Friday, October 30, 2015

If a child's temperature is usually low, how do we define fever?

My child typically runs a temperature around 97°F, so if the temperature is 99°F, is that a fever?

We get a variation of this question all the time.

Sometimes it's the opposite, such as my child usually runs hot, so can you write a note saying 101°F isn't a fever for him?

Short answer (both questions): No.

Long answer: Our body temperature is very complex. Your school district will define a fever with a number, but your doctor might have a different number. A fever is not defined by the change from a person's baseline temperature.

Disclaimer: All information on fever given is for healthy, vaccinated children over 3 months. Young infants, children with chronic disease, or undervaccinated kids do not apply to standard fever discussion and advice.

fever, sick

Most people think of a "normal" body temperature as an oral temperature of 98.6°F. Your temperature may normally be a degree or more higher or lower, which means 99.6°F is normal despite the fact that some daycares define this as a fever. Most often we associate high body temperatures with illness, but elevated temperatures also can be caused by environment temperatures being too high (or over bundled babies), dehydration, medications, poisons, cancer or overactivity. Your normal body temperature changes by as much as 1°F throughout the day, depending on how active you are and the time of day. Body temperature is very sensitive to hormone levels, so may vary with women’s monthly cycles. Our temperature tends to lower as we age - kids tend to have slightly higher temperatures than their parents, even when healthy. It is very common for children to get a fever when sick, but less common for adults. And the thermometer itself can vary in readings significantly, so the number may or may not be reliable, depending on the thermometer.

It is said that a child has a fever when his or her rectal temperature is 100.5°F or higher, which is about 99°F under the arm and 99.5°F and in the mouth. [This was edited 6/21/17 after some perceptive pediatricians found a typo.] This is by convention, but in actuality children’s normal temperatures may be higher than adults so these temperatures might be normal and only higher temperatures may actually indicate fever.

Parents often use the term "low grade fever" to indicate something less than 100.5°F. There is really no such thing. It's either a fever or it's not. A low fever in my mind means a temperature over 100.5°F that doesn't make the kid feel pathetic. Any temperature less than that simply isn't a fever. The child might be sick and temperature doesn't define illness, but it's not a fever.

There also isn't a medical definition of high fever. The temperature is the temperature and illness is better defined by describing all symptoms, not just the temperature. I guess if I had to define a high fever, it would be one that makes a person feel absolutely miserable. There is no magic number that defines this high fever or that tells us when to worry more. It's more important to look at the child than the thermometer to know if they're really sick or not.

Many parents have fever phobia, a condition where they worry that the fever itself will do damage. While a rapidly increasing temperature can cause fever seizures, these are more scary than dangerous. Fever seizures can occur with relatively low fevers if the change in temperature is rapid. It's not necessarily the high high temperatures that cause seizures. The brain will not be permanently damaged from most fevers (even high temperatures), though a fever can be a symptom of serious illness that can damage the brain, such as meningitis. But you would recognize that your child is more sick than the typical illness if they are having symptoms of such a significant illness. You would not use a thermometer to tell you that.

I do not recommend taking a child's temperature frequently. That causes excess worry in parents when the temperature increases by 0.5 degree, which could be a real change or just the thermometer's reading. Respond to your child, and don't rely on the thermometer. Never wake a comfortably sleeping child to take the temperature. Don't use sticky strip thermometers that tell your cell phone if there's a fever (yes, that exists, and it will lead to more parental anxiety than help keep children healthy.) Knowing the temperature helps to know if it is a true fever or not, but it should not direct you to give medicine or not. A temperature can be taken at times you need to know if there's a fever, since schools and daycares have rules to keep kids with fever away (though fever is not the only sign of illness and if your child's sick he might need to stay home despite temperature). It is sometimes helpful to know if a warm or hot child has a true fever, but you don't need to take it every hour to follow the trend with most illnesses. It's not even helpful to see how much medicine brings the temperature down. If a child doesn't improve, you will be concerned regardless of the thermometer reading. Taking a temperature once or twice a day is sufficient. I'd recommend taking it at times that it is likely to be its highest, such as in the evening or when fever reducing medicine has worn off.

