Fevers: How High is Too High?

Despite having fever information on our website and blogging about it many times, including here and here and here, parents often call in or bring their child in with excessive concern for fevers. (Note: paracetamol is the same as acetaminophen and Tylenol in the linked article.)

The information here is only for infants and children over 3 months who are otherwise healthy and vaccinated. If those criteria are not met, the child is in a higher risk category.

Fever is one of the biggest anxiety inducers in parents, and I want that to change. Yes, we should care for our children when they're sick, but we don't need to worry about the numbers on the thermometer.

Maybe one time I'll explain fever in a way that hits home so parents can stop focusing on the number and more on the child. Parents often tell us in detail what the temperatures are at various points of the day but omit how the child looks and acts. I care more about the child's behaviors than the thermometer's reading.

I know fever is scary. Kids are miserable. But the temperature itself is not what we treat. Treat the symptoms!

What is a fever?

The number on the thermometer can be confusing to parents. How the temperature is taken is as important as the number itself to determine if it is a fever. A fever is often defined as a temperature over 100.4 °F (38 °C) but it can vary based on how you take the temperature (rectal vs oral vs forehead).

This is simply the minimum temperature that is no longer considered normal. The American Academy of Pediatrics doesn't recommend treating fevers until the temperature is over 102°F unless the child is uncomfortable. Thermometers are not very accurate, so when you worry more about a temperature that is 0.5 degree higher than another temperature, it might not even be a significant difference. You could take the temperature twice in a row and get different readings. If your child is playful and the thermometer reads 101.5°F that is a very different story than if your child is barely moving, whimpering, and breathing fast with a temperature of 101.5°F. I wouldn't recommend any fever reducers for the first, but I would recommend the second get evaluated by a pediatrician or other medical provider.

Why do we care about fevers?

I think medical professionals help to foster this fear of fevers because we ask about them. It can be helpful to know the actual temperature because many kids are warm but not really running a fever.

• We are more contagious during a fever, which is why schools and daycares won't let kids stay if they have a fever. 
• The height of the fever doesn't indicate if the child has an infection requiring antibiotics or not, but it can cause increasing discomfort as it rises above 102°F. 
• The height of a fever does not cause fever seizures, but a rapid change in temperature can cause a seizure in a child that is susceptible to them.
• If a true fever lasts more than 3-5 days or is accompanied by other concerning symptoms, the child should be seen to look for a source. 

So how high is too high?

Fevers higher than 106°F (41°C) might be the answer parents are asking when they want to know what temperature is too high. It is at this point that brain damage from the temperature itself can occur due to hyperpyrexia (heat stroke). This is not common from a simple infection and other symptoms will be present, such as change in consciousness, vomiting, flushed skin, headache, rapid breathing, and very rapid heart rate. Emergent medical attention and cooling the body is important with hyperpyrexia, which differs from fever.

If your child does not appear very ill and the thermometer reads very high, it is likely the thermometer is in error.

What if the temperature doesn't go down to normal after using a fever reducer?

When parents give a fever reducer, they often worry that the temperature doesn't go back to normal. Returning to normal doesn't mean it isn't a serious infection and not returning to normal doesn't mean that it is a serious infection. Studies show the temperature tends to decrease by 1.8 to 3.6°F. Acetaminophen begins to work in 30 - 60 minutes and has its peak effect in 3-4 hours. The duration of action is 4-6 hours. Ibuprofen begins to work in under 60 minutes and has its peak effect in 3-4 hours. The duration of action is 6-8 hours. The goal should be to make a child more comfortable though, not to get the temperature to normal.

My personal opinion is that most children won't need their temperature taken to verify that they are better. They should be more comfortable. If they aren't, then it is wise to have a medical professional look at them.

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Sick, Sick, and More Sick.

Photo source: Shutterstock

It isn't news that we are experiencing a rough winter as far as illnesses go. Flu is all over the news. Schools have high rates of absenteeism. You hear coughs wherever you are in public places.

A few nuggets of information that might help you treat your family this sick season:

Fever

Fever is a symptom of illness and makes us feel achey and miserable, but the number on the thermometer does not necessarily correlate with the diagnosis or treatment needed. Look at your child. If they are happy with a fever, over 3 months and immunized, let it run its course. If they complain of pain (or if your immunized infant over 2-3 months is fussy) give a pain reliever/fever reducer. Push fluids to avoid dehydration. Treat other symptoms as needed. Don't worry if the temperature on the thermometer goes up ~ worry if your child is in severe pain, having difficulty breathing, or looks dehydrated.

