FEVER IN CHILDREN: SORTING FACTS FROM MYTHS

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1 FEVER IN CHILDREN: SORTING FACTS FROM MYTHS Program Index Fever and its causes What causes fever? Can a fever hurt my child? When should I be concerned about fevers? How do I know if my child has a fever? What does this temperature mean? How do I measure my child s fever? When should fever be treated? How do I treat my child s fever? What fever medications are recommended for children? How do I give fever medications? Are fever medications safe to give with my child s other medications? How can I tell if the fever medications are working? Copyright medschool For You

2 Fever and its causes What is a fever? Fever is a body temperature that is 38C or higher 1. Fever happens when the brain s thermostat dials up the body s normal temperature after it senses the body is sick from an infection or another type of illness 1,2,5. MYTH: Fever is an illness. Fever is not an illness but a sign of illness, and a good sign to boot. Why? 1,2 Fever is one of the body s natural defenses against illness by helping the immune system work faster to kill bacteria and viruses. Fever lets you know that your child is unwell and that his or her body is fighting the infection. What causes fever? What causes fever in infants and children? Some causes of fever in infants and children are 3 : Infections: Infections are the most common causes of fever in children. If your child ever gets a cold, the flu, a stomach bug, or ear infection, he or she will probably get a fever. Vaccines: A fever can happen up to two weeks after your child gets a vaccine, depending on the specific vaccine. This is normal and just means that your child s immune system is building up protection against the vaccine. Copyright medschool For You

3 MYTH: Dressing a newborn in too many layers can cause fever. Bundling newborns less than 3 months of age can make them overheat since newborns cannot regulate their temperatures as well as older children 5. But temperatures above 38.5C (101F) are not likely to be caused by overdressing and should be checked by a doctor 3,4. MYTH: Teething causes fever. Sometimes a child s temperature will spike just before and during the time the tooth breaks through the gums 6. However, a high or persistent fever during teething is not normal. Signs that your child may be ill for a reason unrelated to teething include 6 : A temperature that is higher than 38.9C (102F) A fever that lasts for more than one day before and after the tooth appears Can a fever hurt my child? What are the complications of fever in infants and children? Fever can cause uncomfortable symptoms (like shivering and achiness) and mild dehydration 3. In a small number of children, they can lead to febrile seizures, a harmless type of seizure that happens specifically in young children between the ages of 3 months and 5 years of age with fever 8. Opposite to what most people think, these complications are NOT harmful 1,2. Why? Fever does not actually raise the body s temperature high enough to truly harm the body 1,7. Even children who have serious febrile seizures fully recover and never experience another seizure again 10. Copyright medschool For You

4 Caution! In very rare cases, fever can be a sign of a more serious illness that could harm your child. Have your child checked by a doctor if your child s fever is 40.5C (104.9F) or higher, your child is less than 6 months old, or your child experiences any of the signs listed under When should I take my child to the doctor or the hospital? MYTH: Fevers can cause brain damage. Many people think that a high fever can damage the brain and other organs. Although this can happen at very high body temperatures, the small rises in temperature brought on by fever (between 38.0C to 41.0C) do NOT cause damage 2,7,9. Febrile seizures are also harmless. Even though febrile seizures are very scary to witness, they have NOT been shown to affect brain function 8. Tests have shown that children who have had febrile seizures, both mild and serious, perform just as well in school as children who have not had febrile seizures 8,11. MYTH: A high fever increases the risk of febrile seizures. Whether or not your child will have a febrile seizure depends more on the child and his or her unique risk to have a febrile seizure, rather than anything to do with the fever itself, such as how high the fever is or how long it lasts 11. Copyright medschool For You

