The scenario: Dad brings in little Susie to see the doctor because Susie has a fever, a cough, and a runny nose. She hasn't been acting herself today, not really interacting with people and not wanting to eat. Maybe Mom has a bit of a runny nose too, but she feels fine. Maybe little Susie goes to daycare or school and there are a half dozen other kids sick. She's been sick before, but it's never been quite this bad.
The three things I always want to know in this scenario are: 1) how high was the fever and how was it measured 2) have you given her any medicine for her fever (and if so, how much), and 3) is she still drinking and peeing?
A lot of parents will come in telling me their child just feels hot. And while that is an important measure of fevers, it doesn't really tell us much about the fever itself. And in many cases, there wasn't a fever at all. There really isn't such a thing as a 'low-grade fever'. A fever is defined as a core body temperature of 38.0C - 38.3C (100.4F - 101F), depending on who you ask. Emphasis on the 'core body temperature' part. That means, in really little kids (less than a year or so), you should take their temperature in their rectum (up their bottoms). In older kids, oral is a reasonable way to take a temperature (under the tongue), but can be flawed if they just ate or drank something cold. The thermometers that measure in the ears or across the forehead aren't really good measures of core body temperature.
In general, kids act weird when they have fevers. Sometimes, they'll just be listless and not want to play. Sometimes, it seems more serious, because they start shaking or seeing things that aren't there. One of my mentors has said repeatedly that he doesn't pay attention to anything strange a kid does when he/she has a fever, because fevers do weird things to the mind. And I'm not sure the last time you had a fever, but they aren't comfortable.
Giving medicines, such as Tylenol (acetaminophen) or Advil/Motrin (ibuprofen), in appropriate doses, can reduce fevers. I've seen Tylenol be given to a kid who was barely interacting with me in the Emergency Department (ED), and 15 minutes later, they're up and running around the room. Both acetaminophen and ibuprofen should be given in weight-based dosing, and ibuprofen should not be given to kids under 6 months of age. So you should check with your doctor to see how much medicine your kid should be getting. If they aren't getting enough, their fever might not come down and they still may look sick. Despite their best intentions, alternating between acetaminophen and ibuprofen every 4 hours doesn't really seem to help more than just sticking with one medication, and is more prone to errors that could lead to overdose. So, find one you like and stick with it.
At this point, I'd like to point out that fevers themselves do not harm kids. Even if your kid's fever is 104F*, if it comes down to normal with medicine, I'm less likely to be worried about it. Let me repeat that: fevers themselves do not cause harm. However, fevers are signs that something isn't quite right. Usually, in kids, it's a virus that they haven't been exposed to before, and their immune system is doing what it's supposed to and fighting it off. Every so often, though, it's something more insidious. It's that something else that results in fever that actually does the damage, not the fever itself. In fact, some would even suggest to allow a child to be febrile for a period of time to give them a chance of fight off their infection. I do agree that this is safe, so long as the child is comfortable. But if your child isn't comfortable, treat their fever. It'll make things easier for both of you.
When should you be concerned?
1) If you give the medication, and the fever does not come down. Call your pediatrician or go to an Urgent Care or Emergency Department.
2) If the child does not act normal after the medication is given and the fever has come down. As I said, most kids will bounce right back to their normal selves, but kids with bad infections will still look sick.
3) If the fever lasts more than 3-5 days, or if the child starts to get better and suddenly gets worse again. Both are signs of either another infection that is more worrisome, or a variety of disorders that are marked by prolonged fevers.
If you bring your child in to be seen on day 1 of the fever, there isn't going to be a whole lot your doctor can tell you. The illness hasn't had a chance to 'present itself,' and we can't really differentiate between the number of different diseases that cause fever.
And that brings me to the second thing I ask parents. If we've gotten past the fever part, and the child isn't staying hydrated, then we, as physicians, get a little more worried. See, kids become dehydrated much more quickly than adults. A really bad stomach bug that causes vomiting and diarrhea could dehydrate a kid and leave them looking really sickly. Fever itself can also cause dehydration, not only because kids don't feel like eating and drinking during that time, but it also increases how much they sweat, something we refer to as 'insensible losses'.
When kids are sick, they don't feel like eating. That is fine. Our bodies are used to using energy stores during times of infection. But, not drinking, or not having things like popsicles or other high-water 'foods' can quickly lead to dehydration. In little kids, particularly those in diapers, one of the easiest ways to determine whether they are taking enough in is to check how much they're putting out. If an infant goes from wetting a diaper every 2 hours (12 in a day) to wetting one every 12 hours, there's a problem, and they're not taking in enough liquids (or they have a problem with their kidneys, but that's another discussion).
Taking fluids by mouth is the best way to take them. It's non-traumatic, and the best way to prevent complications from a medical intervention. Kids who are throwing up everything they try to drink, or kids who are having difficulty breathing, are the hardest ones to get to drink. We generally recommend small volumes of fluids in those cases, 1-2 oz every half hour or so. Don't give the baby a full 8 oz bottle of milk if she's been vomiting all morning. Even things like popsicles, if given often enough, can keep kids hydrated. So, we do an oral challenge to see if they are willing and able to take the fluids by mouth.
If they aren't able, we consider admitting to the hospital for IV hydration. It's not preferred, because there's always the risk of injury or infection with placing things like IVs (a low risk, but still a risk), but the risk of dehydration is much greater than those risks, so we do it when it's necessary.
Now, if your child has a chronic disease, most especially something like Cystic Fibrosis or Diabetes, you should follow the instructions of the doctor regarding sick day rules.
Otherwise, managing their fever and making sure they stay hydrated are the two things you can do to get your child feeling well once again. And if you aren't sure, call your pediatrician. Most will have overnight people on call specifically to answer these questions for you and determine if your child needs to be seen right away. There's nothing wrong with getting in to see the doctor, but we can be much more helpful if you've tried a few simple things on your own first.
Next week, we'll talk more about the role of antibiotics in treating children.
*Note: Elevated body temperatures can cause damage, but they must be greater than 40-41C (104-105.8F) for a prolonged period of time for this to happen. This generally does not happen with infections, but more often in things like heat stroke or medication overdose resulting in hyperthermia. Note that at these times, it is not referred to as a 'fever', but 'hyperthermia'.
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