Lifting a Veil of Fear to See a Few Benefits of Fever

By PERRI KLASS, M.D.

Fever is common, but fever is complicated. It brings up science and emotion, comfort and calculation.

As a pediatrician, I know fever is a signal that the immune system is working well. And as a parent, I know there is something primal and frightening about a feverish child in the night.

So those middle-of-the-night calls from worried parents, so frequent in every pediatric practice, can be less than straightforward. A recent paper in The Journal of the American Medical Association pointed out one reason, and a longstanding discussion about parental perceptions reminds us of the emotional context.

The JAMA study looked at over-the-counter medications for children, including those marketed for treating pain and fever: how they are labeled, and whether the droppers and cups and marked spoons in the packages properly reflect the doses recommended on the labels.

The article concluded that many medications are not labeled clearly, that some provide no dosing instrument, and that the instruments, if included, are not marked consistently. (A dosing chart might recommend 1.5 milliliters, but the dropper has no “1.5 ml” mark.)

“Basically, the main message of the paper is that the instructions on the boxes and bottles of over-the-counter medications are really confusing,” said the lead author, Dr. H. Shonna Yin of New York University Medical Center, who is a colleague of mine and an assistant professor of pediatrics.

Too small a dose of an antipyretic (fever medicine) may be ineffective; too much can be toxic. But the dose depends on the child’s weight, which of course changes over time, and on the concentration of the medicine, which depends on whether it is acetaminophen or ibuprofen, children’s liquid or infant drops.

“We always make them get the bottle,” said Kathleen Martinez, a pediatric nurse practitioner who is clinical coordinator of the After Hours Telephone Care Program at the Children’s Hospital in Aurora, Colo. “What do you have at home? Is it the ibuprofen infant drops or the children’s? Have the bottle in hand and verify the concentration.

“And then we have to verify the instrument, and then we give the right dose based on weight. It’s time-consuming, and then of course it changes with the weight, so the poor parents have to call back.”

Concerns about fever — how worried should I be, and how much medicine should I give? — account for many of the calls that parents make at night to their children’s doctors. For me, these tricky measurement questions evoke memories of many conversations, often from a crowded, noisy place (my own child’s Little League game, the supermarket), trying to answer a question about a small child with fever.

One recent night, I talked to the mother of a toddler with fever and abdominal pain. I was more worried about the pain, and about whether he was drinking enough to stay hydrated; she was more worried about the fever, and no matter what I asked she kept coming back to that number on the thermometer.

Finally, I got so worried the child was dehydrated that I told her to go to the emergency room. And when she got there, she told them she was scared because the child had a high fever.

Fever can indeed be scary, and any fever in an infant younger than 3 months is cause for major concern because of the risk of serious bacterial infections. But in general, in older children who do not look very distressed, fever is positive evidence of an active immune system, revved up and helping an array of immunological processes work more effectively.

Of course, that may not be reassuring to a parent whose child’s temperature is spiking at midnight. (Fevers tend to go up in the late afternoon and evening, as do normal body temperatures.)

In 1980, Dr. Barton D. Schmitt, a professor of pediatrics at the University of Colorado School of Medicine, published a now classic article about what he termed “fever phobia.” Many parents, he wrote, believed that untreated fevers might rise to critical levels and that even moderate and low-grade fevers could have serious neurological effects (that is, as parents we tend to suspect that our children’s brains may melt).

A group at Johns Hopkins revisited Dr. Schmitt’s work in 2001, publishing a paper in the journal Pediatrics, “Fever Phobia Revisited: Have Parental Misconceptions About Fever Changed in 20 Years?” Their conclusion was that the fears and misconceptions persisted.

In fact, fever does not harm the brain or the body, though it does increase the need for fluids. And even untreated, fevers rarely rise higher than 104 or 105 degrees.

As many as 5 percent of children are at risk for seizures with fever. These seizures can be terrifying to watch but generally are not harmful and do not cause epilepsy. Still, a child who has a first febrile seizure should be checked by a physician. (These seizures tend to run in families, and children who have had one may well have another.)

“Parents are telling us that they’re worried that fever can cause brain damage or even death in their children,” said Dr. Michael Crocetti, an assistant professor of pediatrics at Johns Hopkins and lead author of the 2001 study. “I’ve been doing this for a long time, and it seems to me that even though I do a tremendous amount of education about fever, its role in illness, its benefit in illness, it doesn’t seem to be something they keep hold of from visit to visit.”

Dr. Janet Serwint, another author of the study and a professor of pediatrics at Johns Hopkins, agreed. “I personally think there should be much more education about this at well visits,” she told me, adding that parents need to understand “the helpfulness of fever — how fever actually is a well-orchestrated healthy response of our body.”

Other studies have looked at attitudes among medical personnel, who can be just as worried about fever as parents.

“Doctors are part of the problem,” Dr. Schmitt said. Some of the phobia “comes from doctors and nurses,” he added — “doctors and nurses who weren’t taught about fever and all the wondrous things fever does in the animal kingdom.”