Treat your child’s fever before the doctor’s appointment

It’s the beginning of cold and flu season. That means a lot of kiddos, big and small, are coming to the office with fever.

As docs, we know that fevers can freak moms and dads out. Kids look pretty awful when their temperature climbs, and it is understandable that parents want to bring them to the office for an evaluation.

In the exam room, I often hear worried parents say something like this: “Dr. Natasha, we gave her some ibuprofen for her fever last night, but we did not give her anything this morning. I wanted you to see what she looks like with no medicine.”

Undoubtedly, my little patient is sitting on her parent’s lap; looking red-cheeked, droopy, and endearingly pathetic. And so the challenge begins. My job to get the correct diagnosis just got harder.

Here’s why:

1. A child with a fever is hard to examine. When a child is ill, I need to be able to do a thorough and accurate exam. But fevers make kids feel pretty rotten. They are hot and sweaty, sore and achey. The last thing they want is to be poked and prodded by a stranger with shiny, unfamiliar tools. So I am often left with a crying, protesting, flailing child who is hard to hold, and even harder to examine.

2. Fevers change vital signs. Fever does not only elevate a child’s temperature, it also increases their heart rate and breathing rate. Fever also can change how the skin appears. These appropriate, natural body changes that occur when body temperature rises can be misleading when looking for signs of illness. Subtle clues to significant illness can be overshadowed. For example, a fever can make it less clear if a child’s rapid breathing is due to pneumonia or due to the fever itself.

3. I believe you. Your story matters. If you tell me that your kiddo has had an elevated temperature, I trust what you say. It is much more important to me for you to share when your child’s fever started, if and how you took her temperature, and what fever reducing medication dosages you are using. I don’t need proof.

The bottom line is that fever is a symptom of an illness, not an illness itself. So, I don’t need to see it.

The next time your child has a fever as part of an illness, don’t hesitate to adequately treat them with fever reducer (here is a dosing chart for help) before bringing them to the office. Your child will feel better, our time together will be more effective, and we can work together to return to wellness.

Natasha Burgert is a pediatrician who blogs at KC Kids Doc.

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  • guest

    Even as a doc it was hard to watch and wait as my little one’s fever went higher and higher before breaking. Remind yourself…fevers have a purpose, fevers have a purpose…

  • Ron Smith

    Hi, Natasha. Good article.

    In my three decades there are few things that have helped me more than most.

    My goal with fever is to calm parents, since most sources are viral. Parents tend to associate the height of the fever with the severity of the illness. That is a function of a number of things of course, but the thing that I tell parents first and foremost is that fever doesn’t fry their children’s brain. Seeing the relief on a parents face is like watching an eraser work on a dirty chalkboard.

    The highest temperature I’ve seen was 108 degrees core. Certainly that caught my eye, but it came down easily also and the child was actually no worse for wear. About 5 or 6 temps of 107 have crossed my way, and of course a lot of 105 and 106 degree temps over the years.

    After educating parents about fever, then next thing is to discuss what is important to me when I see fever in a child. Years ago in my residency I remember an article we talked about which reported that at 102.5 degree core temperature they found about 21% of the children had a bacteremia.

    That is significant because bacteremia (as opposed to septicemia) is the precursor to all the other major infections; pneumonia, UTIs, meningitis, septic arthritis, osteomyelitis, etc.

    Contrary to what I would naturally think, the increasing height of the fever, doesn’t seem to correlate with an increase in bacteremia. This has always been interesting to me, but when I reflect back on the cases of meningitis I’ve seen (I used to see about 2 cases a year of homophiles influenza meningitis before the HIB vaccine was introduced), I really don’t remember any child with a temperature above 103.

    I remember my own daughter about age 2 had a fever pattern that was fairly constantly elevated and not undulating for about 24 hours. I did what I tell my parents to do. After treating the fever for a day, I then went to the ER of the hospital where I as on staff and had them do a CBC. Andrea’s white count was 24,000. The CXR revealed the classic round pneumonia of pneumococcus which was common before that namesake vaccine.

    I didn’t hear her pneumonia and I think about half the time we docs will probably not hear a pneumonia that is really there radiographically.

    The CBC is a lab that I use to great effect in my office. Experience has shown me that a WBC of around 19,000 is where the breakpoint is for positive blood cultures in children with fever. I don’t do many X-rays anymore though because they really help me less than one might think. Nowadays there is a strong move to be careful about how much radiation we get over a lifetime and at younger ages in particular.

