Guide for Fever Diagnosis and Treatment


Temperature Rising

The minute my hands touched her skin, I knew it was going to be a long night. The thermometer confirmed my suspicions: 101 degrees, and my 8-month-old, Mira, was in pain and miserable. I gave her acetaminophen, used a nasal aspirator to clear her stuffy nose (which she fought), and rocked her back to sleep. But the minute her head hit the sheets, she screamed. I picked her up and repeated the routine throughout the night.

By morning, the fever was climbing, despite the fever reducer. I called the doctor. Suspecting she would need antibiotics for an infection, and because it was a Saturday, he told us to go to the emergency room. Her fever was now close to 105 degrees. After several tests and hours of waiting, we had a prescription and a diagnosis: sinus infection. As a frequent victim myself, I instantly understood why Mira cried every time we put her down, and why she fought the aspirator -- the pressure in her head must have been unbearable.

That night I learned my first lesson in childhood triage: the fever is just a symptom, not a disease. I thought that because her temperature was 101 degrees, she had only a cold, but Mira's out-of-character cries and misery were more telling symptoms than the thermometer's number.

You have to ask yourself, "What else is going on?" says David Krol, MD, chair of the department of pediatrics at the University of Toledo College of Medicine, in Ohio. "Has his behavior changed? Is there vomiting, diarrhea, or a rash? Does he seem to be in pain?"

Next: Step-by-Step


Here's a guide to help you determine how sick your child is and how to help him get well.

Step 1: Take a Temperature

A rectal reading is the "gold standard," Dr. Krol says. Doctors really prefer that you use this method, especially with children less than 3 months old. With a digital thermometer and a lubricant, such as petroleum jelly or aloe vera, you can get a reading in a matter of seconds. (Don't use glass thermometers, which can release dangerous mercury into the air if they break.) But doctors know that many parents are averse to "going there," and many babies will fiercely protest. So what are the alternatives?

For children under age 4, digital thermometers work only when used under the arm or in the rectum, because children that young lack the patience and coordination to keep a thermometer tightly in their mouth. If you take an underarm temperature, it's a screening tool at best. "If you get higher than 99 degrees, you should recheck with a rectal," says Dr. Krol. Ear thermometers work great when used correctly, says Barbara Huggins, MD, professor of pediatrics at the University of Texas Health Center, at Tyler. "You need to insert it into the ear canal," she says. "If it's too small, there's a big clump of wax; if you don't have it lined up with the eardrum, you will get a falsely lower result." Dr. Krol recommends using an ear thermometer starting at age 6 months (before that, you guessed it, he'd prefer a rectal). If you're getting a different reading from two ears (this is common, according to Dr. Krol), pick one ear and stick with it. Use that reading to evaluate if the temperature is going up or down.

Step 2: Make a Plan

What constitutes a fever? Your child's age is key in interpreting his temperature. According to the American Academy of Pediatrics (AAP), if your child is less than 2 months old and is running a fever of 100.4 degrees or higher, don't just call the doctor. Your baby should be seen immediately, in the office or, if it's after hours, in an emergency room. (Many doctors even feel that a 3-month-old with a 100.4-degree or higher temperature should get immediate medical attention.) The AAP recommends that you call your pediatrician if your infant is between 3 and 6 months and has a fever of 101 degrees, or if your baby is more than 6 months and has a fever higher than 103 degrees. After age 1, if your feverish kid is eating well, playing, and is in a good mood, don't run to the phone. The illness can be treated at home.

Keep in mind that fevers aren't always the result of an illness. Heat stroke is possible if your baby has been in a hot place, such as at the beach or in an overheated car, or if he's overdressed. If his temperature is more than 105 degrees, move him to a cool place as quickly as possible. Remove his clothing, give him a sponge bath, and then get him to the doctor as soon as possible. A temperature below 105 degrees isn't an emergency, although you should call your doctor if you're concerned.

A recent vaccination also can bring on a fever, especially in 2-month-olds. That's when, often at a single doctor's visit, they get shots for diphtheria, tetanus, pertussis, polio, hepatitis B, pneumonia, and meningitis. One out of 100 infants who received this all-in-one round of vaccines was treated in an emergency room for a fever of 100.4 degrees or higher, according to one recent study that looked at the health records of 4,000 infants. "The vaccination at 2 months of age is a tricky one," Dr. Krol says. "If the baby was fine, got his 2-month shot, and went home and got a fever immediately, the doctor might say, 'Is the child acting okay?' If Mom says yes, he's just got a fever, a lot of pediatricians might say, 'Let's first give him 24 hours and then give him acetaminophen, if needed.' But it should be a decision made by the parent and doctor."

Teething might also be linked with fever, although parents seem to hold more faith in this connection than doctors do. Teething may occasionally cause a low-grade fever below 101 degrees, says the AAP, but if the fever goes higher, says Dr. Krol, illness is the more likely cause.

Comfort and Care

Step 3: Soothe Your Child

Once you see that three-digit number on your thermometer, don't instantly head for the medicine cabinet. Fever reducers are meant to make your ill child more comfortable, but if she is playing and otherwise in good spirits -- and the fever is 103 degrees or lower -- you don't have to bring the fever down, says Dr. Huggins. Once that temperature hits 104 degrees, however, definitely give a fever reducer to stop it from going any higher. You don't want it to reach 106 degrees, says Dr. Huggins. "Fever cannot hurt you neurologically until you get up toward the 107- to 108- degree range."