The American Academy of Pediatrics recommends treating sick children for comfort, which is typically when the temperature reaches about 102°F or if they have pain somewhere. Not all earaches or sore throats cause fever, but you might consider a pain reliever to help symptoms. Most people feel uncomfortable as their temperature approaches 102°F. Only give fever reducers if the child needs it for comfort because the fever is actually helping the child fight off an infection - don't inhibit the immune system if your child is comfortable enough to sleep and drink without significant pain.

Never give a fever reducer to hide a fever so you can send your child to school or daycare. If they don't feel well, they shouldn't go because they'll spread the illness to other kids. A normal temperature because of a fever reducer does not mean that the child is fever free. You can only be fever free if the medicine has worn off and the temperature remains normal. The temperature should be normal off medicines for 24 hours before returning to school or daycare (or work for adults with fever).

So, with the original question, if a child is usually cooler than 98.6°F, when do they have a fever?

A temperature over 100.5°F is the general definition of fever, regardless of baseline temperature. In practical terms though, parents really want to know if a child is sick or not. You can tell when a child is uncomfortable by looking at him ~ you don't need a thermometer. It is not necessary to treat based on the thermometer reading. It is important to give a fever reducer/pain reliever when the child is uncomfortable so he can drink to stay hydrated and sleep. The goal is not to lower the temperature to “normal”, it's to make the child more comfortable.

If you are concerned about your child's illness, especially if he looks dehydrated, is having trouble breathing, is in uncontrollable pain, has symptoms you think might need antibiotics (such as UTI symptoms or Strep throat), or if the fever lasts more than 3-5 days (depending on age of child and overall symptoms), bring him to have an exam to look for sources of fever. 

Sunday, October 18, 2015

When should my child shave?

In my last blog I discussed the common question about when it is appropriate to start using deodorant or antiperspirants, which led me to think of all those questions beginning, "When is my child old enough..."

shaving, tween, teen
Photo source: Wikimedia

One of these questions: When is my child old enough to shave?

This is another question without a one-size fits all answer.

Girls and boys differ in needs and ages of puberty.

I told my own daughter that she could shave her legs when she needed to shave under her arms, since I know that under arm hair becomes longer during puberty, which is also when leg hairs thicken and grow. This just seemed like an easy answer to me. We are born with hairs on our legs, so deciding when those hairs are too long is tricky. It's not of a question of age, but one of quantity, color, and thickness of hairs.

When a boy starts to get visible peach fuzz on his upper lip it may be time to consider shaving, but it depends on the hair color, length, and his desires. Some schools include a "no facial hair" policy, which forces the issue.

Some kids are naturally hairier than others. Some have dark hair, others light hair. Puberty increases hair growth on the arms, legs, armpit, and in the groin in both sexes, and on the face in boys, but the age of puberty varies widely. Culture plays a part in the family's decision whether or not to shave body hairs.

The maturity of a child should be considered. A girl with thick, dark hair entering puberty at 9 years of age who is getting teased at school about her hairy legs might have a strong desire to shave, but if her fine motor skills are weak and she cannot safely handle a razor, it might not be appropriate for her to shave yet - at least not with a standard razor.

If a child has body hair that is bothersome and they want it removed but they are not able to safely use a standard razor, options might include other forms of hair removal, such as the chemical hair removal products, waxing, electric razors, or allowing a parent to help them shave. Each of these has it's own issues to consider.

Chemical hair removal products generally work by weakening the hair so that it is easily broken off at the skin level. Chemical products might lead to skin irritation or allergic reaction, but are well tolerated by most people. If you are planning to use it on the face, be sure to get a product specifically for the face and test a small area first to be sure they don't react to it negatively. Chemical hair removal products are relatively easy to use, can be done at home, and last for several days. Young children should be supervised so that the chemical does not get on other body parts or all over the bathroom...

