Fever in Children

Greg T. Garrison, M.D.

Jill A. Johnston, M.D.
Kevin M. Ponciroli, M.D.

What is a normal temperature?

What should I do when my child has a fever?

The body's average temperature is around 98.6F (37C), but it

normally fluctuates during the day. Many variables determine a
childs "normal" temperature. Mild elevation (100.4 to 101.3F [38
to 38.5C]) can be caused by exercise, excessive clothing, a hot bath,
or hot weather. Warm food or drink can also raise the oral
temperature. In addition, a childs temperature may vary depending
on the time of day it is taken (higher at night) and the age of the child
(younger children generally have somewhat higher temperatures than
school-age children).

Encourage your child to drink extra fluids, but do not force him/her
to drink. Popsicles and iced drinks are helpful. Body fluids are lost
during fevers because of sweating. Clothing should be kept to a
minimum because most heat is lost through the skin. Do not bundle
up your child; it will cause a higher fever. Keep the room
temperature at about 65 - 70F. Keep your child rested, quiet and
comfortable. During the time your child feels cold or is shivering
(the chills), give him/her a light blanket.

What is a fever?

Fever is a sign that the body is fighting an infection. The main

reason to treat your child is to make him/her feel better. When
your child is achy and fussy, you may want to give him/her some
medicine.
Two kinds of over-the-counter medications are
recommended for lowering fever in children: acetaminophen
(Tylenol) and ibuprofen (Motrin, Advil). Both medicines are
effective in lowering fever and work in about 30 to 60 minutes.
Neither is recommended for children under 2 months of age, and only
acetaminophen is recommended for children 2 to 6 months.
Remember, fever is helping your child fight the infection. It is
preferable to use drugs only if your child is uncomfortable or has a
fever greater than 104F (40C). Ibuprofen and acetaminophen are
similar in their abilities to lower fever, and their safety records are
similar. One advantage of ibuprofen as compared to acetaminophen
is a longer-lasting effect (6 to 8 hours instead of 4 to 6 hours). Two
hours after they are given, these drugs will reduce the fever 2 to 3F
(1 to 1.5C). Medicines do not bring the temperature down to
normal unless the temperature was only mildly elevated before the
medicine was given. Repeated dosages of the drugs will be necessary
because the fever will go up and down until the illness runs its
course. If your child is sleeping, it is not always necessary to awaken
him/her for medicine.
Avoid aspirin. In rare cases aspirin can cause Reye's syndrome in
children who have chickenpox or influenza (cold, cough, sore throat
symptoms). Reye's syndrome is a serious illness that can lead to
death. Because it may be hard to tell if a child has one of these
infections, most pediatricians have stopped using aspirin for fevers
associated with any illness.

Fever is a symptom, not a disease. It is the body's normal response to

fighting infections. The elevated temperature turns on the body's
immune system and makes it more difficult for bacteria and viruses to
grow. A fever is defined as any temperature above 100.4F. The
usual fevers (100.4 to 104F [38 to 40C]) that all children get are
not harmful.

How should I take my childs temperature?

The most accurate way to take your child's temperature is rectally
with a digital thermometer. Studies have shown that both oral and
axillary (in the armpit) temperatures correlate with rectal
temperatures. We recommend that rectal temperatures be taken in
any child under the age of 2 months to obtain the most accurate
reading. Oral temperatures may be taken in any cooperative child.
All other children should have their temperature taken under their
armpit. You do not need to add or subtract a degree from the
thermometer reading to compensate for how you took your
childs temperature, regardless of the thermometers instructions.
Other types of thermometers like ear (tympanic), forehead (temporal),
or pacifier thermometers are okay to take quick, screening
temperatures in most children, but are not very accurate (especially in
children under 2 years of age). If you are worried about the height
of your childs fever or how long he/she has had it, always
confirm it with an oral, axillary, or rectal temperature reading.
Other tips for taking your childs temperature:
Don't bundle your baby too tightly before taking the temperature.
Never leave your child alone while taking his or her temperature.
Taking rectal temperatures: Coat the tip of the thermometer
and the opening of the anus with petroleum jelly (Vaseline).
Gently insert it to inch into the rectum (inserting until the
silver tip disappears is about inch). Never try to force it past
any resistance. (Reason: it could cause perforation of the bowel.)
Hold the thermometer still for 2 minutes. Never let go of it.
Taking oral temperatures: Be sure your child has not taken a
cold or hot drink within the last 30 minutes. Place the end of the
thermometer under the tongue and leave it there for 2-3 minutes.
Don't let your child bite on the thermometer.
Taking axillary temperatures:
Place the tip of the
thermometer in a dry armpit. Close the armpit by holding the
elbow against the chest for 2-3 minutes. You may miss detecting
a fever if the thermometer is removed before 3 minutes.
After you're done, wash the thermometer in cool, soapy water.

