17. Managing Fever in Children

Fever in Children Over Three Months of Age

For children over the age of three months, fever is generally NOT an emergency. Small children with viral illnesses tend to spike very high fevers at night. Looking on the bright side, fever is an excellent defense mechanism that helps children fight infections faster. Some studies have shown that bringing down a fever with medication can cause viral illnesses to last longer. Because fever isn’t dangerous to children, parents should not feel obligated to treat fever with medications like Tylenol (acetaminophen) or Advil/Motrin (ibuprofen). For better or worse, these medications are wonder drugs that quickly make children feel better—causing them to resume normal activities when they ought to be resting.

Importantly, a fever’s response to treatment does NOT reflect upon the severity of the illness. Parents often panic when they administer meds and a temperature continues to rise; but sometimes it isn’t possible to bring down a high temperature, especially at night. Allowing a child to sleep while waiting for a fever to resolve on its own may be the best (and only) solution. Placing a febrile child in a lukewarm bath isn’t helpful and will probably just make the child feel cold.

The question I hear most frequently about fever is the following:

“When is a fever too high? Is there a cutoff at which I should go to the emergency room?”

Even at 106 degrees, 80% of children still have viruses. From the standpoint of most pediatricians, therefore, the height of a fever is irrelevant. The more important question is whether the child has any worrisome signs or symptoms (see below). Fever caused by viral illnesses can take three to four days (or sometimes longer) to resolve. As a child fights off a virus, it isn’t unusual for a temperature to return to normal during the day and then spike up again at night. If a fever is lasting more than five days, be sure to schedule a visit with your pediatrician.

Here are few summary points regarding the management of fever in children:

  1. Fever alone in a child over three months of age usually isn’t an emergency; fever helps children fight infections more rapidly.
  1. Unless a child is uncomfortable or has a history of febrile seizures, there is no reason to treat a fever. Bringing down a fever can make an illness last longer.
  1. The response of a fever to medication has nothing to do with the severity of an infection; at nighttime, it may be impossible to bring down a high fever, especially in small children.
  1. Most fevers are caused by viral illnesses that don’t need treatment.
  1. The best treatment for a fever is rest and time.
  1. The height of a fever isn’t important. The associated signs and symptoms determine how promptly a fever needs to be evaluated (see next section). Because fever alone can cause vomiting, I usually don’t get too excited about vomiting in the setting of fever (unless the vomiting is prolonged, associated with other symptoms, or causing dehydration).

In some cases, fever may be associated with worrisome signs and symptoms that warrant an immediate evaluation in the emergency room. These are listed below:

  1. Worrisome rashes:


Non-blanching rashes (i.e. rashes that DON’T get paler when you press your finger over them) in association with fever should be evaluated right away in the ER. In some cases, non-blanching rashes are an indicator that a child has a serious bacterial illness. Petechiae, for example, are tiny, non-blanching purplish spots that can be associated with meningococcemia. As meningococcemia progresses, petechiae may evolve into bigger purpura, non-blanching purple lesions.


Diffuse erythroderma, which resembles a sunburn on the chest, abdomen, and back, is another worrisome rash. It sometimes heralds the onset of septic shock, caused by infections with staph aureus (people with influenza may develop secondary pneumonias from staph, and they sometimes present with a rash).

In the absence of fever, petechiae and erythroderma are less worrisome, but they should still be evaluated quickly. Please call your pediatrician if you encounter these types of rashes.

Rashes which are 100% blanching are generally benign. Incidentally, fingernails and toenails may look bluish-purple at the onset of fever, but this usually isn’t concerning.

