Fever Phobia #2: The High or Unresponsive Fever…..
**Disclaimer** The following discussion is, in my opinion, good medical advice for most caregivers but it does not constitute specific medical advice for you or your child. There do exist specific situations where children with fever are treated differently because of age or underlying medical conditions. For instance, neonates and children with sickle cell disease are treated very differently than a healthy nine-year-old with even a fever of 106 degrees. I strongly recommend that anyone reading this or any other post regarding medical topics discuss any medical concerns with their child’s primary care physician. **Disclaimer**
Fever phobia is everywhere. In preparation for writing this post I took just a few minutes to peruse the internet and, not surprisingly, found a seemingly never-ending supply of flawed information. A great deal of this misinformation can be found in places where I would expect it, such as on chiropractic websites and parenting message boards. But much of it is put out by what would seem to most people to be legitimate sources, including the websites of pediatric practices.
A number of studies looking into fever phobia have consistently found that two of the most common concerns expressed by parents and medical professionals are the risk of health problems related to highly elevated temperatures and to fever that does not respond to antipyretic medication such as acetaminophen and ibuprofen. This concern seems to be based on a number of misconceptions, in particular the unfounded belief that the height of a fever positively correlates with the severity of the infection and that fever over 104-105 degrees can cause brain damage, seizures, hearing loss, or even death. As I will shortly explain, both of these concerns are unwarranted.
Fever due to infection, rather than hyperthermia due to being left in a hot car on a Louisiana Summer day, is a homeostatic process. When the body is exposed to infectious organisms such as viruses and bacteria, a number of so-called pyrogens are produced as part of the inflammatory response. These pyrogens can then act to raise the core body temperature set point, which is regulated in the brain by the hypothalamus. The body then undergoes a variety of physiological and behavioral changes in order to increase our core body temperature to match this new set point. These changes include the clamping down of blood vessels in the skin in order to decrease heat loss, shivering to produce heat, and raising the ambient temperature with blankets and heaters.
At a certain core temperature, depending on the age of the person, the type of infection, the intake of antipyretic medications and certainly a number of currently unknown feedback mechanisms, the body will put into play measures to lower the temperature set point. Our peripheral blood vessels dilate, we become flushed and break into a sweat, and we crank up the AC. This will occur 100% of the time, even if no medications are given to assist the process. It is physiologically impossible, in the setting of infection alone, for our core body temperature to be raised higher than 106-107 degrees without inappropriate exposure to an external heat source.
Even at that extreme of possible core body temperature mentioned above, there is no direct link between fever and brain damage, hearing loss, or death. The height of fever is an independent risk factor for febrile seizures, but treatment does not prevent their occurrence. I covered febrile seizures in an earlier post. There is an indirect association, and this is likely why the fear emerged initially, between fever and poor neurological outcomes however. An infection, in particular a severe bacterial infection involving the blood and/or brain, which has led to a febrile response may, unfortunately, ultimately lead to these dreaded complications. But it is the underlying infection to blame, not the fever. Treating fever in these instances does not improve the outcome.
In addition, the height of fever has not been reliably linked to the severity of the infection that has caused it, especially in the post-vaccine era. A patient can have a life-threatening case of Haemophilus or Staphylococcal meningitis with no appreciable fever just as a child with a minor viral upper respiratory infection can spike to 105. Many protocols in use today still base treatment decisions on the height of fever, but they are not based on current evidence and they lead to increased practitioner/parental anxiety and overuse of testing and imaging modalities. Similarly, a fever that does not come down after administration of an antipyretic is not more likely to be caused by a severe infection. It just doesn’t work that way. What is more important is how the child looks, regardless of what their temperature does with Tylenol on board. A lethargic toddler with a stiff neck, or an infant that refuses to feed, needs to be evaluated while a playful 4 year-old with draining snot and a temperature of 103 degrees can probably just be watched in most cases.
At the heart of fever phobias such as these, is the general misunderstanding of fever as a disease in and of itself. It is more helpful to think of fever as a symptom in the same way we might regard heartburn. There is something that leads to the development of fever, typically an infection, and it is likely that there is a good reason for the febrile response to be so prevalent in the animal world. Although it hasn’t been replicated in humans, studies have shown decreased mortality in a variety of other species related to mounting a fever in response to an infection. There are hypotheses as to why fever may be beneficial. Perhaps pathogens are unable to replicate as efficiently, or perhaps our immune system is more effective, when core body temperatures are elevated. It is a fascinating area of study.
