Fever is often a part of life as a parent, particularly with young children in the winter time (read: 6-10 colds a year is the norm). Although I sincerely don’t like it and do feel naturally uneasy when my boys have a fever, as a pediatrician I know to take fever as one of many symptoms they develop when responding to infection. I certainly use medications like Tylenol when my boys are feverish, refusing to eat, punked out, and exhausted. Thing is, it works! And often they respond beautifully, bouncing back, regaining energy and improving their fluid intake and appetite. But I don’t treat every fever they have and I don’t recommend you run for the medicine cabinet when you feel that warm forehead. It’s not necessary to treat every fever. And it’s certainly not ideal to treat the numbers, themselves. Fever is a natural response of the immune system. Fever ultimately can be productive and may assist your child’s body in fighting off infection.
Fever phobia is pervasive though; we pediatricians are partly to blame. This week the American Academy of Pediatrics published a report on fever (and fever phobia) and the use of fever-reducing medications like acetaminophen (Tylenol) and ibuprofen (Advil or Motrin). Listen to my take in the video. The main take home is not to treat fever per se, but your child. There is no reason to make a fever disappear if your child is otherwise acting well, playful, and staying hydrated. But do know there are some fevers that do require a visit with the pediatricians. It’s important to seek care when fever persists after 3 days in infants and children, any fever in a baby 3 month old or less, and if fever is over 104 degrees. Furthermore, trust your instincts! If your child looks unwell in the face of fever and doesn’t seem to be improving as you would expect, call you pediatrician for help!
What do you think; does fever freak you out? Do you feel like you need to treat fever immediately? Does this information help you feel more at ease with temperature elevation and fever in infants and children?
(Errata: The paper detailed above from the AAP this week isn’t a “Policy Statement” as I mistakenly said in the video. It’s a “Clinical Report.”…and well, that’s a different thing. I apologize if I caused any confusion.)
I think treating the child like you mention is more instinctive for parents. We’re not doctors, so we’re not looking for disease, we are looking for the things that make our little ones not act like themselves–that is the only thing that gets me worried!
It’s not so much my own reaction to fever that this news helps. Other parents and family members pressure many moms to over treat our children, and it can be helpful to have info backing up instincts, as in this case.
Great post — definitely hit home to me, as someone whose tyke is fighting her second ear infection in a month, so we’ve dealing with the double whammy of the possibly-unecessary abx (my first-time-mom thoughts on that: very worried about resistance, but too paranoid to risk that she really needs them and would get worse without them!) and should-we-still-be-giving-motrin-even-though-she-seems-mostly-better drama. Having seen what she’s like when she’s NOT feeling well from a fever, I’ve been inclined to keep giving her Motrin or Tylenol sort of prophylactically as she starts getting better, for fear it’ll come back if we taper off. But I know that’s not wise, so we’re not. Interestingly, though, our peds practice hasn’t mentioned anything about either issue – and they seem to give abx for ear infections without question.
This is pretty much how I have treated fever with the kiddos. Emma doesn’t seem to be as fever prone as her brother, except for when she has vaccinations, then she responds with a whopper of a fever, which I have treated both times it has happened due to her obvious discomfort and lack of interest in nursing/eating. Will, on the other hand, seems to spike a fever whenever he gets even the tiniest bit of sick, so I tend to treat his fevers less. I guess just continuing to learn their individual responses to fever (as you said, “treating the child”) has made a difference in how I treat them when they have one.
I’d be interested in your take on this example:
My daughter was born 8 weeks premature. She had no ongoing problems but we were told to be extra careful with respiratory conditions etc.
When she was 7 months old she developed a cold with fever. She was basically fine, but the fever was quite high (38.5C). It was her first, so I called the provincial health helpline (I’m in Canada) for advice. They follow protocols; and the protocol said because of her age and prematurity she needed to be seen at once. It was 2am in the morning, so that meant a visit to ER. I found that surprising; left to my own instincts I would have waited till morning.
Of course, she was low on the triage list, and we waited for hours – and by the time she was seen the fever had gone away on its own. Meanwhile we’d all had a sleepless night.
When we asked the ER doctor if bringing her in had been the right thing to do, she basically said what you say above: if, as a parent, you’re worried, bring your child in; but go by behaviour more than temperature.
Wendy Sue Swanson, MD says
My take is you all did the right thing! It’s hard to practice medicine over the telephone, and I suspect what you told the helpline alerted them to make sure that there wasn’t anything else going on. But you’re right, nurses and assistants (and doctors) follow protocols, and often protocols protect patients in a triage situation like this. And you were alarmed by the first fever and protective because of your daughter’s history of prematurity, etc. So, although it may have felt like a “wasted” visit in the middle of the night, I think it may have made sense for that protocol to usher you into the ED. Sorry about the icky night in the ED, but it’s always easiest/easier in hindsight to know what the plan would have been. In this case, I suspect it’s a better safe than sorry. And now as an experienced mom you know a ton more!