Cough

Coughs do not need medicine generally. Honey (for those over 1 year) has been shown to be safer and more effective than other cough suppressants. Adding humidification to the air does wonders to loosen mucus and ease breathing.

If the cough is accompanied by rapid breathing, sucking in of the ribs or abdomen, or followed by vomiting, your child should be seen by a medical practitioner for further evaluation and treatment.

If your child has a history of asthma or other wheezing, it is okay to see if the rescue medicine (albuterol or levalbuterol) helps the cough. If not, it either is really bad wheezing that needs further evaluation or a cough. And don't forget your prevention medicine if you use it!

If your child has been exposed to whooping cough and develops a cough, please see your medical provider for evaluation and treatment.

Water's Power

Water is good for most illnesses. Increase fluids to prevent dehydration and help the body repair itself. Sips of water can help a sore throat and ease a cough. Add humidification to the air when the weather is cold and dry. Use saline to clear the mucus from the nose and open nasal passageways. Never underestimate the power of water!

Tamiflu 

Tamiflu is recommended for certain high risk people who are exposed to or sick with influenza. Prophylaxis can be given to prevent illness in children over 1 year of age who have known exposure within the past 48 hours if they meet high risk indications. Treatment of illness can be given to those over 2 weeks of age if they meet high risk criteria. There are shortages beginning this season and resistance can easily develop, so its use should be limited to those who truly need it.

High risks include: less than 2 years, lung disorders, immunologic disorders (immune compromised), chronic metabolic disease, and neuromuscular disorders.

If influenza symptoms have been present for more than 48 hours, it is not indicated unless there are special circumstances.

Tamiflu shortens the symptoms of influenza by 26 hours, about a day. It can help prevent the spread of the virus. It can have side effects, most commonly nausea and vomiting, but also more serious rashes and neurologic symptoms (confusion, delirium, and hallucinations).

Flu Vaccine

Vaccination is the best prevention against influenza. It does not make people get the flu. It is safe and indicated for everyone over 6 months of age. Thank you to all my patients who were vaccinated this year!  Although it is not 100% effective, it should lessen the risk of influenza to you.

Please don't wait to see if it will be a bad season before deciding if it's worth it to get the vaccine. Once the season has started it is less effective because it takes your body about 2 weeks to build immunity. Waiting also puts you at risk for being left out if there are shortages. Our office gave more vaccine than ever this year, but we still ran out earlier than ever this year.

If your family still needs the vaccine, check your local health department and pharmacies.  When we start vaccinating again this summer for next season, be sure to get your family vaccinated! (We will publicize availability on our website, Facebook page, and by email to those registered on our website.)

Vomiting and/or diarrhea

Vomiting and diarrhea can result from many viruses, usually NOT influenza. Treat with an electrolyte solution (such as Pedialyte, Gatorade's G2 - less sugar than regular). Give small volumes frequently. When kids get thirsty, they might gulp and then vomit, so put only 1 teaspoon in a small cup or syringe, or give a popsicle made of the electrolyte solution. Juice, carbonated lemon/lime drinks, and other high sugar drinks should be avoided.

Dairy increases stomach upset, and I generally say to avoid all milk products (except human milk) for 48 hours after the last vomiting or diarrhea. Breast milk can sometimes be tolerated, but it must be given slowly too, so often breast feeding should be stopped. Pump and give the expressed milk by the teaspoon in a syringe.

Evolution of Illness

When kids are sick, parents understandably want them to feel better quickly. They want a sound night's sleep. They want to be able to return to work/school. They want to see a happy, healthy child again. They come to our office hoping for answers and a cure.

Sometimes there is no quick fix, just treating symptoms and time.

This is the season we are seeing a lot of sickness. It's been about 11 years, but I remember the frustrations of having a sick baby when my daughter had bronchiolitis. Some of the details are muddy, but I remember the feelings of inadequacy because I couldn't help her feel any better any faster. I knew the illness tends to get worse before it gets better and there is little we can do to alter its course, but knowing this it didn't make me feel any better as the mom who was helpless.