What is the expected course of a fever?

Most fevers with viral illnesses range between 101 and 104F (38.3
to 40C) and last for 3 to 5 days. In general, the height of the fever
does not relate to the seriousness of the illness. How sick your child
acts is what counts. Fever causes no permanent harm until it reaches
107F (41.7C). Fortunately, the brain's thermostat keeps untreated
fevers below this level. Although all children get fevers, only 4%
develop a brief febrile convulsion. Since this type of seizure is
generally harmless, it is not worth worrying excessively about. If
your child has had high fevers without seizures, he/she is likely safe.

When should I give medication to lower my child's fever?

When should I call the doctor?

IMMEDIATELY if:
Your child is less than 2 months old with a rectal temperature
over 100F (37.7C). Because of his/her immature immune
system, a young infant will not handle infections well and may
not show any other signs of a serious illness other than the fever.
The fever is over l05F (40.6C) in any age child.
Your child looks or acts very sick. More concerning symptoms
include a stiff neck, trouble breathing, crying inconsolably, or
difficultly waking the child.
Within 24 hours if:
Your child is 3 to 6 months old with fever over 102F (38.9C).
The fever is between 103 and l05F (39.4 to 40.6C),
especially if your child is less than 2 years old.
Your child has had a fever more than 48 hours without an
obvious cause or location of infection.
Your child has had a fever more than 5 days.
Your child has other symptoms such as sore throat, ear pain,
abdominal pain, or pain when urinating.
Your child is drinking less fluid than usual and has urinated less
than 2-3 times in the past 24 hours.
You have other concerns or questions.

What are some common misconceptions about fever?

Even in an age of medical sophistication, there still exist fear and
misunderstanding about fever in children. "Fever phobia" makes it
difficult for parents to know when to be worried and when to stay
calm when the thermometer starts to climb. Unwarranted fears about
harmful side effects from fever cause lost sleep and unnecessary
stress for many parents. Let the following facts help you put fever
into perspective.
MYTH: All fevers need to be treated with fever-reducing medicine.
FACT: Fever is not an illness, but a symptom, and almost never
harms a child. The only reason to lower a childs temperature is to
make the child more comfortable or avoid a febrile seizure (in the
seizure prone child). Most fevers are good for children and help
the body fight infection. An elevated body temperature increases
metabolism and produces infection-fighting cells. Also, some
antibiotics work better in the presence of a fever. Therefore,
lowering body temperature may prolong an illness. The best
advice when dealing with fever is to "treat the child, not the
thermometer." Use the following definitions to help put your
child's level of fever into perspective:
100.4 - 102F
Low-grade fevers are beneficial. May
(38 - 38.9C)
need medication for comfort.
102 - 104F
Moderate-grade fevers are still beneficial.
(38.9 - 40C)
May need medication for comfort.
104 - 105F
High fevers cause discomfort but are
(40 - 40.6C)
harmless.
105 - 108F
Higher risk of bacterial infections with a
(40.6 - 42.2C)
very high fever.
> 108F (> 42.2C) The fever itself can be harmful.
MYTH: Fevers cause brain damage, and fevers over 104F (40C) are
dangerous.
FACT: Fevers with infections don't cause brain damage. Only body
temperatures over l08F (42.2C) can cause brain damage. The body
temperature only goes this high with high environmental temperatures
(e.g., confined in a closed car).
MYTH: Anyone can have a febrile seizure.
FACT: Only 4% of children ever have this type of seizure, which
occurs more frequently if there is a family history of seizures with
fever. Also of note, it is not the height of the fever that causes febrile
convulsions but how quickly the temperature rises. They are unusual
after the age of 3 years.
MYTH: Febrile seizures are harmful.
FACT: Febrile seizures are scary to watch, but they usually stop within
5 minutes. They cause no permanent harm. Children with febrile
seizures have no higher incidence for developmental delays, learning
disabilities, or seizures without fever.
MYTH: Without treatment, fevers will keep going higher.
FACT: Most fevers caused by infection top out at 105 or 106F (40.6
or 41.1C) or lower, because the brain's thermostat does not allow the
bodys temperature to exceed these levels.

