The Outpatient Management of Fever in Children and Adolescents

Background: Fever is one of the more common symptoms in children and adolescents, accounting for 20%-40% of all pediatric office visits and ca. 30% of all pediatric contacts with the emergency medical services. The present clinical practice guideline concerns the management of fever of acute onset in otherwise healthy children and adolescents in the outpatient setting.

Methods: A systematic literature search was conducted, with evaluation according to SIGN and GRADE.

Results: For neonates and infants under the age of 3 months, the body temperature should be measured rectally with a digital thermometer. From the age of 1 year onward, it can be measured with an infrared tympanic thermometer (sensitivity 77%, specificity 98%). For infants under the age of 3 months, temperatures above 40°C are associated with an elevated risk of severe bacterial infection (OR 6.3, 95% confidence interval [4.44; 8.95]); in older children, the height of the fever has little prognostic significance (p = 0.11). The decision whether to lower the fever by medical means should be based exclusively on the degree of suffering and impairment of the child. Antipyretic agents should not be given routinely. Parents and other carers should be educated about fever as a normal defense reaction of the body and should be made acquainted with the warning signs (impaired consciousness, cutaneous hemorrhage, dehydration, capillary refill time longer than 3 seconds). Children whose degree of suffering and impairment from fever calls for treatment can be given acetaminophen (10 to 15 mg/kg BW in each individual dose, no more than 4 times per day) or ibuprofen (10 mg/kg BW in each individual dose, no more than 3 times per day).

Conclusion: This evidence-based clinical practice guideline establishes a differentiated, symptom-oriented approach to the outpatient management of fever and emphasizes the education of parents and other carers so that the unnecessary administration of antipyretic drugs can be avoided.

Cite this as: Niehues T, Krafft H, Schemmer J, Schwarz S, Möhler R, Martin D, on behalf of the Guideline Group on Fever Management in Children and Adolescents: Clinical practice guideline: The outpatient management of fever in children and adolescents. Dtsch Arztebl Int 2026; 123: 226–30. DOI: 10.3238/arztebl.m2026.0002

Fever is one of the more common symptoms in children and adolescents. While primary care data from Germany are lacking, data from England and the Netherlands show that 68–74% of all parents report episodes of elevated body temperature at least once every six months in children aged 6–56 months (1). 20–40% of all pediatric office visits and about one-third of all pediatric emergency department visits are fever-related (2, 3). Healthcare professionals and parents—or other caregivers—handle fever very differently. In the authors’ experience, fever is often viewed as a disease that needs to be treated.

Fever is highly conserved in evolution—the fever response has been present in both warm-blooded and cold-blooded vertebrates for more than 600 million years. This conservation, despite its high metabolic costs (for every 1°C increase in body temperature, the metabolic rate rises about 10–12.5%), implies that fever helps the organism survive infection. The fever response is mediated by integrated physiological circuits and confers a survival advantage (4, 5).

The term “hyperpyrexia” is defined inconsistently in the literature. While some authors define it as a body temperature above 41.1°C (106°F) (6), others use a threshold of 40°C (7). These differing definitions make it difficult to compare study results. In the case of infection-related fever, however, the term “hyperpyrexia” has no specific pathophysiological significance, since even at very high temperatures, fever is based on an endogenous, hypothalamically regulated shift in the set point. This differs fundamentally from exogenous hyperthermia (e.g., heatstroke), in which hypothalamic thermoregulation fails.

It was on this background that we have now developed the first German S3 guideline on fever management in children and adolescents (8). The guideline explicitly does not address fever in the hospital setting or in the care of chronically ill children and adolescents, for whom specific guidelines exist (9, 10, 11, 12, 13).

Methods

A 19-member working group consisting of experts from medical specialty societies, professional associations, and patient organizations was formed (eBox 2). A systematic search was conducted in MEDLINE via PubMed for publications from 13 June 2022 to 21 January 2023. Questions were formulated in the PICO framework (eBox 3). The literature search identified 99 studies, 19 of which were included in the final analysis (Figure) (e1, e2, e3, e4, e5, e6, e7, e8, e9, e10, e11, e12, e13, e14, e15, e16, e17, e18, e19). The studies were assessed with SIGN (14) and underwent an external GRADE assessment (15). This guideline is valid for five years; the full version, guideline report, parent version, updates, and an option to register for email notifications can all be found at (8).

Figure

PRISMA representation of data search

eBox 1

Guideline Collaborators

eBox 2

Participating medical specialty societies and organizations and their representatives in the guideline group for the S3 guideline on fever management

eBox 3

PICO Questions for the Systematic Literature Review

Results and Recommendations

The guideline group agreed on 24 recommendations with consensus levels ranging from 92 to 100 percent (eBox 4).

