Fever in Infants and Children
Normal body temperature varies from person to person and
throughout the day (it is typically highest in the afternoon). Normal body
temperature is higher in preschool-aged children and highest at about 18 to 24
months of age. However, despite these variations, most doctors define fever as
a temperature of 100.4° F (about 38° C) or higher when measured with a rectal
thermometer
Although parents often worry about how high the temperature
is, the height of the fever does not necessarily indicate how serious the cause
is. Some minor illnesses cause a high fever, and some serious illnesses cause
only a mild fever. Other symptoms (such as difficulty breathing, confusion, and
not drinking) indicate the severity of illness much better than the temperature
does. However, a temperature over 106° F (about 41° C), although quite rare,
can itself be dangerous.
Fever can be useful in helping the body fight infection. Some experts think that reducing fever can prolong some disorders or possibly interfere with the immune system's response to infection. Thus, although a fever is uncomfortable, it does not always require treatment in otherwise healthy children. However, in children with a lung, heart, or brain disorder, fever may cause problems because it increases demands on the body (for example, by increasing the heart rate). So lowering the temperature in such children is important.
Infants with a fever are usually irritable and may not sleep or feed well. Older children lose their interest in play. Usually, the higher a fever gets, the more irritable and disinterested children become. However, sometimes children with a high fever look surprisingly well. Children may have seizures when their temperature rises or falls rapidly (called febrile seizures). Rarely, a fever gets so high that children become listless, drowsy, and unresponsive.
How to Take a Child’s Temperature
A child's temperature can be taken from the rectum, ear,
mouth, forehead, or armpit. It can be taken with a digital thermometer. Digital
thermometers are easier to use and give much quicker readings (and usually give
a signal when they are ready). Glass thermometers containing mercury are no
longer recommended because they can break and expose people to mercury.
Rectal temperatures are most accurate. That is, they come
closest to the child's true internal body temperature. For a rectal
temperature, the bulb of the thermometer should be coated with a lubricant.
Then the thermometer is gently inserted about 1/2 to 1 inch (about 1 1/4 to 2
1/2 centimeters) into the rectum while the child is lying face down. The child
should be kept from moving.
Ear temperatures are taken with a digital device that
measures infrared radiation from the eardrum. Ear thermometers are unreliable
in infants under 3 months old. For an ear temperature, the thermometer probe is
placed around the opening of the ear so that a seal is formed, then the start
button is pressed. A digital readout provides the temperature.
Oral temperatures are taken by placing a digital thermometer
under the child's tongue. Oral temperatures provide reliable readings but are
difficult to take in young children. Young children have difficulty keeping
their mouth gently closed around the thermometer, which is necessary for an
accurate reading. The age at which oral temperatures can be reliably taken
varies from child to child but is typically after age 4.
Forehead temperatures (temporal artery temperatures) are
taken with a digital device that measures infrared radiation from an artery in
the forehead (the temporal artery). For a forehead temperature, the head of the
thermometer is moved lightly across the forehead from hairline to hairline
while pressing the scan button. A digital readout provides the temperature.
Forehead temperatures are not as accurate as rectal temperatures, particularly
in infants under 3 months old.
Armpit temperatures are taken by placing a digital
thermometer in the child's armpit, directly on the skin. Doctors rarely use
this method because it is less accurate than others (readings are usually too
low and vary greatly). However, if caretakers are uncomfortable taking a rectal
temperature and do not have a device to measure ear or forehead temperature,
measuring armpit temperature may be better than not measuring temperature at
all.
Causes of Fever in Infants and Children
Fever occurs in response to infection, injury, or inflammation and has many causes. Likely causes of fever depend on whether it has lasted 14 days or less (acute) or more than 14 days (chronic), as well as on the age of the child. Fevers are usually acute.
Acute fever
Acute fevers in infants and children are usually caused by
an infection. Teething does not typically cause fever over 101° F.
The most common causes of acute fever are
Respiratory infections due to a virus, such as colds or flu
Gastroenteritis (infection of the digestive tract) due to a
virus
Certain bacterial infections, particularly ear infections
(otitis media), sinus infections, pneumonia, and urinary tract infections
Newborns and young infants are at higher risk of certain serious infections because their immune system is not fully developed. Such infections may be acquired before birth or during birth and include sepsis (a serious infection of the blood), pneumonia (infection of the small air sacs of the lungs), and meningitis (infection of the tissues covering the brain).