Waxing is an option for many girls and women. It can also be used for boys and men, though is less commonly used by men. It's benefits are that it lasts several days and over time might cause the hair to grow in thinner (or not at all- which might not be a great idea for a boy who one day might want a beard). It can be painful, which might not be tolerable for some kids. You can go to a salon for a professional wax, but this is more expensive than the many do-it-yourself kits you can buy at local stores. You can look online for tips on how to find the best waxing product for your needs and how to wax.

Electric razors offer the benefit of a safer cut, but can take more time and often don't get as close to the skin as a standard razor. If your child is using an electric razor, (s)he must be warned about the hazards of using something electric next to a water source (such as the sink or tub). There are many types available, and I would recommend searching for reviews online prior to purchasing. Follow package directions on keeping the razor clean.

If you allow your child to shave with a razor be sure to get a new one just for that child. Never share razors, since this can lead to sharing of germs that cause infection. The choice of using a shaving gel or cream or just shower soap is a personal choice. Also talk about when to change the razor blade. It depends on how often (s)he shaves, how large of an area being shaved, and the body hair type. Someone with thick, coarse and curly hair that grows super fast will need more frequent blade changes than someone who is shaving fine peach-fuzz hair off every few days. Any blade that’s rusted must be changed immediately. When a blade feels like it’s tugging on the hair instead of gliding smoothly, it is time to change. If you’re using an older blade and notice nicks or rashes or razor-burn bumps, it's past time to change it. After each use a razor should be rinsed clean of all hairs and soaps/creams and allowed to dry. Don't lay it in a soap dish because it will stay wet. Wetness allows germs to grow and encourages rust, both of which are dangerous.

If you would be most comfortable shaving your child's skin, you can certainly try this with his or her permission. Be careful though, because if you nick the skin, you will never be forgiven! Kids are like that...

When it comes down to when it is the best time to shave, I think it is a very personal decision.

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Saturday, October 10, 2015

When should my child start wearing deodorant?

I get asked all the time when kids should start wearing deodorant or antiperspirant.

There's no standard answer since kids have different needs. Some kids are active outside and simply carry the smells of the great outdoors and sweat on their body. This isn't puberty sweat, just musty body odor in most young smelly children. Sweat in general makes conditions ripe for bacteria to grow on our skin, and the bacteria make us smell. Kids enter puberty at different ages, and puberty affects how we smell in addition to many other obvious things because sweat glands become more active.

deodorant, tween, teen, puberty
Image source: Wikimedia

First things first: get clean!

Body odor is often related to bathing, since some early elementary school aged kids shower independently, but don't do the best job at actually using soap in all the areas it's needed. Or they argue about needing to get clean daily. Every other day might work in the winter (if they don't sweat a lot with play) but in the summer, they really need a daily cleansing if they smell offensively.

The first step I always recommend is making sure kids who have that funky smell shower (or take a bath) daily with the same soap that the parents use, not a baby wash. Many families buy baby washes for the first year of life and keep using them during toddlerhood and childhood out of habit. Baby washes don't lather up well (which leads to less body surface areas getting lathered up) and aren't designed to get the oils, dirts, and smells off like regular soaps. There really is no need to continue to use these washes for kids beyond infancy and it might contribute to body odors.

Talk to your kids about getting soap suds on all body parts. I think using a shower pouf with a body wash makes it fun for kids to see all the bubbles - and it helps them to see what parts are done and which need suds. If your child likes to play in the bath tub, it might help for them to end with a quick wash and/or rinse in the shower, since they are sitting in the dirty water during the bath. It is hard to wash the submerged body parts with soap, since the cloth or pouf rinses out under water. They will need to stand to wash the lower half of their body properly.

A note about the poufs: Be sure to show your kids how to rinse the bubbles out of the pouf after the shower or bath and hang it to dry between uses. You'll also want to wash the poufs weekly. I sometimes throw them into the washing machine with the towels, but that takes the life out of them more quickly than soaking in vinegar and water.

Go over all the body parts to wash. I looked for a video that they could sing along to (there are a lot for washing hands and brushing teeth), but couldn't find a good one to remind kids of all the body parts. If anyone's musically talented, this would be a great project to help many kids (and parents)! If you find a good video, please share the link in the comments below!