Heather Cooper says
Seattle Children’s offers this flyer with more information on how to treat fever and how to take your child’s temperature: https://www.seattlechildrens.org/pdf/CE145.pdf
Thanks for the great explanation of the AAP’s report!
I grew up having all fevers treated so I did initially think it was the norm (and back then my mom was a pediatric nurse). But early on my own pediatrician said the same thing you are saying so it’s been a challenge to change my ways. Luckily, my daughter hasn’t had a lot of fevers but when she does, this information has helped me calm down and treat her disomfort more than the fever (even though internally I was freaking out!). I’m less afraid of fevers now and more afraid of the 104 fever which will still send me into a panic even though my pediatrician never panicked over it – or even seemed at all disturbed by it. Just said give her some tylenol and bring her in to check for bacterial infection. Ah … to be so calm!
I feel so fortunate to have YOU as our pediatrician. My son loves you and I appreciate and agree with your advice so often. A doctor that you can talk to, that listens to you and that you trust with your most cherished is a rare find. Thank you Dr. Swanson, you fit our bill perfectly!
Wendy Sue Swanson, MD says
Thanks, Heather, that is sure a nice thing to hear today. My privilege, of course!
Is there any evidence that giving ibuprofen (in treating a fever and general malaise) can also help a cough? Three weeks ago my 14-month-old daughter was diagnosed with croup. This past week she was diagnosed with a double ear infection. She has had a persistent deep cough throughout which worsens at night or nap. The past couple nights I have given her ibuprofen before bed. She wakes up after 6 or so hours as the dose is “wearing off,” coughing, gagging and choking. Last night I gave her a second dose of ibuprofen during the night. She coughed a few times after that and slept another 6 hours. Did it work? Or was it a fluke? It sure was nice for all of us to sleep…
PS – I LOVE your blog!!!
Wendy Sue Swanson, MD says
You know, it may be a fluke, it may not be. So hard to speculate…but your quetion got me thinking:
Croup is diagnosed often when a child has a viral infection that causes a characteristic “barking seal” cough and rarely more serious breathing problems like stridor (noisy breathing with inspiration) and respiratory distress. Typical treatment involves steamy bathroom treatments, cool air (stepping out into the night air) and time. In more severe cases we use oral or IV steroids and special breathing treatments. Croup is often caused by a virus called Parainfluenza, but croup-like illness (barking seal cough) is thought to be caused by additional cold viruses, as well. That barking sound comes from swelling around the voice-box that causes the noise to sound unusual when your child coughs and air rushes quickly out….
Your daughter’s cough improvement could be a slight improvement in swelling and irritation somewhere or that the ibuprofen helped your daughter feel better so she rested better and thus didn’t have as much awakening and cough. But I don’t know. We don’t recommend ibuprofen for cough or croup, more for pain and discomfort that can come from cough. Regardless, so glad you got a nice night’s sleep!
I worry that the way we talk about fever contributes to parental fears. In my practice I have moved away from saying “Dont’ treat the fever or be concerned about the numbers -UNLESS it is 104 or above.” This is doctor double-speak. All my parents hear is “Make sure it doesn’t go above 104 or you beautiful child’s head will melt!” There is no evidence that fever above 104 is a sign of a more serious or bacterial infection. (The exception being in my under-immunized patients using “alternate” vaccine schedules who will be at increased risk for Hib and Pneumococcal infections.) The data showing concern for fever >103 was all pre-Hib, pre-prevnar vaccine. We also know how variable home fever measuring can be, with different thermometer types and use leading to differences of multiple degrees.
I know it sounds a little crazy, but i have actually begun instructing my parents at the 4 month check up to throw out thier thermometers or give them to some other newborn or expecting parents. I relay my personal experience of the one time I took my son’s temperature in his post 2-month-old life. I got back a 103 and spent the next 3-4 hours stressing even though he was just as sick before knowing the temp as he was afterwards and i knew the number did not effect his clinical outcome. The numbers really only scare and don’t help me in my practice at all.
I also explain to parents that the only reason i ask “what the temperature was?” during ANY sick visit is because I can’t figure out something else to code and need to put it on the billing sheet.
Hammering home that fever numbers are not a predictor of clinical outcomes or a sign of a more serious illness consistantly is the only way to train our parents out of a fear that is seems as innate as fever itself.
I know its not peer-reviewed etc, but Pediatric Annals from jan 2011 had a great review of the evidence about fevers and outcomes that is definately worth the read.
Any compelling argument for me to bring back the thermometers to worry about those >104 fevers?
[not to cross-post or whatever it is called, re: putting your phone down, but i thank god on a regular basis that i am not as gifted a writer as you and my wife are. (that sentence structure being a great example) If i was as good as you are at what you do, it would be incredibly hard to put it down. thanks for taking time away from your personal life to be a great resource for my patients out here in virginia. )
Wendy Sue Swanson, MD says
I completely agree with you regarding the double speak. And yes, heads don’t melt at 104. And I don’t mean that 104 means there is bacteria, rather,I feel with persistent elevated temp, it may be worth a peek to prove or evaluate is there is something we can do…
And on some level parents want and crave at least some rules, don’t you think? It’s not that I believe we should create quantifiable boundaries that don’t exist, but I do believe 104 is less usual than a lowgrade temp elevation or even fever of 102 and may be meaningful particularly if a child has never had a temp that high.
