1. Fever phobia Lanessa D. Bass, MD, MEd Pediatric Hospital Medicine
Director PHM West Campus

2. Special Thanks Dr. Hank Farrar
Emergency Physician and Toxicologist, UAMS
AAP Section on Clinical Pharmacology and Therapeutics

3. Objectives At the end of the presentation, you will be able to
Explain the physiologic reasons and effects of fever
Effectively reassure parents in the evaluation and treatment of fever
Recognize red flags for fever that would require prompt physician/provider evaluation

4. Beliefs About Fever High Fevers are Dangerous Must Treat Fever
High fevers cause brain damage (93% of parents)
Any fever is dangerous (74% of parents)
Concern that T ≥40oC (104oF) are harmful
Believe T <40oC is a high fever (40-50%)
Must Treat Fever
Untreated Fevers Continue to Rise ≥42oC (107oF)
15% - 45% of parents agree
Schmitt BD, Am J Dis Child 1998
Crocetti M, et.al. Pediatrics, 2001

5. Beliefs About Fever If Parents Believe … Then Parents are Likely to …
Fever is dangerous, especially high fever
If untreated, fever will continue to rise
Then Parents are Likely to …
Worry a lot
Check temperature frequently
Treat early and often
Focus on lowering temperature

6. Fever Phobia Reaction of Parents to Fever Frequent Concern of Parents
10-50% take temperature hourly
20% will treat a temperature <38oC (100.4oF)
50-85% awaken their child to treat
Frequent Concern of Parents
Fever accounts for one-third of acute visits
89% would schedule a visit if their child has a fever
50-90% have taken child to clinic/ED

7. Pediatricians Percent who Agreed
The primary goal of treatment is to improve the comfort of the child
71%
A sleeping child with fever should be left undisturbed
88%
An elevated temperature … can become dangerous to a child*
65%
Dangerous - Most pediatricians can recall a patient who had medical problems with fever – e.g., a child with a poorly controlled seizure disorder who developed status epilepticus with fever. I think this contributes to this high number. I would be surprised if they thought that a fever with a simple illness in a normal child is dangerous.
*Seizures (58%), Dehydration (23%), Brain Damage (10%)
May A, Bauchner H. Pediatrics, 1992

8. Two Big Questions
Will a child’s temperature continue to rise to a dangerous level if left untreated?
Does fever cause brain damage?
Fever with infection vs. Heat-Related Illness

9. Hypothalamic Set Point
Temperature Control
Increase
Temperature
Hot
Hypothalamic Set Point
T=37oC
Shivering
Vasoconstriction
Get a Blanket
Sweating
Vasodilation
Find a Fan
Heat
Dissipation
Cold

10. Heat-Related Illnesses
Exercise & Dehydration
in a Hot Environment
Increase
Temperature
Hot
Hypothalamic Set Point
T=37oC
Sweating &
Vasodilation
become inadequate
Temperature
continues to Rise
Shivering
Vasoconstriction
This is why hyperthermia and heatstroke have temperatures that continue to rise. They are overwhelming the set point. The body is trying to stop the increase in temperature but cannot.
Heat-Related
Illness
Cold

11. Hypothalamic Set Point
Febrile Illnesses
Infection
Fever
T=39oC
Hot
Pyrogens
Hypothalamic Set Point
T=39oC
Shivering
(having a chill)
Vasoconstriction
(mottled skin)
Sweating
Vasodilation
There are 2 reasons why fever with a simple infection does not continue to rise.
It will not go above the set point. It goes to the set point and then stops.
Endogenous cryogens (with or without antipyretics) try to reset the Set Point to 37C
Heat
Dissipation
“Cold”
T=37oC
Cryogens and Antipyretics
reset the Set Point to 37oC

12. Fever is Not Dangerous Fever is a normal response to infection
There is no evidence that fever …
With simple infections will continue to rise
Will result in heatstroke
Brain Damage
Fever alone will not cause brain damage
Brain damage caused by another insult
Febrile Seizures do not cause permanent damage

