Defining fever-related discomfort in children: an international Delphi consensus

Abstract

Fever is one of the most common symptoms in childhood and a frequent reason for medical consultation. Current guidelines recommend treating fever only when discomfort is present. However, the concept of fever-related discomfort remains poorly defined and inconsistently applied in clinical practice and research studies. We aimed to develop an expert-based definition and a pragmatic clinical framework for the assessment and management of discomfort in febrile children. An international modified Delphi consensus was conducted to develop an operational definition and pragmatic clinical framework for fever-related discomfort in children. A steering international committee developed initial statements, which were evaluated across three iterative online Delphi rounds by seven international experts from high-income countries. Agreement was assessed using a 5-point Likert scale, with consensus predefined as ≥ 75% agreement. Experts' feedback was used to refine statements between rounds. The panel reached consensus that fever-related discomfort is a multidimensional construct encompassing behavioral, emotional, and functional indicators. A traffic-light system was developed to stratify discomfort severity into: green (no intervention needed); amber (case-by-case intervention); and red (intervention always indicated) categories. Key clinical indicators were identified for each category. The framework was considered applicable across pediatric age groups and care settings, with individualized clinical judgment recommended for children with chronic conditions or those in intensive care. CONCLUSION: This international Delphi consensus provides a preliminary expert-derived framework for defining and assessing fever-related discomfort in children. Future studies are warranted to evaluate its reliability, feasibility, cultural applicability, and clinical validity across larger and more diverse populations and healthcare settings. WHAT IS KNOWN: • Current pediatric guidelines recommend treating fever in children only when discomfort is present rather than aiming to normalize body temperature. • However, fever-related discomfort remains poorly defined, with substantial heterogeneity across studies and guidelines and no standardized clinical framework currently available. WHAT IS NEW: • This international Delphi consensus defines fever-related discomfort as a multidimensional construct involving behavioral, emotional, and functional indicators. • A pragmatic Traffic-Light System was developed to stratify discomfort severity and support clinical decision-making across pediatric settings and age groups.