5 When should I be concerned about fever? When should I take my child to the doctor or the hospital? If your child has any of the following signs, he or she should see a doctor 1 : Your child is less than 6 months old The fever is 40.5C (104.9F) or higher Your child has a stiff neck and/or a severe headache Your child has had a seizure (including febrile seizures) o Even though febrile seizures are harmless, your child should still be reviewed by a doctor to make sure the seizure was caused by the fever, and not by the infection. Your child has an area on his or her body that is red, swollen, and painful Your child looks and acts very sick, for example: o He or she is extremely irritable, fussy, or will not stop crying more than usual o He or she is extremely sluggish, difficult to wake up, or seems confused Your child just started a new medication and also has a rash Your child has recently received chemotherapy Your child has a serious medical condition (e.g., heart disease, cancer, lupus, sickle cell anemia) The fever has lasted longer than 24 hours without any obvious signs of an infection (e.g., cold, earache, stomach bug, etc.) The fever has lasted for 3 days with or without treatment with medications, (e.g., acetaminophen (Tylenol ) or ibuprofen (Advil )) How do I know if my child has a fever? What are the signs and symptoms of fever? A definite sign that your child has a fever is 1,12 : A body temperature that is 38.0C (100.4F) or higher Other signs and symptoms of fever may include 12 : Skin that feels warm and looks flushed Shivering or sweating Feeling tired or achy Feeling thirsty Copyright medschool For You

6 Most children will also have symptoms of the infection causing the fever, such as a sore throat, stomachache, or earache 12. MYTH: My child has a fever if he or she feels warm. How warm skin is to touch is NOT the most accurate way to tell if your child has a fever. This is because how warm your child s skin feels depends on the temperature of your hand 1. The best way to confirm fever is to measure your child s temperature using a thermometer. What does this temperature mean? At what temperature does my child have a fever? Fever is a temperature of 38.0C (100.4C) or more 1,2. Rectal temperatures are the gold standard for giving an exact measurement of body temperature 13. Measuring other areas, such as the mouth, armpit, and ear, are not as accurate for measuring body temperature, but they are more convenient than taking a rectal temperature 1,13. Normal and fever temperature ranges for the rectum, mouth, armpit, and ear are listed below. Normal and fever temperatures based on area of measurement 1 Area Normal range Fever range Rectum C ( F) Higher than 38.0C (100.4F) Mouth C ( F) Higher than 37.5C (99.5F) Armpit C ( F) Higher than 37.3C (99.1F) Ear C ( F) Higher than 38.0C (100.4F) MYTH: Temperatures between 37.0C and 38.0C are low-grade fevers. Temperatures between 37.0C and 38.0C are actually still considered normal temperatures 14. Although the body s temperature is kept pretty constant at 37.0C, it is normal for body temperature to go up and down throughout the day. Things that normally raise our temperatures above normal are exercise, thick clothing, hot weather, and hot baths. Copyright medschool For You

7 MYTH: The higher the fever, the sicker my child is. In most cases, a high fever does not mean your child is more sick. In fact, high fevers are often caused by ordinary viral infections, like the common cold. On the other hand, some serious infections may only cause a mild fever 7,9. You can tell how severe your child s illness is by how sick he or she looks and acts, NOT by the numbers on the thermometer 2. How do I measure my child s temperature? What is the best way to measure my infant s or child s temperature? The best way to measure your child s temperature depends on his or her age. The preferred areas of for measuring temperature are sorted by age groups in the chart below. Preferred method of temperature measurement by age group 1,13 Age Group First Choice Second Choice Birth to 2 years Rectal (for an exact reading) Armpit (to check for fever) of age Between 2 and 5 years of age Rectal Ear, armpit Over 5 years of age Oral Ear, armpit Which is better: Digital or glass thermometers? Digital thermometers are preferred over glass thermometers because they are more accurate, they are faster and easier to use, and they are safer (for example, if the child bites down on the thermometer). They are also inexpensive and can be used to take temperatures in the rectum, armpit, and mouth. Copyright medschool For You

8 MYTH: Glass thermometers are unsafe because they contain mercury. Modern-day glass thermometers do not contain mercury and are environmentally friendly. But these thermometers can still break and harm your child if they are not handled carefully. Caution! The Canadian Pediatric Society does not recommend mercury thermometers because of their potential to cause mercury poisoning 13. If you have an old mercury thermometer at home, bring it to your city s hazardous waste collection facility for disposal. How do I take a rectal temperature? To take a rectal temperature: 1,5 1. Lay the baby down on his with his knees bent OR on his stomach across your lap OR in the fetal position on a flat surface (e.g., changing table top). 2. After washing and drying your hands, warm the tip of the thermometer by holding the tip between your thumb and fingers for about 60 seconds. 3. Lubricate the anus and the thermometer with a pea-sized amount of petroleum jelly. 4. With one hand, gently insert the thermometer 2 to 3 cm into the rectum, stopping if you feel any resistance. Keep holding the thermometer in place with your hand, while using the other hand to hold the buttocks closed against the thermometer with your other hand. 5. Remove the digital thermometer when it beeps and read the temperature displayed. 6. Wash the thermometer by removing the petroleum jelly with a clean tissue, clean the tip (the end inserted into the rectum) with warm soapy water, and then wipe it down with a cotton ball soaked in rubbing alcohol to kill any germs. Tip! Don t use a rectal thermometer to measure temperatures in the mouth in order to prevent the spread of germs. Copyright medschool For You

