Advise the child's carers to:

• Treat a child who is feeling miserable with fever with either paracetamol or ibuprofen:
• If there is a lack of effect with one treatment alone then consider alternate use of ibuprofen and paracetamol every 4 hours.
• Do not try to reduce fever by under-dressing the child or tepid sponging.
• Encourage the child to take fluids regularly. For infants that are breastfed, continue breastfeeding as normal.

All the recommendations in this section are based upon expert consensus obtained from a group of experts using the Delphi technique, or on evidence reviewed and summarized in the National Institute for Health and Clinical Excellence (NICE) guideline Feverish illness in children. Assessment and initial management in children younger than 5 years [National Collaborating Centre for Women's and Children's Health, 2007]. The CKS recommendation regarding the prescribing of ibuprofen and paracetamol alternately differs slightly from NICE.

Basis for recommendations to manage fever:

• Treating fever in children only if they are distressed or unwell:
• NICE could not find any evidence for any specific indications for the administration of antipyretics.
• Expert consensus was reached using the Delphi technique to support using antipyretic drugs to treat children who are distressed or unwell with fever.
• No expert consensus was reached to support using antipyretics in all children with fever because some experts argue that:
• Fever is a physiological response to infection. Theoretically, suppressing fever may impair the body's response to infection and delay recovery. In addition, antipyretics may have adverse effects. Therefore, experts recommend their use only when there are likely to be clear benefits from treatment.
• Use of either paracetamol or ibuprofen to reduce fever:
• NICE found two systematic reviews and four good quality randomized controlled trials (RCTs) comparing paracetamol and ibuprofen for the treatment of fever in children.
• It concluded from this data that ibuprofen and paracetamol are both effective at reducing fever in children.
• Alternating paracetamol and ibuprofen to treat fever for children who have not responded to either drug taken alone:
• NICE found evidence from one good quality RCT (n = 464) that compared the effectiveness of ibuprofen and paracetamol alone with alternating paracetamol and ibuprofen every 4 hours to treat fever in children.
• This limited evidence suggests that alternating ibuprofen and paracetamol treatment is superior to monotherapy in reducing fever. However, there are no data available on the safety of this regimen and because of this, routine use of alternating paracetamol and ibuprofen to treat fever in children is not recommended.
• CKS recommends using alternating paracetamol and ibuprofen to treat fever in children if a single drug alone has proven to be ineffective, because limited evidence (and clinical experience) suggests that this is effective when monotherapy has failed.
• Not using tepid sponging to control temperature:
• NICE found a systematic review which evaluated the benefits and harms of tepid sponging. It also found two reviews of studies that compared tepid sponging with antipyretic drugs.
• This showed that physical methods of cooling a child can reduce temperature but that these effects are short lived and can cause distress to the child. As relieving distress is the primary goal of reducing fever, NICE concluded that physical methods of cooling are not justified.

Basis for recommendation to encourage the child to take fluids regularly:

• This advice is based upon expert consensus reached using the Delphi technique.

Basis for advice on how to monitor and when to reconsult:

• This advice is based upon expert consensus reached using the Delphi technique.