High Fever

Dear Lisa,

My Child has high fever (102 to 103) can't bring it down.

“Worried mom”

Dear “Worried mom”,

The presence of a fever probably causes more parental anxiety than any other symptom experienced by a child. A fever is actually a good sign, because it shows that a child’s body is fighting an infection that has invaded his body. It is normal for a person’s body temperature to fluctuate throughout the span of a day. This diurnal variation causes the body to reach its highest temperature between 5 and 7 p.m. in the evening and the lowest temperature early in the morning before rising. (1) Because of this, most fevers are first noticed in the evening hours when the Doctor’s office happens to be closed. This probably is another reason why a febrile child causes a parent so much anxiety.

Generally speaking, if a child develops a fever in the middle of the night most health care professionals will tell you to give him an antipyretic (fever reducing medication) and call back in the morning. This is a reasonable approach to a fever in a child over 3 months old because it is likely that the fever will go down during the daytime hours due to normal physiologic responses.

There are certain situations when a child’s fever should cause a parent to be concerned and seek medical attention. All infants, younger than 3 months old with a rectal temperature reading 100.4 degrees Fahrenheit or higher need an evaluation by a health care professional. This is necessary because a child’s immune system is not fully developed at this young age.(1) A young infant will not be able to fight an infection the way that an older child or adult would. In many cases, a fever in an infant may be the only sign of a serious infection such as a Urinary Tract Infection, Bacteremia (blood infection) or Meningitis.(1) Therefore it is urgent that a young infant with a fever be seen by a health care professional without delay.

Other concerning signs include a fever accompanied by; a stiff neck, severe headache, abdominal pain, vomiting, rash, seizure activity or difficulty breathing. These signs may represent a serious condition and require medical attention. Children with chronic medical conditions such as Sickle Cell Anemia, Diabetes, Neutropenia, Immune Deficiency, Cystic Fibrosis, Cerebral Palsy, Cancer or children without a spleen should also be addressed differently. A fever can compromise an underlying chronic medical condition or may be a sign of a complication. Therefore children with chronic medical conditions should have an action plan created by their Doctor so that a parent knows exactly how to address a fever before it occurs.

Children free from chronic medical conditions or any immune deficiencies should be able to tolerate a fever without any harm to their body. A fever is the body’s regulated response to an infection. Because it is a regulated response, the body’s own defense mechanisms should not allow the core body temperature to reach a level that can be hazardous to the child. It is rare for a child’s fever to reach 107 degrees Fahrenheit or 41.7 degrees Centigrade.(1)

An exception can occur when a child develops Heat Exhaustion due to exposure to extreme heat. Conditions that put a child at risk for developing heat exhaustion include confining a child in a closed car or allowing a child to exercise when they are dehydrated or have a fever.(2) When a child develops heat exhaustion, their body’s natural mechanisms to dispel heat are thwarted.

Normal healthy children can tolerate changes in temperature and a higher core body temperature more than most parents expect. Because of their immature sweat mechanisms children tend to have higher temperatures overall. For example, it is not uncommon for children 18 months old and younger to have a rectal temperature reading of 100 degrees Fahrenheit under normal circumstances.(3) This temperature does not represent an infection and is considered to be normal. Therefore a temperature of 102 in a child this age is not particularly alarming. I am not saying that the fever does not need to be addressed; it just means that it is not an emergency situation. It is feasible to monitor and treat temperatures at this level at home until it is possible for a child to be examined by a Physician.

Many parents ask, “At what temperature should I be concerned?” Any fever associated with an ill-appearing child should cause concern. An otherwise healthy child with no other symptoms experiencing a fever can be managed at home until an evaluation by a health care practitioner can be performed. Children with persistent fevers that last beyond 5 days, regardless of the child’s age or appearance should be evaluated by a Physician or Nurse Practitioner in order to rule out a bacterial infection.

Many parents also ask, “At what temperature should my child be taken to the Hospital or Emergency Room?” This question depends upon a lot of variables. If a child has other symptoms along with a fever such as signs of dehydration, difficulty breathing, is not able to eat or drink, has pain, has a rash, is lethargic or is inconsolable an evaluation by a health care professional is necessary. Your Doctor should be able to direct you regarding how to access care. If you do not have a Doctor or cannot get in touch with your Doctor, then an Emergency Room Visit is the quickest way to have an evaluation by a health care professional when these concerning signs are present.

A temperature itself is not the only indicator that determines how serious a child’s condition is. A child can be quite ill and require an Emergency Room visit even if his temperature is not elevated. The height of the temperature does not necessarily reflect the seriousness of an illness either. A persistent low fever can be the sign of a serious condition such as a chronic infection, collagen vascular disease or tumor.(4) On the other hand, a child can develop a very high fever due to a virus, such as Roseola, which is typically benign and self limiting.