Parent education

Parents and other caregivers (guardians) should be informed that fever is a normal and usually beneficial immune response. Evidence-based information sources for caregivers include the FeverApp and information from the German Federal Center for Health Education (Bundeszentrale für gesundheitliche Aufklärung, BZgA) (16, 17).

Temperature measurement and examination

The accuracy of temperature measurement depends on the method used and the age of the patient. Alternatives to rectal measurement can be used to detect fever with high specificity, but insufficient sensitivity. In newborns and infants, the core body temperature should be measured with a digital rectal thermometer. Meta-analyses have shown that alternative methods (infrared tympanic thermometers) have a sensitivity of only 70–77% [0.60; 0.88] in this age group (e1, e2, e3, e4). The mean absolute deviation between index measurement methods and reference methods was −0.26°C (limits of agreement [LOA], −0.97 to 0.46°C) (e1). In children aged one year and older, measurement with an infrared tympanic thermometer is generally considered sufficiently accurate. Meta-analyses have shown a high specificity of 98% [0.95; 0.99] and a moderate sensitivity of 77% [0.60; 0.88] (e1, e2, e3). The mean deviation from rectal measurement was –0.22°C [–0.49; –0.04] (e3). The highest discriminative ability (AUC 0.97) was found at a cutoff value of 37.8°C, with 92% pooled sensitivity [0.90; 0.94] and 91% specificity [0.89; 0.92] (e4). Infrared forehead and temporal thermometers are less accurate than tympanic thermometers when both are compared to rectal measurement as a reference standard; the evidence for their diagnostic accuracy is very low. Nevertheless, they can be used as a practical alternative, especially when the young patient cannot tolerate more invasive measurement. Axillary temperature measurement is unreliable in all age groups and should not be used. The mean difference from rectal measurement was from -0.67°C to -0.85°C (e3, e5), and the sensitivity was a mere 42% [0.25; 0.58] even among trained users, although the specificity was high at 96% [0.91; 0.97] (e1). Palpation can be used to rule out fever but requires confirmation if it raises suspicion of fever (sensitivity 87.5% [79.3; 92.8], specificity 54.6% [38.5; 69.9] (e6).

The assessment of warning signs for severe infection

Parents often wrongly focus on the temperature reading as the supposed main indicator of disease severity. Whatever the temperature is, fever should always be interpreted in the context of the child’s general condition, well-being, and warning signs. Infants under 3 months of age with a rectal temperature of ≥38°C should be meticulously examined by a physician to rule out severe bacterial infection; those whose temperature exceeds 40°C are at a significantly higher risk of severe bacterial infection than those whose temperature is under 40°C (odds ratio [OR] = 6.3, [4.44; 8.95]). This increase in risk is lower in older children (OR = 1.63, [1.11; 2.40]) (e7). A very important finding is that, in 30.4% of infants with invasive bacterial infection, the peak temperature was below 38.5°C (18). Thus, fever is often absent in this age group even in the presence of a severe bacterial infection. The clinical findings, rather than the temperature reading, are determinative. Key warning signs include the overall clinical impression of severe compromise (as assessed by experienced medical personnel), impaired consciousness, sensitivity to touch, severe pain, high-pitched crying, skin hemorrhages, dehydration, capillary refill time exceeding three seconds, very pale/gray/blue skin, and a fever lasting more than three days. Age-dependent values for an excessively rapid respiratory rate (tachypnea) are: up to 1 year >40/min, 1–5 years >30/min, 6–18 years > 20/min. On the basis of the above data, a structured, “traffic-light” system for risk assessment was developed for the guideline (green = low risk, yellow = moderate risk, red = high risk), incorporating information on the patient’s general condition, skin color, activity level, respiration, and circulatory status (Table).

Table

Traffic-light system for assessing the risk of a serious disease in a child or adolescent with fever

Fever reduction

Fever is usually self-limiting and is considered a protective response of the immune system. In clinical practice to date, the decision to treat fever has often been based mainly on the numerical height of the measured temperature. Even children without any marked pain or clinical impairment were given antipyretic drugs solely because of a high temperature. Current evidence does not support this temperature-centered approach.

As for the treatment of fever at home, parents should be advised as follows: as the body temperature rises, a child or adolescent will often feel cold (e.g., cool hands and feet, shaking chills). During this phase, the patient should be dressed and covered as needed for warmth and comfort. If, on the other hand, the patient feels too warm, lighter clothing suffices. A sense of calm and security should also be communicated by loving care.