    CBCs in the 5,000 to 15,000 range are much more common with fever than a granulocytosis of course. But one of the more common second sources of fever is undiagnosed strep pharyngitis which doesn’t raise the WBC.

    The two most common signs of associated with strep in my experience are headache and stomach ache. The least associated sign is tonsillar purulence, which I see more commonly with viruses, and especially mono.

    Strep is a good thing to pay attention to however. I’ve had one case of rheumatic fever in my career which presented with Sydenham’s chorea. I was actually seeing this child’s sister and not her! Repeated untreated strep is the cause and clearly the reason we don’t see more rheumatic fever in this day and age is because of aggressive use of antibiotics. My Father’s oldest brother died of rheumatic carditis in the late 1940s or so, and no doubt that was because of chronically recurring strep pharyngitis.

    If I see a child with fever and with headache and stomach ache even without a sore throat or even a red throat I will consider a strep test. But you have to understand the limitation of the strep test itself. A negative test is around 93% accurate meaning that if you aren’t careful, you are going to miss up to 7 to 10% of those kids. This is where the art of medicine trumps evidence based medicine. Given the right clinical findings and the persistence of a sore throat for three days, I will usually discuss these issues with parents and together we will make the best decision given all the limitations.

    In summary, fever is concerning, but not in and of itself. The source of the fever is what I must know. Children under 2 months rarely have serious illness with fever. They will become listless and fail to eat for several meals in a row long before they will have a fever. They need to be evaluated with the greatest concern of course. My guess is that if I see 100 kids in a month with fever , I probably won’t see more than 2 to 4 or 5 with a bacteremia.

    These tidbits of information have served me well in private practice.

    Warmest regards and Merry Christmas,

    Ron Smith, MD
    www (adot ronsmithmd (adot)

  • medicontheedge

    Unless, of course, you are on welfare, and either can’t or don’t care to, purchase Tylenol OTC. Then, by all means, bring your child to the ED, by ambulance, for the $1,200. Tylenol.

  • David King

    Personally I think we need to educate parents that fevers are benign. It is the underlying illness which is potentially harmful. There may be an argument apyrexial children are easier to assess but a period if observation is probably just as good.

    Telling parents to always treat temperatures merely heightens their anxiety about a normal physiological response. There is no evidence antipyretics make children get better faster, no evidence they reduce the risk of febrile seizures and some evidence they may prolong certain illnesses. We do parents a disservice if we do not reflect these uncertainties rather than merely telling them to give a dose of ibuprofen every time their child has a fever above 37.5.

  • Ron Smith

    Hi, LastoftheZucchiniFlowers.

    Re: “The latter child is more likely to seize as a result which we ALWAYS need to prevent.”

    Hmmm. Febrile seizures are not in themselves dangerous.

    As to treatment with antipyretics to prevent seizures, I would have to disagree as this has been shown I believe to be ineffective in the prevention of febrile seizures. In particular this is because the febrile seizure is not due to the height of the temperature, but to the speed with which it rises.

    I can’t count how many times in the last 30 years I’ve seen patients who had a febrile seizure, whose parents were unaware there was a fever until the onset of the seizure.

    The only thing that I have found effective is in children who are prone to febrile seizures, and whose parents are having a difficult time coping, is to use daily ativan in a small dose for about 5 days. This raises the seizure threshold which fever must overcome in order to cause the convulsion.

    Urgent treatment of fever to prevent dehydration has never been a primary concern for me. If the child is drinking some and there are not ongoing fluid losses through diarrhea or vomiting then they are probably going to do OK. Dehydration is one of the most inaccurate and subjective of the physical diagnoses we doctors make. Our bodies have the ability to function within a fairly substantial variation of body fluid volumes. It would be unsurprising to me for example if someone working out the Texas heat on a hot summer day wouldn’t drop even 5% of their body weight by supper time.

    We are just designed with the ability to withstand many environmental variations.

    What usually leads to concern over fever, seizures, etc., is the appearance of a sick child. It is scary watching a child seize, but we physicians must remain calm and keep our heads on. Parents feed on our example.

    As you stated and so also did I in my primary reply, the source of the fever is key. That must remain our focus, and not ancillary observations that feed our emotions and increase anxiety.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

  • buzzkillerjsmith

    Never had a bad outcome when mom didn’t treat the fever before junior came in. Agree that treating is fine but I’ve never stressed about it much in all these years.

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