I lost sleep for several nights as I watched her pant (not breathe, but pant). I resorted to giving asthma-type breathing treatments (because my son had wheezing so we had everything we needed to give a treatment at home) despite the fact that they didn't seem to help her much. It was probably the humidified air that helped more than anything. But the vaporizer in her room and the saline to suction her nose wasn't helping, so I wanted to at least try the asthma medicine. She kept wheezing. We brought her in to the office 3 days in a row to have someone else check her. I can't check oxygen levels at home and needed someone to objectively examiner her.  So three days in a row we went in for repeat exams. She was able to maintain her oxygen level and stay hydrated despite breathing 60-70 times/minute for days. I still don't know how. I remember wishing her oxygen level would drop enough that we could hospitalize her, not critically, just enough. Then she'd be on monitors, and maybe I could sleep a bit knowing someone else was watching her. Thankfully she never got that sick, and eventually we were all sleeping again, but it took a long time for that.

So I understand the frustration when we tell parents things to do at home and ask that they come back in  __ days or if ___, ____, ___ symptoms worsen. It really isn't that we are holding out on a treatment that will fix the illness, it's just that we don't have a quick fix for many illnesses. We need to be able to examine at different points in the evolution of the illness to get a full picture of what is going on.

The exam can tell us a lot, but it doesn't predict the future. One minute ears can look normal, the next they develop signs of an infection. I cannot say how many times I've heard a parent complain that someone else "missed" something on exam that I now see. Yes, sometimes things can be missed, but I suspect that most of the times the exam has simply changed.

I learned this phenomenon as a resident on the inpatient unit. I had a patient who had been admitted for an abdominal issue. I did a physical on the child in the morning before rounds, including looking at ears, which were normal. Late that afternoon the nurse called because a fever had started. New symptom, so another exam was done. This time the ears were red and full of pus. Within hours this child had developed a double ear infection. I examined the ears both times and they were definitely different.

I understand the frustration (and expense) to take kids back in to be seen if symptoms worsen, change, or simply just don't resolve at home. If symptoms change, we need to re-evaluate, which includes an exam. Medical providers cannot look into the future to see what will develop. It is not appropriate (or effective) to put kids on an antibiotic or iv fluids to prevent the illness from taking its natural progression. Sometimes we need time to see how the illness progresses to see what other treatments might be needed.

When parents call back and want something else done, they are often upset that we want to see the child again. I hear many types of complaints.

Money is probably the biggest issue. It is not because we want your co pay. The "we" I use here is not just my office and I am not speaking of any particular situation. With online doctor rating sites, social media sites, and knowing doctors around the country, I write with many examples in mind. I've seen online complaints that doctors are just money hungry, trying to get someone to come back in just so we can charge more money. It is true that we charge for every visit. We are not able to waive the co pay because we did "something wrong" or "missed a diagnosis" the first time. Each is a separate visit with updated information and a separate exam. Insurance contracts dictate that a separate co pay is charged. We must adhere to legal contracts or it would be considered insurance fraud.

Increasing our numbers for "production" is sometimes brought up. It is not because we want to fill our waiting room with more children to increase the waiting time for everyone else. We don't want to waste your time or ours. But we need to see a child to know what is happening at that moment to be able to give any valuable advice and treatment.

We want to see your child again because we need to see your child to know what to do. Maybe now the child's symptoms have changed.  Maybe not, but without the history and exam we do not know. The exam might now show wheezing, low oxygen levels, a new ear infection or sounds of pneumonia. Sometimes the exam still is overall normal, but the fever's been going on long enough without any identifiable cause, which requires lab and/or xray evaluation. 

Please remember that if you get a different answer at a different visit, it doesn't mean that the first assessment was wrong. Usually it is due to a progression of the illness, and things change. Human bodies are not static.

Fever is...

 

Fever is scary to parents.

Parents hear about fever seizures and are afraid the temperature will get so high that it will cause permanent brain damage.  In reality the way a child is acting is more important than the temperature.  If they are dehydrated, having difficulty breathing,  or are in extreme pain, you don't need a thermometer to know they are sick.

Fever is uncomfortable.

Fever can make the body ache. It is often associated with other pains, such as headache or earache.  Kids look miserable when they have a fever. They might appear more tired than normal.  They breathe faster. Their heart pounds. They whine.  Their face is flushed. They are sweaty.  They might have chills.

