Babies and Infection – My Baby has a Fever! (Part 2)

Part 1 of My Baby has a Fever discussed the definition, causes and the mechanism of fever. Specific age groups doctors use to assess a baby with a fever was also addressed.  Part 2 of the series will now discuss how to evaluate a child who requires a doctor and discuss the management of fever.

It is important to know when a child with fever should be taken to the doctor’s office.  The table above serve as a small guideline to determine whether the child needs to be taken to the hospital immediately or not.  There is no right or wrong in bringing your child to the hospital.  Parents know their child the best and if your gut feeling is telling you something is not right then a trip to your doctor is always the right decision.  Pediatricians often obtain valuable information from the parents.  Parents should be careful not to mix objective observations with biased observations caused by online “web doctor” syndrome.  Sometimes this can be misleading and cause a delay in proper diagnosis.  Finding the cause of fever is a “team effort” and most importantly parents and pediatricians alike want to alleviate the child’s discomfort as soon as possible.

Sometimes the parent may feel inhibited to go to a doctor due to prior experience in that there was nothing done for the child except for reassurance and simple treatments that was already found over the internet.  However a doctor is not only there to give you reassurances but there to make sure there are no other serious diseases causing the fever.  When fever is prolonged for more than 3 days, the likelihood of fever caused by a bacterial focus of infection increases with each day – antibiotic therapy may be needed.  Contrary to popular belief, fevers are not usually associated with a simple common cold.  While most fevers may turn out to be benign, doctors are trained to find that one time where a more serious medical treatment is needed.

The primary goal of treatment of a child with a fever is to bring overall comfort and well-being.  Emphasis should not be placed on achieving normal body temperatures for the child.  Fever medication may not be given at all in cases where the child is not showing any distress from the fever.  There are some studies that fever may bring some beneficial effects to the immune system.  However too much of anything is always bad.  Lowering fever provides benefits in relief of discomfort and decreased water loss of the patient.  As of yet, there is no evidence of giving ibuprofen or acetaminophen (or its combination) increasing the risk in complication with certain infections.

There are two main fever medications used in infants – acetaminophen (Tylenol) and ibuprofen (Advil).  As discussed in part 1, these drugs reduce PGE2 production lowering the hypothalamic set point which in turn lowers the fever.  It is to a great consensus that antipyretic drugs are started when the child has a fever over 101°F (38.3 °C).  Acetaminophen doses of 15 mg/kg per dose are given every 4 to 6 hours.  Ibuprofen doses of 10 mg/kg orally given every 6 to 8 hours are generally regarded as safe and effective.  Dosing should never be based on age especially in children from 0~24 months of age.

(Click the picture to download the full Dosage Chart for Infants – Acetaminophen and Ibuprofen in PDF 2011)

It is important to note the dose for all over-the-counter drugs are regulated by the FDA.  As one can see in the table above, there are two different concentrations of infant fever medication.  However, since July 2011 the U.S. FDA has decided to phase out the infant “concentrated drops” of 160 mg/ 1.6 ml to sell only less concentrated (160 mg/ 5 ml) ones.  The reason is to increase safety by preventing accidental overdose.  This only applies to the United States.  Canada will continue to sell the more concentrated forms – one should read the dosing information carefully before administering.

Typically, the onset of an antipyretic effect is within 30 to 60 minutes, approximately 80% of children will experience decreased temperature within that time.  Alternating between ibuprofen (Advil) and acetaminophen (Tylenol) is a safe and highly effective method in the treatment of fever versus a single regimen of either acetaminophen or ibuprofen alone.

Aspirin should never be given to a child – this can cause the development of Reye Syndrome (particularly associated with influenza and varicella).

Damage to the brain is one of the greatest concern of a child’s parents – thus the term “Fever Phobia”.  It is important to note that fevers lower than 107.06°F (41.7°C) do not cause brain damage!  There are cases where babies can go into seizures because of fever.  One should not panic.  Although this is a traumatic experience, the seizure will not cause brain damage.  However, one should take the child to the hospital immediately.

If the fever is hovering around upper 103°F (39.4°C), one should consider the option to physically cool the child by taking off the top clothing of the baby and start wiping down the child with a luke warm washcloth.  Placing a cool washcloth beneath the armpits will facilitate faster cooling.  Do not use cold water!  A cold washcloth will constrict the pores of the skin and the body will react in an opposite fashion in an effort to retain heat.  The process of water evaporation from the body will cool the body down – aka. “evaporative cooling”.  The only place where a cold washcloth should be used is usually behind the neck and in the forehead area.

Hydration is another area where the parent should be watchful.  Drinking lots of fluids will prevent dehydration due to fever and aid in the well-being of the child.  A way to determine whether your child is getting enough fluids is skin turgor.  If pulling up the skin on the abdomen does not immediately return to its original position, then your child need more fluids.

Hopefully the two-part series Babies and Infection – My Baby has a Fever provided more insight to the identification, mechanism and management of fever.  If you have a specific topic you would like discussed, please email happybabyusa@gmail.com. Thank you.

References and Additional Readings:

1.  Kliegman, R., et. al. Nelson textbook of Pediatrics, 19th Ed. PA:  Elsevier, 2011.

2.  Hay, W. et. al. Current Diagnosis & Treatment: Pediatrics, 20ed.  OH:  McGraw Hill, 2011.

3.  Longo, D. et. al. Harrison’s Principles of Internal Medicine, 18 ed. OH:  McGraw Hill, 2012

4.  American Academy of Pediatrics. American Academy of Pediatrics.2011. 15 Sept. 2011 http://www.aap.org