Fever management in children and insights into fever of unknown origin: a survey among Italian pediatricians

Abstract

Background: Fever is a common symptom in children, but despite existing guidelines, pediatricians may not fully apply recommendations. Fever of Unknown Origin (FUO) is generally referred to as an unexplained prolonged fever. However, a standardized FUO definition and management is missing.

Objective: To collect updated data on the approach to fever and FUO among Italian pediatricians.

Methods: A cross-sectional anonymous survey was conducted among a large sample of primary care and hospital pediatricians. The panel group formulated and proposed a practical FUO definition, using a modified Delphi approach. A 75% consensus was required to reach an agreement.

Results: Among 620 respondents, paracetamol was the first-choice antipyretic for 97.7% of participants, followed by ibuprofen; 38.4% prescribed antipyretics based on a specific body temperature rather than on child's discomfort, while physical methods were almost completely abandoned. Alternate treatment was recommended by 19.8% (123/620) of participants, 16.9% (105/620) would prescribe antipyretics to prevent adverse events following immunization. Regarding FUO diagnosis, 58.3% (362/620) considered as cut-off a body temperature above 38°C; the duration required was one week according to 36.45% (226/620) of participants, two weeks according to 35.32% (219/620). The FUO definition proposed by the expert panel reached 81% of consent. Large agreement was observed on first-level laboratory and instrumental investigations in the diagnostic evaluation of FUO, whereas more discrepancies arose on second and third-level investigations. Compared to what participants reported for the treatment of non-prolonged fever, a significant decrease in the prescription of paracetamol as first-choice drug in children with FUO was observed (80.5%; P < 0.0001). Interestingly, 39% of participants would empirically recommend antibiotics, 13.7% steroids, and 4.5% Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) for persistent FUO.

Conclusion: Non-recommended behaviors in fever management persist among pediatricians, including alternating use of paracetamol and ibuprofen, and their prophylactic use for vaccinations. Our data confirm the variability in the definition, work-up, and management of FUO. We observed that in children with FUO paracetamol was significantly less commonly preferred than in non-prolonged fever, which is not supported by evidence. Our findings combined with evidence from existing literature underlined the need for future consensus documents.

Keywords: children; fever; fever of unknown origin; ibuprofen; paracetamol.

Figure 1

Criteria for the diagsnosis of FUO according to survey participants. (A) Body temperature cut-off. (B) Fever time duration (weeks).

Figure 2

Investigations recommended by survey participants. (A) Laboratory tests. CBC, complete blood count; CRP, C-reactive protein; LDH, lactate dehydrogenase; ANA, anti-nuclear antibodies; ENA, extractable Nuclear Antigen Antibodies. (B) Microbiological tests. CMV, cytomegalovirus; EBV, epstein-barr virus; GABHS, group A beta-hemolytic Streptococcus; RAD, rapid antigen detection; HIV, human immunodeficiency virus.

Figure 3

Instrumental tests recommended by survey participants. US, ultrasound; CT, computed tomography; MRI, magnetic resonance imaging.

Figure 4

Specialist evaluations recommended by survey participants.

Figure 5

First-choice antipyretic in case of unspecified case of fever in children or FUO according to survey participants. *P < 0.0001.

Figure 6

Therapeutic strategy to persistent fever. (A) Subgroup of participants who prescribe paracetamol as first-choice antipyretic. (B) Subgroup of participants who prescribe ibuprofen as first-choice antipyretic.