Fever is often feared as something bad.

Parents often fear the worst with a fever: Is it pneumonia? Leukemia? Ear infection?  

Fever is good in most cases. 

In most instances, fever in children is good.  It is a sign of a working immune system.  

Fever is often associated with decreased appetite.

This decreased food intake worries parents, but if the child is drinking enough to stay hydrated, they can survive a few days without food.  Kids typically increase their intake when feeling well again.  Don't force them to eat when sick, but do encourage fluids to maintain hydration. 

Fever is serious in infants under 3 months, immune compromised people, and in under immunized kids.

These kids do not have very effective immune systems and are more at risk from diseases their bodies can't fight.  Any abnormal temperature (both too high and too low) should be completely evaluated in these at risk children.   

Fever is inconvenient.

I hate to say it, but for many parents it is just not convenient for their kids to be sick.  A big meeting at work.  A child's class party.  A recital.  A big game or tournament.  Whatever it is, our lives are busy and we don't want to stop for illness.  Unfortunately, there is no treatment for fever that makes it become non-infectious immediately, so it is best to stay home.  Don't expose others by giving your child ibuprofen and hoping the school nurse won't call.

Fever is a normal response to illness in most cases.

Most fevers in kids are due to viruses and run their course in 3-5 days.  Parents usually want to know what temperature is too high, but that number is really unknown (probably above 106F). The height of a fever does not tell us how serious the infection is.  The higher the temperature, the more miserable a person feels.  That is why it is recommended to use a fever reducer after 102F.  The temperature does not need to come back to normal, it just needs to come down enough for comfort.

Fever is most common at night.

Unfortunately most illnesses are more severe at night.  This has to do with the complex system of hormones in our body. It means that kids who seem "okay" during the day have more discomfort over night.  This decreases everyone's sleep and is frustrating to parents, but is common.  

Fever is a time that illnesses are considered most contagious.

During a fever viral shedding is highest.  It is important to keep anyone with fever away from others as much as practical (in a home, confining kids to a bedroom can help).  Wash hands and surfaces that person touches often during any illness.  Continue these precautions until the child is fever free for 24 hours without fever reducers.  (Remember that temperatures fluctuate, so a few hours without fever doesn't prove that the infection is resolved.) 

Fever is an elevation of normal temperature.

Normal temperature varies throughout the day, and depends on the location the temperature was taken and the type of thermometer used.  Digital thermometers have replaced glass mercury thermometers due to safety concerns with mercury.  Ear thermometers are not accurate in young infants or those with wax in the ear canal.  Plastic strip thermometers and pacifier thermometers give a general idea of a temperature, but are not accurate.  

To identify a true fever, it is important to note the degree temperature as well as location taken.  (A kiss on the forehead can let most parents know if the child is warm or hot, but doesn't identify a true fever and therefore the need to isolate to prevent spreading illness.)  I never recommend adding or subtracting degrees to decide if it is a fever.  In reality, you can look at a child to know if they are sick.  The degree of temperature helps guide if they can go to school or daycare, not how you should treat the child.  Fevers in children are generally defined as temperatures above 100.4 F (38 C).

Fever is rarely dangerous, though parents often fear the worst.

This is the time of year kids will be sick more than normal.  With each illness there can be fever (though not always.)


What you can do:

• Be prepared at home with a fever reducer and know your child's proper dosage (especially with the recent dosing changes to acetaminophen!) 
• Use fever reducers to make kids comfortable, not to bring the temperature to normal.
• Have an electrolyte solution at home in case of vomiting. 
• Teach kids to wash their hands and cover coughs and sneezes with their elbows.  
• Stay home when sick to keep from spreading germs.  It is generally okay to return to work/school when fever - free 24 hours without the use of fever reducers.  
• Help kids rest when sick.
• If the fever lasts more than 3-5 days, your child looks dehydrated, is having trouble breathing, is in extreme pain, or you are concerned, your child should be seen.  A physical exam (and sometimes labs or xray) is needed to identify the source of illness in these cases.  A phone call cannot diagnose a source of fever.
• Any infant under 3 months or immune compromised child should be seen to rule out serious disease if the temperature is more than 100.5.

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