  • Hair - It is tricky for kids to massage all parts of their scalp when washing hair, so show them to use their fingertips up and down then side to side to cover all parts of the head. The frequency of how often hair needs to be washed can be debated. Hair can trap pollen and other outdoor smells and the scalp's sweat can lead to funky odor, so hair needs to be washed at least a couple days per week and daily for those with allergies to pollens that are in the environment at that time.
  • Face - Kids won't want to get soap in their eyes so many parents just have them rinse with water, but many kids need to actually wash with a mild soap or cleanser. Eyelids can get what my parents used to call "sleep dust" - little crusties - if they are never washed. You can use a baby "no tears" shampoo to wash eyelashes if needed or a mild soap or cleanser with closed lids and careful rinsing. When kids start getting oily skin on the face they should wash it twice a day. A quick reminder not directly related to cleaning: A daily moisturizer with sunscreen is great all year long for our faces, which are exposed to the sun and elements every day.
  • Armpits - While it seems obvious when you've talked to your kids about having smelly pits, you'd be surprised that it doesn't always equate to kids being conscious of washing those pits. With soap. Kids just don't make the connections you think are obvious. 
  • The whole back - It is hard for any of us to wash our own back, so show your kids how to use a back scrubber or wash cloth to reach all areas.  
  • Belly, arms, and legs - Again, have them look to see where the suds are and where they're missing to hit all the areas.
  • The bottoms of the feet - Show kids how to hold on to something when washing their feet and consider adding a non-slip surface to your shower or tub. Have them wash one at a time so they can stand on the non-soapy foot. Soapy feet are slick!
  • Between the legs - Kids need to be taught to wash between the buttocks and around their genitals, with special care given to rinsing these areas well. Trapped soaps can irritate the skin and cause rashes, so rinsing should get special attention in these sensitive areas. I really like removable shower heads that can come down to help rinse, but kids can also use several cups of clean water to rinse hard to reach areas. Girls might need to sit in the tub to do this rinsing with a cup because it's hard to splash the water up between skin folds sufficiently.


Kids might have a favorite shirt that they want to wear every day, but clothing (especially shirts, socks, and underwear) must be washed regularly. Putting stinky clothes on a clean kid just makes the kid stinky. Avoid polyester (except the special polyester in performance wear- designed to wick sweat away) and rayon clothes, since they do not absorb the sweat well. Cotton is a great choice: it absorbs sweat well and is relatively inexpensive. 

If kids have sweaty feet, white socks might be better than colored ones due to the coloring irritating the feet. Changing socks when the feet get sweaty, such as after playing a sport, can help. Changing shoes and allowing each pair to dry thoroughly between wears can help too.

Deodorant vs Anti-perspirant?

Deodorant is used to cover up smells. It is often what I recommend for those younger kids who sweat during active play or outside in the heat. 

Anti-perspirant is designed to decrease sweating and often is mixed with a deodorant. Before puberty a deodorant is probably sufficient, but during puberty our sweat glands are activated and we sweat a lot more, especially under the arms, on hands and feet, and in the groin. It is personal choice if one wants to decrease underarm sweating with an antiperspirant. 

Over the years I have seen many concerns with the aluminum in antiperspirants - everything from it causes Alzheimer's to it causes cancer. Studies do not support those claims. You can read more about the proposed risks of antiperspirants on WebMD.

When is sweating abnormal?

Sweating is abnormal if it is excessive for the body's needs or if a child has other signs of puberty before the normal ages (8 years in girls, 10 years in boys- some sources say 7 years in girls and 9 years in boys). 

There are many reasons for excessive sweat that are relatively uncommon, so I won't go into detail here. If you think your child sweats excessively or is entering puberty too early, please take him or her to their doctor to be evaluated. (A phone call isn't sufficient because they will need to look for associated signs and symptoms on an exam.)

Next up...

I will cover "When should my child shave?" next, since it is also a very common question!