9 How do I take an armpit temperature? To take an armpit temperature: 1,5 1. Remove your child s shirt and place the tip of the thermometer in the centre of the armpit. 2. Fold the child s arm down and hold his elbow in place to make sure the thermometer stays put. 3. Hold it until the digital thermometer beeps, then remove and read the temperature displayed. 4. Wash the thermometer every so often by washing the tip with warm, soapy water. How do I take an oral temperature? To take an oral temperature: 1,5 1. Place the tip of the thermometer either between the gum and the cheek OR under the tongue. 2. Remind the child not to bite down and to keep his or her lips sealed around the thermometer. 3. Have the child breath through his or her nose while the thermometer is in place. 4. Hold it until the digital thermometer beeps, then remove and read the temperature displayed. 5. Wash the tip of the thermometer with warm, soapy water. Tip! Wait 30 minutes after your child has eaten or drank hot or cold foods or liquids. Choose another method of measurement (e.g., armpit or ear) if your child does not want to cooperate (e.g., he can t keep his lips sealed around the thermometer or the thermometer under his tongue) or if your child is stuffed up and has to breathe through his mouth. Copyright medschool For You

10 When should fever be treated? Does fever in children need to be treated? Despite what most people think, fever does NOT need to be treated. In fact, there are many reasons to NOT treat fever, since 1,2 : Fever is the body s natural defense to help fight infection Fever lets you know if the infection is getting better or worse The complications of fevers, including febrile seizures, are harmless Caution! In certain circumstances, fever can be a sign of a more serious illness that needs to be treated. In these situations, it is more important to treat the underlying cause of the fever, rather than the fever itself. Get your child checked by a doctor if he or she experiences any of the signs listed under When should I take my child to the doctor or the hospital? When should I consider treating my child s fever? Treating fever is only recommended if it is making the child feel distressed or uncomfortable 1,2. Caution! In very rare instances, fever can be a sign of a more serious illness that needs to be treated. Get your child checked by a doctor if your child s fever is 40.5C (104.9F) or higher, your child is less than 6 months old, or your child experiences any of the signs listed under When should I take my child to the doctor or the hospital? Copyright medschool For You

11 MYTH: Fevers must be treated to prevent febrile seizures. There is also no evidence to show that bringing down a fever with medications prevents febrile seizures 8,11. MYTH: Fevers need to be controlled to stop the temperature from rising higher. The brain still regulates the body s temperature during fever. Just like turning up the thermostat at home, the body s temperature will stop rising once it reaches the new temperature set point 15. How do I treat my child s fever? How do I treat my child s fever? You can help bring down your child s temperature and relieve fever symptoms by 1,2 : Removing extra bedding and clothing Keeping your child s bedroom at a cooler temperature Having your child rest and avoid vigorous playing Hydrating your child with lots of fluids You can also give a fever medication, which helps bring down the body temperature by resetting the brain s thermostat set point to a lower temperature. Caution! Before you start to treat your child s fever, make sure it is safe to treat him or her at home without talking to your doctor first. Do not treat fever at home if he or she develops any of the signs listed under When should I bring my child to the doctor or hospital?. Copyright medschool For You