MYTH: Temperatures between 98.6 and l00F (37.0 and 37.8C) are
low-grade fevers.
FACT: The normal temperature changes throughout the day and peaks
in the late afternoon and evening. A reading of 98.6F (37C) is just
the average oral temperature. It normally can change from a low of
97.6F (36.4C) in the morning to a high of 100.3F (37.9C) in the
late afternoon.
MYTH: Placing a hand on a childs forehead is an accurate way to
read a fever.
FACT: Studies have shown that most parents could tell if their child did
not have a fever by touch, but could not tell how high body
temperature was if their child did have a fever. Fever makes the
childs face hot and a 101F temperature might feel the same as a
103F temperature.
MYTH: The higher the temperature, the more serious the illness.
FACT: The number on the thermometer does not indicate the severity
of the disease. A youngster can have walking pneumonia, an ear
infection, or meningitis with a low-grade fever of 101F. On the
other hand, pediatricians see children many times a day with fevers
over 104F caused by a viral infection that will run its course without
treatment. The general condition of the child is the main determining
factor between a "very sick" and a "somewhat ill" youngster, not the
youngsters temperature. A child whose temperature is 104F but
who seems active and normal probably is healthier than a child who
is listless, refuses food or drink, and has a body temperature of
101F. Fever is one sign of illness but it is certainly not the only or
the best one.
MYTH: Sponging is always necessary to treat a fever.
FACT: Sponging is usually not necessary to reduce fever. Never
sponge your child without giving him/her acetaminophen or
ibuprofen first. Sponge immediately only in emergencies such as
heatstroke, delirium, a seizure from fever, or any fever over 106F
(41.1C). In other cases sponge your child only if the fever is over
104F (40C), the fever stays that high when you take the
temperature again 30 - 60 minutes after your child has taken
medication, and your child is uncomfortable.
Until the
acetaminophen or ibuprofen has taken effect (by resetting the body's
thermostat to a lower level), sponging will just cause shivering,
which is the body's attempt to raise the temperature. Often, a cool
washcloth placed on the childs forehead or neck will make them
more comfortable. If you do sponge your child, sponge her in
luke-warm water (85 to 90F [29 to 32C]). (Use slightly cooler
water for emergencies.)
Sponging works much faster than
immersion, so sit your child in 2 inches of water and keep wetting the
skin surface. Cooling comes from evaporation of the water. If your
child shivers, raise the water temperature or wait for the medication
to take effect. Don't expect to get the temperature below 101F
(38.3C). Don't use cold water or add rubbing alcohol to the water.

MYTH: With treatment, fevers should come down to normal.

FACT: With treatment, fevers usually come down 2 or 3F (l - l.5C).

MYTH: An alcohol rub is a safe way to reduce a fever

FALSE: The alcohol rub now is considered dangerous because alcohol
can be breathed in or absorbed through the skin and cause
intoxication. The best ways to lower temperature include drinking
extra fluids, limiting clothing, and medications (ibuprofen and
acetaminophen).

MYTH: If the fever doesn't come down (if you can't "break the fever"),
the cause is serious.
FACT: Fevers that don't respond to fever medicine can be caused by
viruses or bacteria. It doesn't relate to the seriousness of the infection.

MYTH: A child with a fever should not receive a routine immunization.

FALSE: Immunizations are only contraindicated when the illness
causing the fever is severe. A mild illness (such as an ear infection)
is not a reason to withhold a vaccine, even if the child has a fever.