Thinking of fever as a symptom rather than as a disease helps to put it into perspective. Many people, when their head begins to ache after a long day at work, reach for an analgesic medication such as Ibuprofen or Naproxen while others prefer to see if it will progress before attacking that childproof lid. Some will even tough it out until the pain is excruciating or forego treatment alltogether. Almost all headaches will eventually resolve on their own. The overwhelming majority of headache sufferers do not treat their headache because they are worried that the headache itself will lead to a bad outcome, such as a brain tumor or stroke. They treat the headache because it makes them uncomfortable and they will only seek medical attention in certain instances. With fever, parents absolutely should treat with antipyretics when their child is uncomfortable. Helping a sick kid feel better, in my opinion, is more important than preserving the possible minor benefit gained from a febrile response to infection. And parents absolutely should seek medical attention when the fever occurs in the context of other risk factors for serious infection, such as age less than 28 days or a very ill appearance, to single out just a couple. When in doubt, I always recommend that a caregiver call their child’s pediatrician or family doctor. In general though, if you have a healthy older child who doesn’t seem to be bothered by the fever it is okay to not give antipyretics, and it is okay to not even recheck the temperature. Just focus on their appearance and behavior.
A 2001 study in Pediatrics revealed that almost 75% of parents sponge their children in the setting of fever, with many doing so at temperatures of less than 100 degrees. This is problematic for two reasons, the most important of which is that sponging doesn’t work. And if you are one of the two-thirds of parents that use improper technique, then you may be making your child more uncomfortable and putting their health at risk. The proper technique, or at least the technique least likely to add insult to injury, is the use of a sponge or rag soaked in tepid water to dampen a febrile child’s head and neck. While this might lead to some subjective improvement, perhaps secondary more to the loving attention of the child’s caregiver than to any specific effect, it will not lower core body temperature. Unfortunately many caregivers use cool or cold water to sponge with, submersion in cool or cold water, application of ice packs and even topical rubbing alcohol in an attempt to treat fever. These techniques are ineffective and potentially dangerous in the case of rubbing alcohol. Use of cool or cold water leads to constriction of skin blood vessels and impairs the child’s ability to lose heat which can cause intense shivering. This is uncomfortable and actually raises body temperature. Rubbing alcohol can be absorbed through the skin and result in lethal toxicity.
Some have described fever as our friend, typically as a means of getting across the message that it might actually have a beneficial purpose during an infection. Some friend. Fever can make a child feel absolutely lousy and I don’t blame parents for not wanting it to come over and play after school. Although the evidence is not clear that fever plays a significant positive role during some illnesses rather than the traditional part of the Snidely Whiplash, it is clear that fever phobia is counterproductive and potentially harmful. The same studies that delved into parental and medical professionals’ fears regarding fever also showed us that concerning numbers of parents give doses of antipyretics that are higher and more frequent than recommended. They also showed that a majority of parents will give, and medical professionals will recommend, alternating Tylenol and Motrin despite the lack of evidence for safety and efficacy of the practice. The AAP specifically recommends against it.
The final fever myth I’ll discuss is the belief that medications, like Tylenol and Motrin, are safe because they are over-the-counter. The truth is that they are both pretty darn safe, especially acetaminophen, but there are reasons to be cautious. First and foremost, if there is no benefit from the administration of a medication, any risk is unacceptable. Giving antipyretics to comfortable children with fever falls into that category most of the time. Tylenol, when overdosed, can cause irreparable liver damage. Motrin, even when dosed appropriately, can cause kidney and gastrointestinal damage, especially in the context of dehydration and it should not be given to children under 6-months. During the first several years of life for most children, there will occur numerous febrile episodes. During many if not most of them, there will be a legitimate need for antipyretic medication. But it is impossible to make rational decisions regarding the care of a child without the proper information to base those decisions on. Acting out of fear, and on misinformation, should be avoided at all costs.