The guideline emphasizes a paradigm shift: the child’s well-being and complaints of pain and discomfort, rather than the temperature reading, are the determinative criteria for treatment. Treating a fever in a previously healthy child is not indicated merely to lower the temperature. The level of fever is no more than weakly correlated with the severity of illness in children aged three months and above. In infants under three months of age, temperatures above 40°C indicate an increased risk of severe bacterial infection (SBI) (OR = 6.3, 95% confidence interval [4.44; 8.95]). In children aged three months and older, even though a statistically significant association was found between temperatures above 40°C and SBI (OR = 1.36, [1.16; 1.61]), the absolute risk difference was both statistically insignificant (p = 0.11) and clinically irrelevant (e7). In a recent cross-sectional study (published after the guideline was finalized), hyperpyrexia (temperature ≥ 40.0°C) had no significant association with SBI (adjusted OR 1.40, [0.92; 2.12]) (7). Antipyretic medications should only be used for pain relief and to improve the patient’s well-being, and not in reflex fashion just to lower a high temperature. (Dosages: acetaminophen; single dose: 10 to 15 mg/kg, maximum single dose: 1000 mg, maximum daily dose: 4000 mg [over 12 years of age], no more than four to six doses per day; ibuprofen; single dose: 7 to 10 mg/kg, maximum single dose: 600 mg [over 12 years of age], maximum daily dose: 40 mg/kg or 2400 mg, no more than four doses per day).

Systematic reviews have shown that paracetamol and ibuprofen have comparable antipyretic efficacy at the recommended doses, with average temperature reductions of 0.9 to 1.85°C within two to four hours (e8, e9, e10, e11). Metamizole (10–15 mg/kg) is also comparably effective. A small number of studies have shown slightly greater temperature reductions with ibuprofen, but these differences are not clinically relevant. What matters is the improvement in well-being and pain relief, not the absolute reduction in temperature.

Giving ibuprofen and acetaminophen in alternation, or changing the antipyretic drug, may be considered after consulting a physician if the child remains affected. Compared to monotherapy with an antipyretic drug, alternating therapy with two different ones resulted in an average mean temperature that was 0.6 °C lower one hour after the second dose (MD = −0.60 °C, [−0.94; –0.26]; 78 subjects, 1 study) and 1.6°C lower three hours after the second dose (MD = −1.60°C, [−2.27; −0.93]; 40 subjects, 1 study) (e9). Another meta-analysis examined the endpoint “number of patients with fever,” comparing the alternating regimen with monotherapy at four hours (RR = 0.33, [0.07; 1.43]; 511 participants, 2 studies) and six hours (RR = 0.30, [0.15; 0.57]; 580 participants, 3 studies) (e10). The potential risk of accidentally giving the wrong drug and causing an overdose when alternating between two drugs must also be considered.

Metamizole can be given to very ill children who fail to respond adequately to ibuprofen or paracetamol (10 to 15 mg/kg up to 4 times daily). A meta-analysis (79 randomized controlled trials, with mainly adult subjects) has shown that serious adverse events with metamizole are rare, but the risk of agranulocytosis must be taken into account (e12). Detailed, continuously updated information on dosages, contraindications, interactions, and adverse effects of antipyretic drugs in children and adolescents can be found in the evidence-based online resource www.kinderformularium.de (19).

The response to antipyretic drugs does not correlate with the severity or nature of the infectious disease (viral or bacterial) and cannot be used to draw such distinctions. An overview of eight studies from 1947 to 2013 on fever in persons up to age 18 revealed that a positive response to antipyretic medication is not a suitable criterion for ruling out a serious disease (e13).

Antibiotics

A fever alone is not an indication for antibiotics. Most infections in children and adolescents are of viral origin, and even some bacterial infections do not need any antibiotic treatment.

Non-pharmacological measures

Rest, a feeling of security, keeping the child warm if he or she feels cold (cool hands/feet, shaking chills) as the fever rises, offering fluids regularly, ensuring undisturbed sleep, and light meals if the child has an appetite are recommended. Children and adolescents with a fever should not be undressed and/or exposed to cold ambient temperatures. Studies have shown that undressing the child as the sole treatment of fever causes discomfort and only minimally lowers the body temperature(e14). A meta-analysis on sponging found it to be less effective at lowering the body temperature than paracetamol alone (final temperature reduction 0.55–0.75°C vs. 0.9–1.85°C) (e8). Moreover, moderate to poor comfort was reported more frequently after sponging than after paracetamol administration alone. The focus should be on the well-being of the child or adolescent. There is only very limited evidence regarding the efficacy of calf wraps, and the available systematic reviews contain little data on this traditional method. The recommendation, based on expert consensus, is that calf wraps may be considered for warm hands and feet (no centralization) and subjective discomfort in the child. They should be at body temperature to avoid counter-regulation and should only be used if accepted by the child.