  1. Difficulty breathing: A child’s respiratory rate will increase slightly due to fever, but this doesn’t represent true difficulty breathing. When a child is truly struggling to move air, the rib cage may start retracting or “caving in,” due to the use of accessory chest wall muscles. A hypoxic child may look blue around the lips. Children with significant respiratory distress may breathe quite rapidly, out of proportion to the fever. Anyone with noisy breathing, such as wheezing (an expiratory whistling noise) or stridor (an inspiratory noise) should be evaluated promptly.
  1. Stiff neck: Known as meningismus, pain with neck flexion (placing the chin to the chest) is a sign of meningitis. People with meningitis frequently have photophobia as well, meaning that bright light bothers their eyes. This explains why children with meningitis sometimes arrive in the doctor’s office wearing sunglasses. Anyone with suspected meningitis should be evaluated immediately in the ER.
  1. Bulging fontanelle: A baby’s soft spot is normally flat. While a sunken fontanelle can be a sign of dehydration, a bulging fontanelle is a worrisome finding that can indicate the presence of meningitis or hydrocephalus (“water on the brain”) in infants.
  1. Stomach pain: There are many important organs in the abdomen, pelvis, and retroperitoneum, and they are all susceptible to infection. Severe abdominal pain combined with a fever can indicate that a child has a kidney infection, appendicitis, or pelvic inflammatory disease, amongst other serious conditions. Children with fever who also have significant abdominal pain should be examined by a pediatrician right away.
  1. Severe pain, anywhere: this is always a good reason to head to the ER.
  1. Extreme lethargy: Most children with fever tend to look tired, but a child who is extremely lethargic, difficult to arouse, or unresponsive requires an immediate evaluation.
  1. Fever in association with foul-smelling urine can be a sign of pyelonephritis (infection of the kidneys). In babies under the age of three months, pyelonephritis is a potentially life-threatening infection.
  1. Cold, clammy skin may be a sign of poor perfusion, resulting from bacterial sepsis or shock.
  1. Something doesn’t seem right, and your anxiety is skyrocketing. Parental intuition is a powerful force. It should never be ignored.

Fever in Children Under Three Months of Age

Fever in infants less than three months of age is considered a medical emergency until proven otherwise. What is a fever, anyway, in this age group? A normal rectal temperature for new babies ranges from 97 – 100.3 degrees Fahrenheit. The fever protocols in young infants are all based upon rectal temperatures. If your baby feels warm and you think he might have a fever, the only accurate way to document the temperature is rectally. Therefore, one piece of essential equipment that every new parent should have at home is a digital rectal thermometer, along with some Vaseline. Keep in mind that hypothermia is just as worrisome as hyperthermia. If your baby’s temperature is less than 97, or greater than or equal to 100.4 F, your next stop should be a pediatric emergency room. Febrile infants (especially those less than one month of age) usually undergo an extensive evaluation to rule out bacterial sepsis. Testing may include blood work, urine catheterization, and lumbar puncture (a spinal tap to rule out meningitis).

A Few Words about Febrile Seizures

One of the extra-special ways in which febrile children between the ages of six months and six years can terrify their parents is by having a seizure. Simple febrile seizures, while frightening to witness, aren’t dangerous and usually DO NOT warrant a trip to the ED. What characterizes a non-emergent, simple febrile seizure?

The seizure is generalized (meaning the child loses consciousness).

The seizures lasts less than 15 minutes.

The seizure is non-focal (meaning it involves the whole body).

Only one seizure has occurred in a 24-hour period.

Febrile seizures have occurred in the past, and the parents know exactly what is going on.

The good news about simple febrile seizures is that children usually outgrow them, and they don’t increase the risk of having epilepsy in the future. The bad news is that febrile seizures have a 30% recurrence risk. Most parents of children with a history of febrile seizures use Motrin and Tylenol liberally during times of illness; because seizures are frightening to witness, treating children aggressively with medication in this situation isn’t unreasonable. Importantly, a fever’s rate of rise is responsible for causing febrile seizures. Children who are prone to febrile seizures, therefore, may seize at relatively low temperatures.

If your child is having a febrile seizure for the first time, you should take him to the pediatrician’s office or ED for an evaluation. The following situations also warrant an immediate evaluation for febrile seizures:

Your child has a stiff neck (the neck hurts when flexing the chin down to the chest).

Your child has worrisome neurologic signs/symptoms (vomiting, pupil changes, lethargy, confusion, etc.).

Your child is under one year of age.

More than one seizure has occurred in less than 24 hours.

Your child had a partial seizure (he was conscious during the event).

The seizure was focal (only one part of your child’s body was shaking).

The seizure lasted for more than 15 minutes. If a seizure of does not appear to be resolving within a few minutes, call 911 for assistance.

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