If you do decide to medicate, there's another very important number you must know: your child's weight. (Unsure of your baby's weight? Try this trick: weigh yourself on the bathroom scale. Then get on the scale again, holding your child. Subtract the difference and you have her weight.) It's the first question your doctor will ask you when you call to find out the proper dosing, and you should call if you don't know how much medication to give. Otherwise, if your child weighs less than you think, you'll be giving her too much medication. And if she's gained weight, she won't get enough medicine to lower the fever.

Improper dosing is common and dangerous. More than 50 percent of children are given the wrong amount of medication, according to a recent review of 70 American and British studies published in the Journal of Advanced Nursing. Not knowing a child's correct weight is one cause of this mistake, but so is underestimating the ill effects of overmedicating. "Sometimes if it's a really high fever, parents will double the dose," says Anne Walsh, RN, lead researcher of the review. "But overdosing can cause liver toxicity." Also, if you're giving your child cold medicine for a stuffy nose only, make sure it doesn't contain a fever reducer. And if you give your stuffy and feverish child cold medicine designed to relieve both symptoms, make sure you don't administer separate ibuprofen or acetaminophen (e.g., infants' or children's Tylenol or Advil).

So what fever reducer should you use? First, as a reminder: Never give a child aspirin. It can cause a dangerous condition called Reye's syndrome. That said, you should never give any medicine to a baby less than 2 months without first calling your pediatrician, and ibuprofen is approved only for kids 6 months and older. Acetaminophen is recommended mostly for low-grade fevers, and ibuprofen is used for fevers above 102 degrees. Many parents prefer ibuprofen at night -- it lasts six hours rather than four. If your child is vomiting, you might want to use an over-the-counter acetaminophen suppository.

There are other ways to lower a child's temperature. "If she has a fever, we dress her coolly, in a T-shirt and panties, and give her cool baths," says Boston mom Kelly Quinn of her 3-year-old. "I give her cool compresses and lots of water." For compresses, use only water and no alcohol, which is dangerous when absorbed through the skin. Another dated practice is bundling a child up so the fever breaks. This is counterproductive and will raise her temperature, says Dr. Krol. Sponge baths do work when done properly: 20 minutes in tepid water that's cool enough to bring down the fever but warm enough so that she won't shiver. (Add warm water throughout the bath to keep the temperature consistent.)

How to Treat a Fever
How to Treat a Fever

Step 4: Monitor Progress

How long will your child be sick? A fever of 103 degrees or higher rarely lasts more than a day. If it does, call your doctor. Make an appointment if three days have gone by and a fever higher than 100.4 degrees is lingering. Antibiotics may be necessary to help fight any existing infection.

Illnesses can have other scary symptoms besides fever. Seizures are a common parental concern but are relatively rare, occurring in only 1 in 25 children, according to the AAP. They usually last less than a minute and are most common between 6 months and 5 years of age. Once your child has had one seizure, especially if he was less than 15 months old at the time, he is at risk for others. Children with a family history of febrile seizures are also at greater risk.

The good news is that while they are incredibly frightening, febrile seizures are generally harmless and short. Seek medical attention if a seizure lasts for about 10 minutes, says Dr. Krol. Delirium (seeing things that aren't there, being frightened for no reason) is another cause for concern. These symptoms usually accompany very high fevers and disappear once the fever comes down. But call your doctor; he'll likely want to see your kid to rule out any dangerous infections.

Step 5: Road to Recovery

Is baby's temperature coming down? Great. Has your sleepy child started begging you to turn on her favorite show? Even better. You don't know exactly how long an illness will last, but once you and your child have gone through it, celebrate -- it means your baby's immune system is stronger than before. Pat yourself on the back too. You'll be more confident the next time around -- and you can be certain there will be a next time.

Too Sick for Daycare?

If your child is in daycare, you've probably wondered more than once whether you should keep him home or send him to school when he is feverish. The answer: It depends. National guidelines state that a feverish child with no other symptoms should not be excluded, but childcare centers are free to establish more stringent rules, such as a 24-hour fever-free requirement.

When you enrolled your child in the program, you should have received the center's policy regarding sick children. That's your starting point. Is your daycare center one of those that refuses to allow feverish children? If so, there's little you can do. "When you enroll your child in a center, you agree to those rules, so I would encourage parents to ask centers about sick policies when shopping around," says Kristen Copeland, MD, assistant professor of general pediatrics at Cincinnati Children's Hospital Medical Center.

So what about giving your child a fever reducer in the morning and hoping the fever doesn't return? Parents do it, Dr. Copeland says, and childcare providers know that they do it. But expect a phone call if the medication isn't enough to help the child function throughout the day. It's not only a matter of containing germs -- a sick child needs more time from caregivers, which threatens the health and safety of other kids. "You can't have a childcare provider in one room caring for your kid while the rest of the class is out playing," says Dr. Copeland, who led a study on whether pediatricians, parents, and childcare providers follow national illness-exclusion guidelines.

The bottom line: A child who can't comfortably participate in planned activities, whether or not your daycare has a fever policy, shouldn't go to childcare, says Dr. Copeland.

Not All Fevers Are Bad

Watching your child suffer through an illness is never easy. But getting sick is just one part of growing up -- and an important one. Fever is a response to an infection, not a disease in itself. So when the body raises its thermostat, it is using one of its weapons in the war against viruses and bacteria. White blood cells and the other disease-fighting agents of our immune system kick into high gear. Each time they battle an infection, our immune system gets stronger and is better able to fend off the next attack.

Cynthia Ramnarace, a freelance writer and mom to Mira, lives with her family in Brooklyn, New York.

Originally published in American Baby magazine, January 2007.


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