Febrile seizures and vaccinations

Antipyretic drugs do not shorten febrile seizures and are not indicated in acute situations; nor do they prevent febrile seizures, and they should not be used for this purpose. Meta-analyses have revealed no significant difference in the recurrence rate of febrile seizures between children with and without antipyretic prophylaxis (e15, e16). Published meta-analyses of two and three randomized controlled trials yielded OR = 0.92; [0.57; 1.48] (e15) and OR = 0.9, [0.57; 1.43] (20), respectively, for febrile seizure recurrence under antipyretic treatment: in other words, no statistically significant protective effect was found.

The prophylactic administration of antipyretic drugs in children undergoing vaccination should be avoided. Systematic reviews have shown that prophylactic antipyretic treatment with acetaminophen (but not ibuprofen) led to significantly lower antibody levels after pneumococcal conjugate vaccination (e17, e18), albeit within a titer range that is still thought to be protective. Note: The STIKO recommendation of 18 January 2024 regarding the prophylactic administration of paracetamol during meningococcal B vaccination, which has since been revised, was published after the consensus meetings for this guideline.

Recovery

Children should be without fever and feeling well for at least one day before returning to preschool or school (this recommendation is based on expert consensus, not on direct evidence from the literature).

Discussion

The definition of fever and temperature measurement

There are international differences in the definition of fever in children. While in German-speaking countries a temperature of 38.5°C or higher is often defined as a fever, English-language guidelines mainly set the threshold at 38.0°C. The present guideline follows the definition of ≥38.5°C, corresponding to the usual clinical practice in Germany.

Symptom-based rather than temperature-based treatment indication

For otherwise healthy children and adolescents, there is no evidence-based temperature threshold above which antipyretic therapy is absolutely indicated. The key factors determining the need for treatment are not the temperature reading itself, but rather the child’s subjective well-being, the presence or absence of pain, and the overall clinical impression. National guidelines from other European countries also emphasize this (21, 22, 23). Epidemiologic data on the prevalence of high fever in otherwise healthy children are not available. The clinical experience of the guideline group indicates that many children do not exhibit any marked discomfort even at temperatures >39°C and therefore do not require antipyretic intervention.

Limitations and strengths

The quality of evidence from the studies underpinning this guideline (assessed by the GRADE scheme) was predominantly moderate to low. Its main limitation is the scarcity of methodologically sound randomized controlled trials on patient-relevant outcomes (well-being, quality of life). Its strengths include the systematic approach in accordance with AWMF standards, the comprehensive literature review, and the broad interprofessional consensus that was reached with the additional involvement of parent representatives.

Long-term aspects

The available evidence on the potential long-term effects of repeated antipyretic therapy in childhood is limited. In a meta-analysis of 27,932 children in the first two years of life, the rate of serious adverse effects (including kidney damage) was 1.4% for ibuprofen and 1.3% for acetaminophen (e11). In Germany and the United States, acetaminophen is among the more commonly reported drugs associated with poisoning in children. These factors underscore the importance of a restrictive, symptom-oriented approach to prescribing, as recommended in this guideline.

Financial support
This guideline was funded by the Innovation Task Force (Innovationsausschuss) of the German Joint Federal Committee for the Promotion of Health Services Research (Bundesausschuss zur Förderung von Versorgungsforschung), in accordance with §9a(2), item 4, second alternative, of the German Social Code, Book V (SGB V) (funding reference: 01VSF21023; Fever Guideline – AWMF S3 Guideline: Fever Management in Children and Adolescents – G-BA Innovation Fund).

Conflict of interest statement
TN is a member of the German Medical Association’s Drug Commission (AKdÄ), receives payment for writing on the subject (Uptodate.com), and receives reimbursement for travel expenses and third-party funding for research projects (KidSafe Study, GBA Innovation Fund), as well as travel expense reimbursement for consulting work for the European Medicines Agency (EMA) and for the Steering Committee of the Penta Foundation (an international scientific network for child health research).

DM advises the German Federal Ministry of Health, serves on scientific advisory boards (Hufeland Society, Pharmacovigilance Commission of the Federal Institute for Drugs and Medical Devices [BfArM]), and receives travel expense reimbursement for speaking engagements (BVKJ, DGKJ, DGHNO-KHC, DGÖG, BVÖGD, DGAAP, AWMF) and third-party funding for research projects (BMBF/Software AG Foundation-funded FieberApp development, Joint Federal Committee [GBA] Innovation Fund).

SS receives reimbursement for travel expenses (BMBF, BVKJ, BVÖGD).

The remaining authors and guideline group members state that they have no conflict of interest.

Manuscript submitted on 29 October 2025, revised version accepted on 8 January 2026.

Translated from the original German by Ethan Taub, M.D.

Note: clinical practice guidelines that are published in the Deutsches Äzteblatt and many other medical publications are not subject to peer review, because S3 guidelines are already texts that have been extensively evaluated, discussed, and broadly agreed upon by experts (peers).

Corresponding authors
Prof. Dr. med. David Martin

Prof. Dr. med. Tim Niehues

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