Fever in Small Children
Guest: Dr. Tim Givens – Medical Director
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m talking, today, with Dr. Tim Givens, Medical Director of the brand new Children’s Hospital pediatric emergency department here at the Medical University of South Carolina. Dr. Givens, let’s talk about a very common clinical situation that virtually all parents face with their children from time to time, which is fever. Can you tell us, first, what are the rough guidelines for parents, what they should do when a child first develops a fever?
Dr. Tim Givens: Well, I think, first of all, it’s important to define what a fever is. Let me start this way. Your body has a little thermostat inside that keeps your temperature relatively constant throughout the day, within one or two degrees centigrade of 37 degrees, which in common parlance is 98.6, and probably up to 100.5, and down to 97.2. So, a fever, technically, is anything outside that range, 100.5 or greater. Anything below that is not a fever.
I have people come and tell me all the time, he’s running a fever of 99, or 100. That’s not, technically, a fever. That’s within the normal realm of everyday. If you walked around with a thermometer hanging out of you mouth all day long, all of us would probably hit near 104 at some time during the day, usually late afternoon, and we’d probably drop down to the 97.5 range during the middle of the night while we’re sleeping. That’s just normal. And when you get too hot, you body has this little thermostat, it kicks on its own internal air conditioning, and it brings your temperature down by making you sweat, and then you evaporate that and cool. When your temperature is too low, your body turns on its furnace and makes you shiver and generate heat, so it brings it back up into the normal range. And that’s normal standard care.
When you have a fever, there is some stimulus, usually an infectious organism that gets into your system that your body is trying to attack and kill. One of the ways it does that is by raising the temperature. These organisms don’t grow well in high temperatures. And it’s one of the reasons, if you think about it, that we cook food. We cook it for taste, but we also cook it to kill microorganisms, such as salmonella and trichinosis, before we ingest the food.
Your body is trying to kill these organisms. So, it sends white blood cells in to check out what’s going on with the infection. They send chemical signals back to your brain that turn up your thermostat, so your thermostat is now set at 102 or 103, or whatever the body picks. Just like food, you don’t cook everything, like a casserole, at 350 for an hour. You wouldn’t do your Thanksgiving turkey that way; it would never get done. So, your body picks the temperature and the length of time it wants to cook, and it determines that.
Dr. Linda Austin: Now, does it determine that based on what kind of organism it is?
Dr. Tim Givens: Yes. So, when your body picks, and it wants to be, 102, if you did nothing, your body would stay at 102 for a week, or however long it felt it was necessary to kill this invader. When we give Tylenol or ibuprofen, or any of those over-the-counter fever reducers, what we’re doing is chemically interfering with the signal, and so your body, for a period of time, drops back into what we consider the normal range. But when the medicine wears off, because your temperature wants to be 102; your thermostat is set there, your body will go right back up. Many people are confused about that. They’ll say, I gave Tylenol, the temperature went away, and it came back.
Dr. Linda Austin: But let me ask a question about that. It would seem, then, as if you’re interfering with your body’s potentially helpful attempt to cook that bacteria, can you actually prolong the period of infection by treating the fever?
Dr. Tim Givens: Well, some people speculate that. And some people say we shouldn’t treat fever, that we should let it run. But you and I know that when you have a fever, you feel awful. You don’t sleep well. You don’t eat well. It’s also important to get proper rest and nutrition in order to help fight this infection. So, for comfort, it’s worth treating the fever with those medicines, realizing that when the medicines wear off, the temperature is going to go back up.
There are also other things that are going on internally. The warmth of your body is only one mechanism for fighting the infection. There are other chemical agents, cytokines, and things like that, inflammatory markers, that are attacking the organism and trying to kill it. But that’s one signal, if you will, and one aspect of why your body fights these infections. So, we’re not saying don’t treat the fever, but realize that you are interfering with a natural body process to some extent, and it is going to come back, and it is going to be what it is. You can’t worry if you can’t keep the temperature under 101.
Dr. Linda Austin: So, let’s imagine a mom has a child, or a dad has a child, the temperature is 101, should they give Tylenol at that point?
Dr. Tim Givens: So the next thing is: how old is the child? That makes a big difference. We, generally, don’t say give Tylenol to the youngest of infants, so, under maybe two or three months of age. And that’s for fear of masking a true temperature. Those children have immature immune defense mechanisms. For instance, if you have bona fide fever, 100.5 or greater, and you’re under a month of age, when you come to the hospital, you’re going to get a battery of tests, including a spinal tap, and you’re going to be admitted to the hospital and treated with antibiotics. And that is anywhere in the United States today. That’s the standard of care.
