepiness or marked weakness. Encourage small, frequent drinks and seek medical advice if the child cannot drink, repeatedly vomits or becomes less alert. [1][2][15–19]

Teething does not cause fever

Teething is a normal developmental process. It may cause sore gums, drooling, fussiness and a desire to chew, but it does *not cause a true fever.

If a teething child has measured fever, diarrhoea, vomiting, cough, breathing difficulty, weakness or poor feeding, another cause should be considered.

Teething may cause discomfort, but it should not explain a fever.

When to test for malaria

In malaria-endemic areas, malaria should be considered in a child with fever, but fever alone does not prove malaria. Where available, malaria should generally be confirmed with a rapid diagnostic test or microscopy before treatment. [3][4]

If the test is negative, the child should be assessed for other causes, including viral infection, pneumonia and urinary tract infection.

A doctor may occasionally treat malaria despite a negative test after considering the child’s examination, severity, local malaria risk, test quality and timing, previous antimalarial use, and the possibility of a false-negative result. *This should be an individual clinical decision, not routine treatment for every fever or negative test.* Caregivers should not start, continue or repeat antimalarial medicines without medical advice.

Antibiotics require medical evaluation

Antibiotics treat selected bacterial infections; they do not treat viruses, which cause most colds and many uncomplicated coughs, sore throats and diarrhoeal illnesses.

Antibiotics should be prescribed after medical evaluation by an appropriately qualified medical practitioner. They should not be selected or supplied over the counter by caregivers, medicine vendors, patent and proprietary medicine vendors, or other non-medical practitioners. The prescriber should determine whether an antibiotic is needed and select the appropriate drug, dose and duration. [5][6]

The routine use and sale of over-the-counter antibiotics are wrong practices. Unregulated sales encourage self-medication, inappropriate treatment and antimicrobial resistance. [11–13]

Antibiotics may be required for pneumonia, urinary tract infection, meningitis, sepsis, certain skin infections or dysentery. They should not be used simply because a child has fever, is teething, has cold hands and feet, or previously improved after taking one. Leftover medicines and another person’s prescription should also be avoided.

The risk of antimicrobial resistance

Antimicrobial resistance occurs when organisms no longer respond to medicines that previously treated them. In children, resistant infections may:

- Fail to respond to first-line treatment.

- Become severe, causing pneumonia, meningitis, sepsis or other complications.

- Require longer hospital admission and more expensive care.

- Require less available, injectable or more toxic medicines.

- Spread to siblings, caregivers and the wider community.

- Make surgery, intensive care and care of premature or chronically ill children more hazardous. [11–13]

Unnecessary, incorrectly dosed or unsupervised antibiotic use encourages resistance. *Appropriate antibiotics can be lifesaving, but they should be used only when clinically indicated, at the correct dose and for the prescribed duration.*

Red flags: seek immediate care

Take the child to hospital immediately if there is:

- Difficulty breathing, grunting, gasping, very fast breathing or chest indrawing.

- A convulsion, collapse or fainting.

- Unusual drowsiness, confusion, inability to wake or failure to respond normally.

- Inability to breastfeed or drink, or repeated vomiting.

- Severe dehydration, including very little urine, dry mouth, sunken eyes, no tears or extreme weakness.

- A stiff neck, severe headache, sensitivity to light or severe persistent pain.

- A rash that does not fade when pressed.

- Blue, grey, very pale, mottled or unusually cold skin.

- Severe abdominal pain, blood in vomit or stool, or rapidly worsening illness.

- *Any fever in a baby younger than 3 months*, particularly a temperature of 38°C or higher. [1][2][7]

Do not force fluids into a drowsy or unconscious child. Keep the child lightly dressed while seeking help.

Author’s note

Fever should be managed with calm observation, supportive care, appropriate testing and timely medical review—not automatic medication. Continue breastfeeding and fluids, keep the child lightly dressed, and monitor breathing, alertness, feeding, urination and activity.

Remember: teething is not a disease and does not cause fever. Fever alone is not an indication for antibiotics. Antibiotics should be prescribed only after medical evaluation, not chosen over the counter by caregivers or non-medical practitioners.

In malaria-endemic settings, test when appropriate and allow the treating doctor to interpret the result in context. Although a doctor may occasionally treat malaria despite a negative test, this is an individual decision and is not necessary in every case.

Early recognition of danger signs can save a child’s life.

References

1. Evans SS, Repasky EA, Fisher DT. Fever and the thermal regulation of immunity. *Nature Reviews Immunology.* 2015;15(6):335–349. doi:10.1038/nri3843  

2. Oka T. Prostaglandin E2 as a mediator of fever. *Frontiers in Neuroscience.* 2021;15:648574. doi:10.3389/fnins.2021.648574  

3. Blatteis CM. The initiation of fever. *Progress in Brain Research.* 2007;162:3–14. doi:10.1016/S0079-6123(06)62002-1  

4. National Health Service. *High temperature (fever) in children.* https://www.nhs.uk/symptoms/fever-in-children/  

5. National Institute for Health and Care Excellence. *Fever in under 5s: assessment and initial management.* NICE guideline NG143. https://www.nice.org.uk/guidance/ng143  

6. World Health Organization. *Pocket Book of Hospital Care for Children.* 2nd ed. https://www.who.int/publications/i/item/9789241548373  

7. World Health Organization. *WHO Guidelines for malaria.* 2025. https://www.ncbi.nlm.nih.gov/books/NBK588130/  

8. WHO Regional Office for Africa. *Guidelines for case management of malaria.* https://www.afro.who.int/sites/default/files/2017-05/casemgt.pdf  

9. World Health Organization. *The WHO AWaRe antibiotic book.* 2022. https://www.who.int/publications/i/item/9789240062382  

10. World Health Organization. *Recommendations for management of common childhood conditions.* https://www.who.int/publications/i/item/9789241502825  

11. World Health Organization. *Antimicrobial resistance.* https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance  

12. McKinnell JA, et al. The growing threat of antibiotic resistance in children. *Current Opinion in Pediatrics.* 2018;30(1):65–72. https://pmc.ncbi.nlm.nih.gov/articles/PMC5927609/  

13. UNICEF. *Antimicrobial resistance: A crisis for children everywhere.* https://www.unicef.org.uk/campaign-with-us/futures-at-risk/antimicrobial-resistance-a-crisis-for-children-everywhere/  

14. World Health Organization. *Integrated Management of Childhood Illness: Chart Booklet.* https://www.afro.who.int/sites/default/files/2017-06/chartbooklet.pdf  

15. National Health Service. *High temperature (fever) in children.* https://www.nhs.uk/symptoms/fever-in-children/  

16. National Institute for Health and Care Excellence. *Fever in under 5s: recommendations.* https://www.nice.org.uk/guidance/ng143/chapter/recommendations  

17. National Institute for Health and Care Excellence. *Fever in under 5s: information for the public.* https://www.nice.org.uk/guidance/ng143/informationforpublic  

18. NHS Inform. *Fever in children.* https://www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/fever-in-children/  

19. World Health Organization. *Pocket Book of Hospital Care for Children.* 2nd ed. https://www.who.int/publications/i/item/9789241548373