Children under 3 years old who develop a fever (particularly if their temperature is 102.2° F [39° C] or higher) sometimes have bacteria in their bloodstream ( bacteremia). Unlike older children, they sometimes have bacteremia with no symptoms besides fever (called occult bacteremia). Routine vaccines against the bacteria that usually cause occult bacteremia ( Streptococcus pneumoniae and Haemophilus influenzae type b [Hib]) are now widely used in the United States and Europe. As a result, these vaccines have nearly eliminated occult bacteremia in children in this age group.
Less common causes of acute fevers include side effects of
vaccinations and of certain drugs, bacterial infections of the skin (
cellulitis) or joints ( septic arthritis), encephalitis, and viral or bacterial
infections of the brain ( Kawasaki disease), the tissues covering the brain (
meningitis), or both. Heatstroke causes a very high body temperature.
Typically, a fever due to vaccination lasts a few hours to a
day after the vaccine is given. However, some vaccinations can cause a fever
even 1 or 2 weeks after the vaccine is given (as with measles vaccination).
Children who have a fever when they are scheduled to receive a vaccine can
still receive the vaccine if the fever is low and they have no serious illness.
Chronic fever
Chronic fever most commonly results from
A prolonged viral illness
Back-to-back viral illnesses, especially in young children
Chronic fever can also be caused by many other infectious and
noninfectious disorders.
Infectious causes of chronic fever include
Sinusitis
Pneumonia
Abdominal abscesses (pockets of pus in the abdomen)
Infections of the digestive tract caused by bacteria or
parasites
Bone infections (such as osteomyelitis)
Heart infections (such as endocarditis)
Tuberculosis
Noninfectious causes of chronic fever include
Inflammatory bowel disease
Juvenile idiopathic arthritis or other connective tissue
disorders
Cancer (such as leukemia and lymphoma)
Occasionally, children fake a fever, or caregivers fake a
fever in the child they care for. Sometimes the cause is not identified.
Evaluation of Fever in Infants and Children
Detecting a fever is not difficult, but determining its
cause can be.
Warning signs
Certain symptoms are cause for concern. They include
Any fever in infants less than 2 months old
Lethargy or listlessness
Ill appearance
Difficulty breathing
Bleeding in the skin, appearing as tiny reddish purple dots
(petechiae) or splotches (purpura)
Continuous crying in an infant or toddler (inconsolability)
Headache, neck stiffness, confusion, or a combination in an
older child
When to see a doctor
Children with fever should be evaluated by a doctor right
away if they have any warning signs or are less than 2 months old.
Children without warning signs who are between 3 months and
3 years of age should be seen by the doctor if the fever is 102.2° F (39° C) or
higher, if there is no obvious upper respiratory infection (that is, children
are sneezing and have a runny nose and nasal congestion), or if the fever has
continued more than 5 days.
For children without warning signs who are over 3 years of
age, the need for and timing of a doctor's evaluation depend on the child's
symptoms. Children who have upper respiratory symptoms but otherwise appear
well may not need further evaluation. Children over 3 years of age with fever
lasting more than 5 days should be seen by the doctor.
What the doctor does
Doctors first ask questions about the child's symptoms and
medical history. Doctors then do a physical examination. A description of the
child's symptoms and a thorough examination usually enable doctors to identify
the fever’s cause ( see Table: Some Common Causes and Features of Fever in
Children).
Doctors take the child’s temperature. It is measured
rectally in infants and young children for accuracy. The breathing rate is
noted. If children appear ill, blood pressure is measured. If children have a
cough or breathing problems, a sensor is clipped on a finger or an earlobe to
measure the oxygen concentration in blood ( pulse oximetry).
As doctors examine children, they look for warning signs
(such as an ill appearance, lethargy, listlessness, and inconsolability),
noting particularly how children respond to being examined—for example, whether
children are listless and passive or extremely irritable.
Occasionally, the fever itself can cause children to have
some of the warning signs including lethargy, listlessness, and ill appearance.
Doctors may give children fever-reducing drugs (such as ibuprofen) and
reevaluate them once the fever is reduced. It is reassuring when lethargic
children become active and playful once the fever is reduced. On the other
hand, it is worrisome when ill-appearing children remain ill-appearing despite
a normal temperature.
Testing
The need for testing depends on the child's age, overall
appearance, vaccination status, and whether the fever is acute or chronic.
Doctors may also do testing for particular disorders they suspect ( see Table:
Some Common Causes and Features of Fever in Children).
For acute fever, doctors can often make a diagnosis without
testing. For example, if children do not appear very ill, the cause is usually
a viral infection; a respiratory infection if they have a runny nose, wheezing,
or a cough; gastroenteritis if they have diarrhea and vomiting; or an ear
infection (otitis media). In such children, the diagnosis is clear, and testing
is generally not needed. Even if no specific symptoms suggest a diagnosis, the
cause is still often a viral infection in children who otherwise do not appear
very ill. Doctors try to limit testing to ill-appearing children who are under
3 years of age or who look as though they may have a more serious disorder.