13. Fever Can Be Disruptive
Caregiver Reports
Changes in activity, sleep and feeding
Mean duration of changes – 3.5 days
Disruption of family routine – 4 days
Concerns of Health Care Providers
Affects overall clinical picture
More difficult to assess overall well-being
Greater risk of dehydration
Mistry RD et.al., Pediatr Emerg Care 2007

14. Effects of Antipyretics
Normalized Temperature
Fever increases discomfort
Reducing fever improves comfort
Better Sense of the child’s well-being
Reduced Pain
Many illness include pain
Pharyngitis, Acute Otitis Media, Myalgia
Reducing pain will improve comfort

15. Effects of Fever Positive Effects of Fever
May improve the outcome of infections
May improve the antibody response to vaccines
Some Patients do not Tolerate Fever
Do not tolerate increased metabolic demands
Cardiomyopathy
Multiple complex medical problems
Debate over critically ill patients

16. The Goal of Treatment
“A primary goal of treating the febrile child should be to improve the child’s overall comfort.”
American Academy of Pediatrics
Section on Clinical Pharmacology & Therapeutics
and the Committee on Drugs; Pediatrics 2011

17. Treating with antipyretics
Ibuprofen
Typically use over 6 months
Antiplatelet effect
Can cause/worsen gastritis
May contribute to acute kidney injury or worsen chronic kidney disease (especially if dehydrated)
Acetaminophen
Can use younger
Doesn’t affect platelets
Liver toxicity possible high dose or if underlying liver injury

18. A Treatment Question
The Problem: Management of children with simple febrile illnesses
The Question: Is there a benefit to alternating ibuprofen and acetaminophen when compared to treating children with either drug alone
Outcomes: Does it improve comfort
Does it increase fever phobia

19. Antipyretics and Comfort
Mild to Moderate Discomfort
APAP 12.5 mg/kg Q6 hours / IBU 5 mg/kg Q8 hours / Alternating Q4 hours
Uses the Non-Communicating Children’s Pain Checklist (NCCPC) – max score =90; mild/mod = 6-10; normal <4
Fewer total doses of antipyretics given each day using combined therapy – also fewer daycare days missed.
Authors state that the curve is steeper for combined therapy but did not provide statistical analysis or data.
Sarrell ME et.al., Arch Pediatr Adol Med 2006

20. Point, Counter-Point To Alternate Not To Alternate
May lower fever more effectively than one drug
May allow return to usual activities sooner
Doing more may reduce the parents’ anxiety
No toxicity has been reported
Not To Alternate
May not improve the overall comfort of the child
May interfere with the body’s usual defenses
May worsen fever phobia
This could get confusing and result in errors
Is toxicity under-reported

21. Assessing fever
No correlation with height of fever and severity of illness.
When patient has fever, please assess:
Patient’s general appearance, level of awareness, etc.
Perfusion (skin warmth, cap refill)
Other vitals-heart rate, respiratory rate, blood pressure

22. Quiz Which patient with fever is most concerning:
A 6 month old with vomiting and fever and found to have UTI.
A 2 y/o seen in EC with cellulitis/abscess on buttock and with fever.
An 18 m/o with history of febrile seizure with fever for 3 days.
A 2 week old admitted with RSV who now has a fever.
A 5 y/o with pneumonia admitted for oxygen and has fever during hospital day 1.

23. Red flag conditions Fever in young infant
Fever in immunocomprised patient (cancer patient, patient on chronic immunosuppresants including steroids, sickle cell patients).
Fever in short gut patient
Fever in patient with central line
Fever with other vital sign changes, concerns for SIRS/shock

24. My Message to Parents Fever is a normal reaction Fever is not bad
It is part of your body’s defense
It may help fight infection
Sign of something. If we know from what, then more reassuring.
Fever is not bad
Does not cause brain damage
It does not continue to rise and cause heatstroke

25. My Message to Parents Focus on Comfort
Improving appetite, sleep and activity
If the fever is not bothering them then leave it alone
Don’t wake them up for treatment
Keep things simple
When to call your doctor or return
Altered activity when not febrile
Signs of dehydration

26. ? Questions ?