Adenovirus is a great example. So many kids get adenovirus and have accompanying unusually high fevers…doesn’t change what I can do, but helps when they come into office I can help reassure, discuss hydration, discuss reasons to return and what to do on day 4 or 5 of fever, for example.
I don’t tell people to throw out the thermometer, because on some level I think it helps families understand when their child is sick. Knowing and having ownership about a child’s illness is important to many families/parents (ie what day did fever start, when did child complain about ear pain, on what day did fever end, and how many more days of cough). Another issue with the no thermometer at home is that schools, preschools, daycare still subscribe to the archaic idea that kids only have to go home when they have a temp 100 or up (not when they are hacking and dripping green snot from their nose). So, how are families to live in those two worlds–one that remains dependent on body temp and one that doesn’t? What have you found?
I’ll hunt down Pediatric Annals (I don’t think it arrives at my house anymore).
And thanks for your very thoughtful and comprehensive response. And compliment. I appreciate both. This may demand a fever rebuttal.
Wendy Sue Swanson, MD says
And Dr Scott,
Yes, the reliability of the device and technique you use to measure temp is a whole additional issue (rectal versus tympanic versus temporal versus oral temp measurement) and likely demands a post, too….
A Los Angeles Cardiologist says
I think this is an important topic as it is a such a common problem. As I mother and a doctor, I personally get concerned when my kids have a fever and it is rising above 102. I know that in a way a fever may be the body’s way of fighting an infection; however, I like to treat my kids fevers when they are above 101 and if they do not feel well. It seems to me a lot of times it is not the absolute temperature but the rate of rise that causes symptoms. With some infections, there seems to be a more steady fever and with others a more of spiking pattern. When they get infections that have more of a rapid rise of temperature, I am more concerned as I am not sure where the temperature will stop and therefore tend to treat earlier.
There’s a typo in the transcription of your interview on the KING5 site: “Morton” for Motrin.
Although I doubt parents will be reaching for the salt, you might ask KING5 to correct it…
Isn’t it too bad the generic medication names don’t roll of the tongue as easily as the brand names (gee, wonder why!)
Thanks for the excellent blog, and this post especially.
I have a microbiology degree, so I think understanding our immune system and how it is SUPPOSED TO work helps me not freak out about things like fever. It’s also why my 3 year old has only had antibiotics once in her life and my 14 month old has never had them (wish I could say the same for my 5 year old, she had lots due to surgeries, but not once due to any other infection).
One thing that’s always fascinated me about fevers is how individual peoples’ fever responses seem to be… my 3 year old runs a fever SO easily – if she is fighting off any little bug, she runs a fever, and it tends to hang around for a long time (which won’t be fun once she starts school!) My 5 year old gets the exact same infection and doesn’t run a fever. She’s only had one or two fevers in her life due to illness. BUT her temperature spikes to around 101 exactly 36 hours after she has surgery every single time (happened 6 out 6 times!) for no apparent reason (never an infection, so it’s just her body’s reaction to being cut on). Just interesting to me.
Oh and I love your sweater 🙂
Wendy Sue Swanson, MD says
Thanks, Vera (on multiple levels) 🙂
I think you’re on to something that I talk about in clinic often. The idea that there are some people/kids who are just BIG FEVER MAKERS and others who aren’t. Precisely why at times, the number is less relevant.
I’m unsure if data backs this up but I think it reflects the individual, their own immune system and response. Not being a big fever maker from what I understand, doesn’t change how you fight off infection. But like you, I know differences in myself versus my sibling and notice differences in fever response to (possibly) the same infection between my own children.
Trusting your instinct on how your child looks remains exceptionally important in how you respond. And how long a fever continues.
Peter Palmieri, M.D. says
Pediatricians should be mindful that every visit, even for the most seemingly trivial problem, has the potential to raise fears and anxiety. We should also be careful when offering advice, to recommend things that are based on evidence whenever possible. The recommendation of alternating acetaminophen and ibuprofen, though common, is one example of a poorly though out intervention. It peaked parental anxiety and is completely unnecessary. A survey of pediatricians taken years ago showed that about 50% of pediatricians routinely advised this practice, with 29% believing that it was a guideline from the American Academy of Pediatrics (no such guideline existed).
This is only one of many erroneous beliefs that we pediatricians subscribe to. There is also the over-diagnosis of formula intolerance, the misdiagnosis of ear infections (studies show this may occur 50% of the time), the mis-diagnosis of throat infections and sinus infections, the mis-treatment of asthma, the ordering of unnecessary laboratory studies with the subsequent exposure of children to superfluous treatments. For more on this, I recommend reading my e-book: Suffer the Children: Flaws, Foibles, Fallacies and the Grave Shortcomings of Pediatric Care, available on Kindle and Nook.