In general, a fever over 104 degrees Fahrenheit should cause some concern and warrants an evaluation in order to determine if a bacterial infection is the culprit. Fevers at this level should be followed closely by a Health Care Professional. A fever as high as 106 degrees Fahrenheit or 41 degrees Centigrade requires urgent medical attention.(4) A visit to the Emergency Room would be warranted in this situation.

The treatment for a fever includes giving anti-pyretics, tepid baths, administering cool fluids and dressing a child appropriately. Ibuprofen is typically recommended for children 6 months old or older with a fever greater than 102 degrees Fahrenheit. Before administering Ibuprofen it is wise to consult with your Doctor to make sure the medication in not contra-indicated in your child. For example, children with PKU should not take over-the-counter products such as Ibuprofen because some formulations may contain aspartame which can worsen the child’s condition.(5)

Acetaminophen is also commonly recommended for children with fever. The overall effect of this medication is dependent upon the dosage used. The Acetaminophen dosage recommendation ranges from 10 to 15 mg of medication per kilogram of child’s weight to be given every 4 to 6 hours.(6) Even though many parents believe that Acetaminophen is not as good as Ibuprofen in reducing fevers; studies have shown that Acetaminophen dosed at the higher end of the dosage scale, 15 mg per kg of child’s weight, is equally effective as Ibuprofen.(6)

When administering Acetaminophen be sure to give the correct dosage because an over dosage can lead to serious complications such as liver damage.(7) In addition, children with G6PD deficiency should not receive Tylenol or any products containing Acetaminophen. (8)

Around the clock treatment with anti-pyretics is not recommended when treating a child’s fever unless your Doctor instructs you to do so. This practice can mask symptoms and interfere with the diagnosis of the cause of the fever. A persistent fever needs to be re-evaluated by a Physician or Nurse Practitioner so that a proper diagnosis can be made. It is a good idea to wait the appropriate time between dosages and administer an anti-pyretic only after the temperature is taken and recorded.

Tepid baths can help reduce a child’s temperature approximately one degree. Unfortunately the effect is usually short lived and the procedure needs to be repeated every 2 hours.(3) When giving a tepid bath, make sure that the temperature of the water is not too cold and the bathing does not cause your child to shiver. Shivering increases a child’s metabolism and causes the fever to rise even higher.(3) In some cases it may be more feasible to gently wipe your child down with a moistened cloth instead of putting his whole body in the tub.

A child with a fever should be dressed in loose fitting cotton clothing. Using layers of light cotton blankets as opposed to a heavy wool blanket is also recommended. Clothing and blankets made from heavy fabrics such as fleece causes heat to become trapped under the material. This can cause an elevation in the child’s temperature. Sipping cool liquids during a fever also aids in reducing the temperature. The added benefit to increasing fluid intake is that it also helps prevent the child from becoming dehydrated due to insensible water loss.

Many parents feel that the minute that a child gets a fever that they need to treat it. Not every fever needs to be treated. If a sleeping child develops a fever it is okay to let him sleep if he is over 3 months of age and free from any other symptoms or chronic medical conditions. In this case scenario it is okay to monitor the temperature and only treat it if the child wakes and is uncomfortable. The fever itself helps fight the infection and as long as the child is comfortable there is no urgency in treating it.

As a parent, if you feel uncomfortable with the way your child appears or with the height of your child’s fever, it is important that you communicate your feelings with your child’s Doctor who can give you further guidance.

If your are interested in reading other Pediatric Advice Stories abvout topics discussed:

Getting a Temperature Reading

Tylenol Dosage

Heat Exhaustion

Exposure to Cold Air

References:
(1)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990:429-433.
(2)Unusual case of heat stroke in a young boy. The Clinical Advisor. 2006. March:50-58.
(3)Bellack J, Bamford P. Nursing Assessment, A Multidimensional Approach. 1984. Belmont California:283-286.
(4)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 557-561.
(5)Jackson P, Vessey J. Primary Care of the Child with a Chronic Condition. St. Louis, Missouri: Mosby –Yearbook, Inc. 1992:435.
(6)Bell E. Take another look at acetaminophen, ibuprofen or both for managing fever. Infectious Diseases in Children. 2006. April:12.
(7)Physician’s Desk Reference for Nonprescription Drugs, Dietary Supplements, and Herbs. 2007. Montvale, NJ. Thomson PDR at Montvale:679,686.
(8)Greene M. The Harriet Lane Handbook. St. Louis, Miss

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Parents