Dr. Linda Austin: So, any child under the age, did you say two months?
Dr. Tim Givens: One month.
Dr. Linda Austin: One month?
Dr. Tim Givens: Yes.
Dr. Linda Austin: With a fever even as low as 101?
Dr. Tim Givens: Yes, yes. So, we don’t want to cover that up. We want to know whether the child has a bona fide fever. And if they do, even if they look well, they need to come to the emergency department, and they will likely get all those tests done and be admitted to the hospital. And that’s because their system is immature. Just like their liver, and their brain, and their muscles, and everything, is immature. Their ability to fight infection is immature, and we need to be conservative in managing those children.
Now, as you get older and develop a mature immune system, the rules change. So, between one and two months, there’s a lot of gray area, there’s a lot of debate among physicians about how much needs to be done: whether or not you do all the tests; including the spinal tap, whether or not you give antibiotics, whether or not you hospitalize.
Over two months of age, we presume that most people have a mature immune system by that time. But if you’re abnormal, if you have sickle cell disease, if you have congenital heart disease, if you have some underlying condition that might modify your risk, that’s a different story. But if you’re a healthy person, and you’re over two months of age, then, generally, it’s safe to treat the fever, see what your response is, and then seek care at some other point with your pediatrician, or that kind of thing.
And what we do with those children is assess two things: how toxic they look. There are some children that are just sick and need all those batteries of tests and treatment anyway. But then if you look well enough, we will look for a source of that infection: an ear infection, a throat infection, pneumonia, something like that, and will likely treat that on an outpatient basis, if you meet the criteria for that treatment. So, I think, a lot of that decision-making has to do with you and your physician, comparing notes and seeing where we go from there, after you’re assessed by your care provider.
So, fever is an important trigger. It signifies illness or inflammation somewhere. In the youngest infants, it’s a true emergency. Over that age, you can treat the fever, but realize that you may just be interfering with your natural body defenses, and the fever is probably going to come back. And it’s not a bad thing. I often tell parents, once we have identified what the source of the infection is, not to make themselves crazy by checking the temperature every four hours. If you know they have a fever, and they’ve been assessed by a medical professional, and they have either found, or not found, the source, then you give the same dose of acetaminophen, or Tylenol, or the same dose of ibuprofen, whether their temperature is 101 or 105. The dose doesn’t change. So don’t make yourself nuts by checking the temperature every so often. If it’s been four hours since their last dose, and they feel warm and their acting cranky, it’s okay to treat them with the Tylenol; it doesn’t matter what their temperature is.
Dr. Linda Austin: Kids get colds all the time, and colds often have fevers associated with them. So let’s imagine it’s a child two years of age or older. They have a fever of 101, 102, and a runny nose, and you’re pretty confident that it’s a cold. That child can safely be taken care of at home, is that right, without a call to the pediatrician?
Dr. Tim Givens: I think it’s reasonable. You know your child better than anyone. But, of course, medical Professionals, your pediatrician, and others, are there to help you. And if you’re concerned, they’re happy to see you; in most cases, you know, just provide reassurance that there’s nothing further going on. And that’s a legitimate aspect of our care. But I think, yeah, you can manage most of those illnesses at home, as long as your child is adequately hydrated and they’re getting adequate sleep, and they’re mentally with it, and it’s a minor illness.
Now, the other question that raises is whether or not you ought to be giving things like Robitussin, or any of those over-the-counter cold medications. You and I grew up on those. Even when I feel ill now, I’ll take Robitussin or NyQuil, or something like that. Recently, within the last year or two, those medications have been found to be potentially dangerous in young kids, and have caused deaths in several children around the country. So the FDA, now, has pretty much banned use of those medications in children under the age of two. And there are some people who are suggesting that they revise that upward to the age of six.
So, we’re not actively prescribing any over-the-counter medications. And if you are using a Tylenol preparation, make sure that it’s pure Tylenol, and not Tylenol Cold, or one of those other combination medications that has the potentially dangerous over-the-counter components.
Dr. Linda Austin: Dr. Givens, thanks so much for talking with us.
Dr. Tim Givens: Sure.
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