We found conflicting statements and a lack of evidence regarding one fundamental category that affects almost all other recommendations. This concerns the question: “is there a temperature above which antipyresis should be attempted in acute febrile infections in children?”–in short: the threshold question. Since the NICE guidelines [11] have previously been judged to be of high quality [8], and make a recommendation to treat distress rather than body temperature, we thoroughly examined their data for evidence supporting a lack of temperature threshold and determined that the conclusion they came to was unjustified based on the evidence that they provided.

Two authors then independently attempted to address this question using the GRADE method [12]. One author used the search terms: “fever AND temperature threshold AND children AND guideline AND permissive treatment” and identified a pilot RCT trial [13] and 8 papers related to threshold that were surveys and thus deemed ineligible for inclusion in a GRADE analysis. The other author used the terms: ((("acetaminophen"[MeSH Terms] OR "acetaminophen"[All Fields]) OR ("acetaminophen"[MeSH Terms] OR "acetaminophen"[All Fields] OR "paracetamol"[All Fields]) OR antipyresis[All Fields] OR ("ibuprofen"[MeSH Terms] OR "ibuprofen"[All Fields]) OR threshold[All Fields] OR ("antipyretics"[Pharmacological Action] OR "antipyretics"[MeSH Terms] OR "antipyretics"[All Fields] OR "antipyretic"[All Fields])) AND (harm[All Fields] OR benefit[All Fields] OR outcome[All Fields] OR ("mortality"[Subheading] OR "mortality"[All Fields] OR "mortality"[MeSH Terms]) OR ("epidemiology"[Subheading] OR "epidemiology"[All Fields] OR "morbidity"[All Fields] OR "morbidity"[MeSH Terms]) OR ("immune system phenomena"[MeSH Terms] OR ("immune"[All Fields] AND "system"[All Fields] AND "phenomena"[All Fields]) OR "immune system phenomena"[All Fields] OR ("immune"[All Fields] AND "function"[All Fields]) OR "immune function"[All Fields]) OR distress[All Fields])) AND ((peak[All Fields] AND ("body temperature"[MeSH Terms] OR ("body"[All Fields] AND "temperature"[All Fields]) OR "body temperature"[All Fields])) OR ("fever"[MeSH Terms] OR "fever"[All Fields]) OR ("fever"[MeSH Terms] OR "fever"[All Fields] OR "febrile"[All Fields]) OR ("fever"[MeSH Terms] OR "fever"[All Fields] OR ("elevated"[All Fields] AND "temperature"[All Fields]) OR "elevated temperature"[All Fields])) and identified 1704 papers.

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