12 MYTH: Sponging is recommended to help bring down fever. Although sponging can help lower body temperature, studies have shown that it actually makes children feel more uncomfortable and is therefore not recommended to bring down fever temperatures 1,3. What fever medications are recommended for children? What fever medications are available to treat fever in infants and children? Acetaminophen (e.g., Tylenol, Tempra ) and ibuprofen (e.g., Advil, Motrin ) are both used to safely treat fever in infants and children 1,2. Even though naproxen (e.g., Aleve ) and ASA (aspirin ) can be used to treat fevers in adults, they are not recommended for children 1. Fever medication medications in infants and children 1,2 Recommended in Generic Name Brand Name(s) Comments Infants and Children? YES For children 3 months and older YES For children 6 months and older NO Do not use in children under 18 years of age NO Do not use in children under 12 years of age Acetaminophen Tylenol, Tempra Available in many different formulations (e.g. drops, suspension, chewable tablets). Ibuprofen Advil, Motrin Acetylsalicylic acid (ASA) Aspirin Not recommended in children under 18 years of age since it can cause Reye s Syndrome, a rare illness that affects the liver and brain in children with viral infections. Naproxen Aleve Not recommended in children under 12 years of age since there is not enough safety data to recommend its use in children. Which is better for treating fever: acetaminophen or ibuprofen? Both acetaminophen and ibuprofen are effective for reducing fever, but there are certain situations in which you might consider one over the other. These situations are listed below. Copyright medschool For You

13 When to consider acetaminophen or ibuprofen 1,2 Acetaminophen Pain is also present (e.g., sore throat) Ibuprofen is NOT an option o Child is vomiting and/or has diarrhea o Child is sensitive to ibuprofen sideeffects o Child is allergic to ibuprofen o Child is less than 6 months old Ibuprofen Pain and inflammation is also present (e.g., ear infections) 16,17 Child needs longer-lasting relief* of feverrelated discomfort or pain (e.g., because he or she wakes up during the night). Did you know? Ibuprofen relief usually lasts for about 6 to 8 hours, whereas acetaminophen relief typically lasts for about 4 to 6 hours. MYTH: It s better to alternate between acetaminophen and ibuprofen American Academy of Pediatrics does NOT recommend alternating acetaminophen and ibuprofen since: The extra reduction in fever temperature from using both products has NOT been shown to benefit children with fever 2 Any potential benefit of using both products is outweighed by the risk of accidentally giving the wrong dose of either medication 2. Stick to one product instead. It s safer and just as effective as using both products. How do I give fever medications? What dose of acetaminophen or ibuprofen should I give? To find the BEST dose of acetaminophen or ibuprofen for your child: 1. Get your child s weight or age: o Find your child s weight. Age can be used instead if you can t measure your child s weight. Copyright medschool For You

14 2. Check the acetaminophen or ibuprofen dosing chart: o Look on the label of the specific product you would like to use OR check the charts below o Find the right dose for your child s weight or age and specific product AND/OR 3. Ask the pharmacist to help you calculate the correct dose. Caution! The Canadian Pediatric Society recommends that you do NOT treat fever in children 6 months and under without talking to your doctor first. Follow the directions on the label of the specific product you would like to use or give as directed by the doctor. If your doctor s directions are different from those on the product s label, follow the doctor s directions instead. Acetaminophen dosing by weight, age, and formulation 18 Weight Age Concentrated Drops (80 mg/1 ml) Suspension (160 mg/5 ml) Melting tablets (160 mg/tablet) lbs kg 4-11 mo* 1 ml Ask pharmacist. Ask pharmacist lbs kg mo 1.5 ml lbs kg 2-3 years Ask pharmacist. 1 tsp (5 ml) lbs kg 4-5 years 1½ tsp (7.5 ml) lbs kg 6-8 years 2 tsp (10 ml) 2 tablets lbs kg 9-10 years 2½ tsp (12.5 ml) 2½ tablets lbs kg years 3 tsp (15 ml) 3 tablets 95+ lbs kg 12+ years Use adult strength acetaminophen products. Ibuprofen dosing by weight, age, and formulation 19,20 Weight Age Concentrated Drops (50 mg/1.25 ml OR 40 mg/1 ml) Suspension (100 mg/5 ml) Chewable tablets (100 mg/tablet) Regular tablets (100 mg/tablet) lbs kg 6-11 mo 1.0 ml to 1.25 ml Ask pharmacist. Ask pharmacist. Ask pharmacist lbs kg mo 1.4 ml to ml lbs kg 2-3 years Ask pharmacist. 1 to 1¼ tsp (5 to 6 ml) Copyright medschool For You

