Fighting a fever

Fevers and kids go together like England and rain. It makes everyone miserable, confines you to the house, but you know there’s no avoiding it. If you open any parents’ medical cabinet you’ll find most toddlers drug of choice: sweet, pink (though sometimes not now), gloopy, sticky. What’s not to love? But do we really know how to treat a fever? I’m sort of aware of the guidelines, but until writing this I confess: I was a little muddled. This concentrates on fevers in young children (under fives), though much will also be applicable to older ones too!

Why do children get fevers?

Fevers are very common in children. A fever is a normal immune response to infection, and while it may be uncomfortable for the child, it isn’t in itself a bad thing, and may even be beneficial (there isn’t a consensus on this).

Around 5% of children under five may experience a febrile seizure or convulsion – a fit caused by their high temperature. While these are scary, they do not usually have any long term effects. (In very specific cases they may increase the likelihood of developing other types of seizures).

While a fever may not be a bad thing, research into parents perceptions have shown that parents fear their children getting fevers (myself included). It’s termed “fever phobia” in the medical community and here’s a good editorial piece on it. While us parents need to watch a child with a fever carefully for signs of more serious illnesses, we perhaps are guilty of over-medicating and worrying unnecessarily (I know I am).

What are the guidelines?

The NHS website confusingly has two pages on fever in kids: one called “high temperature” and one “fever“. I’m not a health professional, so it’s best you read them rather than listen to me!! In summary, they state to use paracetamol or ibuprofen only if the child is in pain, keep them hydrated, and avoid stripping them or sponging them down as there’s no evidence of these things helping (the NICE guidelines review this well, pg 198).

There are also the NICE guidelines (2013). While these are aimed at health professionals, they are also the basis of the NHS information for parents. These two statements in the NICE guidelines interested me:

  • Using antipyretics (paracetamol or ibuprofen) does not prevent a febrile convulsion so shouldn’t be used just for this.
  • Reported parental perception of a fever should be considered valid and taken seriously by healthcare professionals

Is Calpol the answer?

I have always treated a fever with paracetamol, without really thinking through my motivation. As a parent, my fears with fevers are twofold:

1. Is it a sign of something more serious?

Unfortunatley, giving paracetamol or ibuprofen won’t prevent any serious illness. It’s worth parents knowing the signs and symptoms of serious illnesses such as meningitis, and there is an NHS page called “does your child have a serious illness” which is worth a read.

2. Will they have a febrile convulsion?

Less intuitively, but as highlighted in the NICE guidelines, these medicines also don’t appear to prevent febrile convulsions. The data is limited, but here’s one recent review (as usual I can’t access the full text – one is looking at recurrence of seizures).

So why are we treating the fever? To increase the comfort of the child. The NHS guidance is clear that if they aren’t too uncomfortable, then the fever isn’t in itself an issue and they don’t need paracetamol or ibuprofen. The NICE guidelines suggest:

  • Only use paracetamol or ibuprofen as long as the child appears distressed
  • Consider changing to the other medicine (paracetamol or ibuprofen) if the child’s distress is not alleviated
  • Do not give both medicines at the same time
  • Only consider alternating between the two medicines if the distress persists or recurs before the next dose is due

In terms of alternating paracetamol and ibuprofen, scientists are still not sure whether there’s is any benefit to this. And in terms of which one you choose to use, it doesn’t appear to make much difference, with both being effective and safe in the correct doses. Here’s a good review of the two medicines, their safety and the practice of alternating them.

Should you trust your thermometer?

I often “take” my childrens’ temperature based on a hand to their head and assessing how they are acting. While I do get the thermometer if they feel hot and are miserable, it’s reassuring to hear that NICE recognise that parents often know when something is wrong before reaching for the thermometer, and state we should be taken seriously.

It’s also worth considering that all thermometers are not created equal, and where you take the reading is going to have an effect. The NHS have a page on taking a child’s temperature. Generally, a digital in-ear or under armpit thermometer is your best bet.

Aside from choosing the right thermometer, another thing to consider is the accuracy of the information leaflet that comes with it. This study suggests that you should not rely on the information leaflet, as advice on the definition of a fever, how to manage fevers and when to seek advice was varied and not always in line with current recommendations. Best to check the NHS sites instead!

What do I do?

I’ve been pretty lucky with my two, to date. They’ve both had only a handful of fevers, all pretty uneventful. There was the time the GP found a fever I was unaware of. Boybug had conjunctivitis (again), but hadn’t been particularly unwell. The GP seemed a bit incredulous that I hadn’t checked, but I was taking his behaviour as my guide. If he was flopped on the couch all morning and off his food I would have check for fever, but he was running around causing mischief! And taking Boybug’s fever can be a pain. I bought a fancy-pants ear thermometer but he will not entertain the idea of anything in his ear. It’s a two person job, and obviously he wouldn’t be kind enough to have a fever while there are two adults around!

I do worry that poor little Boybug, up on the 98.5th percentile, might be getting a lower dose than necessary. I’ve just checked our Calpol bottle, and he is supposed to have a 5ml dose based on age, which contains 120mg paracetamol. He’s around 15kg, and given that less than 10ml/kg is thought to be subtherapeutic, it looks like I might be right. Certainly when he had his only antibiotics at 11 months, the GP took one look at him and said “maybe we should go on weight, rather than age!”. I wouldn’t advise messing with the dosages though – we’ll be sticking to what the bottle says!

What I definitely do is agonise about whether or not to take the kids to the GP. Here’s an interesting paper that shows I’m not alone! It’s often so hard to judge, and not something that anyone can really cover in a leaflet or website (or my blog!). Each situation is so specific. I think this is the major issue. As a parent you aren’t able to say for sure whether a fever is caused by a cold, chest infection, or something much worse. You can look for other signs as to what might be causing the illness, but I’m always plagued by that sense of “what if”.

I think the overall message is that a fever itself isn’t a bad thing so it only needs to be treated if they are uncomfortable. If under six months, check the NHS site as to what temperature to take them to the GP with. If over six months, look at the other signs and symptoms to determine what you do from there. If in doubt, consult a health professional.

Good luck.