Tuesday, March 16, 2010

Treating a Fever - Education for parents....Yikes! this is a long one!!

My post the other day regarding the lack of parents treating their children's fever was out of frustration.....out of that frustration is now coming EDUCATION!!  Please remember, though I am a Registered Nurse, I am offering this education & advice as a mother.  You know your child best.  Always consult your pediatrician, family doctor, PA, or Nurse Practitioner anytime you have concerns about your child's health.

Fever  is a common medical sign.  The normal range for body temperature (the "set-point" for thermoregulation) is generally 98 - 100 degrees Farenheit (though many people tend to run under 98 degrees, and that is completely normal for them).  In our hospital, we don't consider it a "fever" until it reaches 100.4 degrees (38 degrees Celsius), RECTALLY.  Any child less than 3 years of age, or if unable to cooperate with an oral temperature, should have a rectal temperature taken.  Go HERE for a comparison of rectal, oral, axillary, and tympanic temperatures.  Rectally is considered the most accurate - a "core" temperature.

As your body temperature rises, you feel cold.  You may shiver, shake, have increased muscle tone and want to pile on the blankets.  The body has a purpose - the shivering and shaking, aka "chills" - actually increase heat production,  like your furnace turning on when you turn up the thermostat.  Once the body reaches the fever point, you may feel hot.  You have body aches, you may want to sleep, children may become listless, fussy, and flushed.  The body then uses vasoconstriction (making the blood vessels smaller) to reduce heat loss and maintain the temperature.  This is why a person with a fever has cold hands and feet.  

Fever in and of itself is not a disease.  Fever is often a response to an infection - either viral or bacterial.  It actually is one way your body attempts to neutralize the "invaders."  A pyrogen is a substance that brings on fever.  Some pyrogens are part of our own immune system, others are within the bacteria or virus themselves (this is a very simplistic explanantion - our immune system is extremely complex!).  

The usefulness of fever is controversial.  There are arguments for and against treatment of fever.   In theory, the hot environment produced by the fever increases the efficiency of some components of our immune system.  However, they are uncomfortable and can rapidly produce dehydration in small children and the elderly via insensible loss - sweating, evaporation, increased metabolic rate, etc.

 Fever is not a medical emergency in and of itself.....the exception being extremely high fevers (like 106 and above) that may represent a more serious underlying condition (systemic infection, neurological problems, medication reaction).  Febrile seizures can occur in children, particulary in toddlers, and are fairly common. Read more about them HERE

A word of caution for parents - don't get hung up on the number.  What I mean is, a fever of 105 is not necessarily any more serious than a fever of 101.  The concern is always the underlying cause of the fever.


**NOTE:  any fever above 100.4 degrees Fahrenheit in a baby less than 30 days old needs to be checked out by a medical provider - call your doctor or go to the ER.  Newborns have immature immune systems and are particularly vulnerable to infection.  This is why I would not recommend taking a newborn to the mall or any other place where there are crowds of people in close proximity.

This is how I approach fevers in my own children.  I ask myself these questions:
  • How does my child look?  is she up and about, drinking normally and having wet diapers?  or is she hard to wake up, refusing water, with strong-smelling urine?  Is she really fussy?  or just a little "sensitive?"
Rationale:  I'm not as concerned about the cause of the fever if she is behaving pretty normally and taking in enough fluids.  I would seek medical care if she was lethargic, with signs of dehydration.  If she is really fussy, is she in pain?  Babies and small children communicate how they feel with their behavior.
  • How long has the fever been present?  
Rationale:  Most fevers associated with viruses last 2-3 days.  If the fever is present more than 3 days, there is a chance it is a more serious infection that may require antibiotics.  For me, if it's been more than 3 days in a small child, we go to the doctor.  For my bigger kids, I may wait a day or two longer.
  •  Are there other symptoms present that i'm worried about?  a persistent cough with or without wheezing, pulling at the ears, green snot, rash, swollen & red gums, vomting &/or diarrhea, etc.
Rationale:  I'm less likely to worry about a fever in a baby with red, tender, swollen gums (likely teething) than I am a child that is coughing or pulling at their ears.  Small children can become dehydrated quickly, so vomiting and diarrhea always needs vigilant attention.
  • Since I know my child best, am I worried in my gut?  Trust your instincts!!! 

WebMD has a useful chart HERE that can help you sort all of this out for kids under 3.


There are 3 common "antipyretic" medications available over the counter.  Tylenol (Acetaminophen), Motrin (Ibuprofen), and Aspirin.  Here is a little about each:

** As with all medications, keep out of reach of children.  A Tylenol overdose can cause fatal liver damage.  An Ibuprofen overdose can cause multi-system damage.  I recommend you keep the number posted for your local poison control center.  

1.  Tylenol (one of several brand names), generic name is Acetaminophen.  Yes, it's OK to buy the store brand.  It has been FDA approved since 1951.  Generally accepted as a very safe medication in normal doses.  The exact mechanism of action is unknown, but it works!  Give every 4 hours as needed and follow the dosing guidelines on the bottle, which are based on weight. Generally safe to take during pregnancy and breastfeeding. 

2.  Motrin, generic name Ibuprofen.  Used only in children 6 months of age and older.  Ibuprofen is an anti-inflammatory medication.  It has been FDA approved since 1974.  Ibuprofen works by blocking part of the fever-producing pathway in the body.  Can be given every 6 hours as needed, dosage is based on weight.  Do not use during pregnancy, is ok to use while breastfeeding.  People with some chronic medical conditions, esp kidney disease, should not use Ibuprofen. 

3.  Aspirin.  Do not use in children or teens due to risk of Reye's Syndrome.  Also be aware of any over the counter products containing "Salicylates" - the active ingredient in aspirin.  Products include Pepto-Bismol, Alka Seltzer, Excedrin, pamprin.  See a list HERE.  For more info, or if you know someone affected by Reye's Syndrome, go HERE.  End of discussion.

Can Tylenol and Motrin be given together?  Why YES - they are different medications that work in different ways!! I'm so glad you asked!  This is one of the most common strategies for controlling fever.  Here is what I do for my kids:

If my child has a low-grade fever (up to 101) but seems comfortable, is playful, consolable, and drinking fluids - I don't give medication, but do monitor the temperature every 4 hours or with any change in signs or symptoms.

My first line medication (for kids over 6 months) is Ibuprofen.  Often it will control the fever and relieve the aches and pains that go with it.  I often don't need to add Tylenol.   But  if I do, this is how:

Fever discovered - give a dose of Tylenol and Ibuprofen.  4 hours later, give Tylenol.  2 hours after that give Ibuprofen, 2 hours after that give Tylenol, 4 hours after that give Ibuprofen and Tylenol.  Continue for 24 hours, then you can stop and see if the fever returns.  If it does, start over.  Remember, 4 hours between doses of Acetaminophen and 6 hours between doses of Ibuprofen.  No more than 5 doses of any one medication in a day.  

Go HERE for other tips on managing fever.

Remember, the concern should always be with what is causing the fever.  Also, this education is for non-diabetic children.  Fever management in diabetic children is different - that's another post!

Disclaimer (again) - this is educated motherly advice, not medical advice.


Thanks for reading and commenting!

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