15 36-47 lbs kg 4-5 years 1½ to 2 tsp (7.5 to 10 ml) lbs kg 6-8 years 2 to 2½ tsp (10 to 12.5 ml) lbs kg 9-10 years 2½ to 3 tsp (12.5 to 15 ml) lbs kg to 3¾ tsp years (15 to 19 ml) 95+ lbs kg 12+ years Use adult strength ibuprofen products. 2 tablets 2 tablets 2½ tablets 2 or 2 ½ tablets 3 tablets 3 tablets Did you know? One half of parents give the wrong dose of fever medications to their children 1,2. Caution: Teaspoons and Tablespoons Pay attention to the difference between teaspoons (tsp = 5 ml) and tablespoons (tbsp = 15 ml). Accidentally giving one tablespoon instead of one teaspoon triples the recommended dose! Caution: Drops are NOT Suspensions! Drops and suspensions are NOT equivalent! The same volume of drops and of suspension contains different doses of the medication. Talk to your pharmacist if you would like to switch between drops and a suspension and ALWAYS double check the label. Should I use my child s weight or age to find the right dose? Always use weight if possible. Using age is not as accurate for estimating the correct dose since dosing by age assumes that your child is at an average weight for his or her age group. If a child is above or below the average weight of his or her age group, you could end up giving too high or too low a dose 2. Copyright medschool For You

16 How often should I give acetaminophen or ibuprofen? 1. Give a dose acetaminophen or ibuprofen only as often as recommended o Wait at least 4 hours after giving acetaminophen to give a second dose o Wait at least 6 hours after giving ibuprofen to give a second dose 2. Do not give more than the maximum number of doses that can be taken in a day o Give a dose of acetaminophen no more than 5 times in a day o Give a dose of ibuprofen no more than 4 times in a day 3. Only give acetaminophen or ibuprofen IF NEEDED o If your child is sleeping, do not wake him or her up to give medication 2 o Stop giving these medications if the child s bothersome symptoms go away Dosing of acetaminophen and ibuprofen 2,18,19 Medication How often doses can be Maximum number of doses given that can be given per day Acetaminophen Every 4 to 6 hours 5 doses Ibuprofen Every 6 to 8 hours 3 or 4 doses (check the label) Caution! Always double check the directions by looking on the label of the specific product you would like to use or by asking your pharmacist. MYTH: Kitchen spoons are accurate measuring utensils. Do NOT use kitchen spoons. They are not measuring tools and will either give your child too much or too little medication. Use the medicine syringe or cup included with the medication to measure out the exact amount of medication to give. Ask your pharmacist to give you a measuring syringe or cup if you don t already have one. Copyright medschool For You

17 Tip! Give ibuprofen with food or a glass of milk to prevent it from upsetting your child s stomach. Copyright medschool For You

18 Fever and Medications Are acetaminophen and ibuprofen safe to continue with antibiotics? Acetaminophen and ibuprofen are safe to give with most antibiotics, but you should always ask your pharmacist about the safety of starting a new medication if you aren t sure. Continue giving fever medications as long as the child is uncomfortable from fever or pain, or until the antibiotic makes the fever and its bothersome symptoms go away. Are acetaminophen and ibuprofen safe to take with other medications my child is taking? Always ask your pharmacist if your child s medications (including over-the-counter medications, prescription medications, supplements, and herbal products) are safe to combine with a new medication. Caution: Avoid combination cough and flu products! Over-the-counter cold and flu products contain multiple ingredients and usually include either ibuprofen or acetaminophen. Combining these products with fever medications can lead to an accidental overdose 1,2. These products should always be avoided in children. How can I tell if the fever medications are working? Will fever medications bring the body temperature down to normal? Acetaminophen and ibuprofen will typically bring down a fever by about 1 to 2C 2. Although this drop in temperature may not be enough to bring your child s body temperature down to normal, it should help relieve some symptoms of fever, such as discomfort and shivering. Copyright medschool For You