If newborns (28 days old or younger) have a fever, they are
hospitalized for testing because their risk of having a serious infection is
high. Testing typically includes blood and urine tests, a spinal tap (lumbar
puncture), and sometimes a chest x-ray. Stool tests are done in newborns who
have diarrhea.
In infants between 1 month and 3 months old, blood tests,
tests of urine ( urinalysis), and cultures of urine are done. The need for
hospitalization, a chest x-ray, and a spinal tap depends on results of the
examination and blood and urine tests, as well as how ill or well infants
appear and whether a follow-up examination can be done. Testing in infants
under 3 months old is done to look for bacteremia, urinary tract infections,
and meningitis. Testing is necessary because the source of fever is difficult
to determine in infants and because their immature immune system puts them at
high risk of serious infection.
If children age 3 months to 3 years look well and can be
watched closely, tests may not be needed. If symptoms suggest a specific
infection, doctors do the appropriate tests. If children have no symptoms
suggesting a specific disorder but look ill or have a temperature of 102.2° F
(39° C) or higher, blood and urine tests are usually done. The need for
hospitalization depends on how well or ill children look and whether a
follow-up examination can be done in a timely fashion.
In children over 3 years of age, tests are typically not
done unless children have specific symptoms suggesting a serious disorder.
For chronic fever, tests are often done. If doctors suspect
a particular disorder, tests for that disorder are done. If the cause is
unclear, screening tests are done. Screening tests include a complete blood
cell count, urinalysis and culture, and blood tests to check for inflammation.
Tests for inflammation include the erythrocyte sedimentation rate (ESR) and
measurement of C-reactive protein (CRP) levels. Other tests doctors sometimes
do when there is no clear cause include stool tests, tuberculosis tests, chest
x-rays, and computed tomography (CT) of the sinuses.
Rarely, fevers persist, and doctors cannot identify the
cause even after extensive testing. This type of fever is called fever of
unknown origin. Children with a fever of unknown origin may require additional
testing and evaluation.
Treatment of Fever in Infants and Children
If the fever results from a disorder, that disorder is
treated. Other fever treatment is focused on making children feel better.
General measures
Ways to help children with a fever feel better without using
drugs include
Giving children plenty of fluids to prevent dehydration
Putting cool, wet cloths (compresses) on their forehead,
wrists, and calves
Placing children in a warm bath (only slightly cooler than
the temperature of the child)
Because shivering may actually raise the child’s
temperature, methods that may cause shivering, such as undressing and cold
baths, should not be used.
Rubbing the child down with alcohol or witch hazel must not
be done because alcohol can be absorbed through the skin and cause harm. There
are many other unhelpful folk remedies, ranging from the harmless (for example,
putting onions or potatoes in the child's socks) to the uncomfortable (for
example, coining or cupping).
Drugs to lower fever
Fever in an otherwise healthy child does not necessarily
require treatment. However, drugs called antipyretic drugs may make children
feel better by lowering the temperature. These drugs do not have any effect on
an infection or other disorder causing the fever. However, if children have a
heart, lung, brain, or nerve disorder or a history of seizures triggered by
fever, using these drugs is important because they reduce the extra stress put
on the body by fever.
Typically, the following drugs are used:
Acetaminophen, given by mouth or by suppository
Ibuprofen, given by mouth
Acetaminophen tends to be preferred. Ibuprofen, if used for
a long time, can irritate the stomach’s lining. These drugs are available over
the counter without a prescription. The recommended dosage is listed on the
package or may be specified by the doctor. It is important to give the correct
dose at the correct interval. The drugs do not work if too little drug is given
or it is not given often enough. And although these drugs are relatively safe,
giving too much of the drug or giving it too often can cause an overdose.
Rarely, acetaminophen or ibuprofen is given to prevent a
fever, as when infants have been vaccinated.
Aspirin is no longer used for lowering fever in children
because it can interact with certain viral infections (such as influenza or
chickenpox) and cause a serious disorder called Reye syndrome.
Key Points about Fever in Infants and Children
Usually, fever is caused by a viral infection.
The likely causes of fever and need for testing depend on
the age of the child.
Infants under 2 months of age with a temperature of 100.4° F
or higher need to be evaluated by a doctor.
Children age 3 months to 3 years with fever who have no
symptoms suggesting a specific disorder but look ill or have a temperature of
102.2° F (39° C) or higher need to be evaluated by a doctor.
Teething does not cause significant fever.
Drugs that lower fever may make children feel better
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