19 MYTH: The goal of treating fever is to bring the temperature down to normal. The goal of treating fever is to make the child comfortable. It doesn t matter how little or far the temperature drops as long as the child is no longer bothered by fever symptoms 1,2. MYTH: A fever that can t be brought down by fever medications requires immediate medication attention. It is normal for a fever to resist or to bounce back after fever treatment 14. In these cases, the fever will go away on its own as the body recovers from the infection. But if fever persists or keeps coming back after 3 days, it should be checked by a doctor (See When should I take my child to the doctor or the hospital? ). How often should I check my child s temperature? You only need to measure your child s temperature if he or she feels warm or looks unwell 1. Aside from this, there is no need to take a temperature more than 2 to 4 times a day 1. Constant monitoring is discouraged because it only makes parents feel more worried about fever. Caution! Have your child checked by a doctor if his or her fever lasts longer than 24 hours without any obvious sign of infection or lasts for 3 or more days, or if your child develops any of the signs listed under When should I take my child to the doctor or the hospital? Copyright medschool For You

20 References 1. Shevchuk YM. Fever. In: Carol Repchisky, editor-in-chief. Patient self-care. Ottawa: Canadian Pharmacists Association; P Sullivan J, Farrar H, Section of Clinical Pharmacology and Therapeutics, Committee on Drugs. Fever and fever medication use in children. Pediatrics [Internet] Mar [cited 2015 Jan 8];127(5): Available from: 3. Ward M. Patient information: fever in children (beyond the basics). Uptodate [Internet] Apr [cited 2015 Jan 12]. 4. Grover G, Berkowitz CD, Thompson M, Berry L, Seidel J, Lewis RJ. The effects of bundling on infant temperature. Pediatrics Feb [cited 2015 Jan 18]. 5. KidsHealth [Internet]. Fever and taking your child s temperature. Izenberg N, editor-in-chief. [Place unknown]: The Nemours Foundation; [cited 2015 Jan 12]. Available from: 6. Macknin ML, Piedmonte M, Jacobs J, Skibinski C. Symptoms associated with infant teething: a prospective study. Pediatrics Apr [cited 2015 Jan 10];105(4 Pt 1): Medline Plus [Internet]. Fever. [Place unknown]: A.D.A.M., Inc.; [cited 2015 Jan 8]. Available from: 8. National Institute of Neurological Disorders and Stroke [Internet]. Febrile seizures fact sheet Sept [cited 2015 Jan 12]. Available form: 9. Tunkel AR. Fever. Merck Manuals [Internet]. [New Jersey]: Merck Sharpe & Dohme Corp.;2012 Oct [cited 2015 Jan 9]. Available from: Verity CM, Butler NR, Golding J. Febrile convulsions in a national cohort followed up from birth. II--Medical history and intellectual ability at 5 years of age. Br Med J (Clin Res Ed) 1985 [cited 2015 Jan 10];290: Chung S. Febrile seizures. Korean J Pediatr Jul [cited 2015 Jan 10];57(9): Healthychildren.org [Internet]. Signs and symptoms of fever. [Place unknown] American Academy of Pediatrics June [cited 2015 Jan 11]. Available from: Leduc D, Woods S, Canadian Pediatric Society, Community Pediatrics Committee. Position statement: temperature measurement in pediatrics. Canadian Pediatric Society [Internet] Jan [cited 2015 Jan 13]. 14. Schmitt BD. Fever myths and facts. Childshealthnetwork.org [Internet] Jun [cited 2015 Jan 12]. Available from: Bernheim H. Temperature regulation and fever. The Reticuloendothelial System [Internet] [cited 2015 January 8]: Available from: Bertin L, Pons G, d Athis P, Duhamel JF, Maudelonde C, Lasfargues G, Guillot M, Marsac A, Debregea B, Olive G. A randomized, double-blind, multicentre controlled trial of ibuprofen versus acetaminophen and placebo for symptoms of acute otitis media in children. Fundam Clin Pharmacol [cited 2015 Jan 15];10(4): Steehan J. 8 Children s health debates: Acetaminophen or ibuprofen. Parents Magazine [Internet]. Available from: Pfizer Consumer Healthcare. Children s Advil dosing chart. Pfizer Inc Aug [cited 2015 Jan 20]. 19. Johnson & Johnson. Children s Tylenol dosing guide. Johnson & Johnson Inc [cited 2015 Jan 20]. 20. Motrin.ca [Internet]. Product details for infants Motrin concentrated drops; product details for child s Motrin liquid suspension [cited 2015 Jan 22]. Copyright medschool For You