Fever in Babies: When to Worry & When to Watch

It’s 2:00am and your 2 year old feels like she is burning up. And now you are really worried. What should you do?

Fever in babies and children are probably one of the things parents face that cause you the most fear.  There is just something about those numbers on that thermometer that send panic into your heart.

I understand your fear because I have helped countless parents just like you in this situation. So, just like them, I am going to give you some guidelines to follow that will set your mind at ease. These guidelines will help you know what to do when your child has a fever, know when to worry and when you can watch a little while.

I have also created for you a little cheat sheet for when you should seek help when your child has fever. Get the cheat sheet here

I want you to actually look on fever more as your friend. - an ally in the fight against illness. How can you do that?

Let’s start with the BASICS of FEVER

Your normal body temperature, which is typically around 98.6 F /37 C can fluctuate during the day. It is typically lowest in the morning and a little higher in the evening. It can vary if kids are running around and playing and if babies are bundled up too warmly.

 There are so many methods for taking temperatures and they each vary just a little bit. Some of them are not very accurate. Especially in an infant. The technique has a lot to do with whether it is accurate.

A rectal temperature is the most accurate in an infant. I know that seems to freak parents out but babies really don’t mind this. It does not hurt and it is really very simple.

A flexible tipped digital thermometer is easy to use, inexpensive and very accurate.

An axillary (underarm temp) will register a very low temperature if the thermometer is not touching skin - it is often in the hollow of the armpit. You have to have it against the body and hold the arm tightly against it so that the thermometer it sandwiched between arm and body.

Temporal artery scanners - the ones that run across the forehead to the temple can be very accurate but confusing to get just right. These can be very expensive.

Oral digital temperatures are accurate and inexpensive but little children can’t keep them under their tongue. Don’t use the same one that you use for the rectal thermometer. (may seem obvious but gotta say it!)

Ear thermometers can be very accurate but not in young children ( less than 2 years)  because their ear canals are so tiny and the angle is different than older children. Sometimes if the ear thermometers is not reading accurately it may be because the ears are full of ear wax. Don’t try to remove the ear wax. It is normal and serves a protective purpose. Take the temperature several times in each ear to get a consistent reading. The price on these varies widely, too. 

Two fever detectors that are not recommended are the forehead strips and the pacifier thermometers. 

Whatever method you use, practice so that when you need to use it you will be comfortable knowing know how to use your thermometer properly.

You may even want to take your thermometer to your health care provider's office and compare it to their method to see how accurate yours is. Or ask what method they prefer.

Putting your hand on your child’s forehead is not an accurate way to judge if your child has a fever and how high it is. Studies show that parents are not a good judge of how high their child’s fever is by touch. If you think your child FEELS hot, use a thermometer. The true temperature is very important.

Knowing how high the temperature is and how long your child has had it is important in your health care provider making decisions for how to treat. Make sure you have a thermometer on hand. Digital thermometers do not cost that much.

Report the reading exactly how you got it. (i.e. 101 with an axillary thermometer. 100.5 rectal.) Don’t add or subtract anything.

People will often say that they need to add 1 degree etc but the temperatures vary depending on the thermometer, so just report it and how you took it and let your provider sort out what the meaning is. If you took a temperature and it was 100 axillary and you tell the doctor it is 101 (because you added a degree but fail to mention that)  that can means something totally different to the doctor. Just tell them how you took it and what it measured.

So what does fever mean?

If the body is exposed to a foreign invader - like a bacteria or virus -the body can reset the normal temperature higher in hopes of causing an unwelcome environment for those germs.  The fever will begin fighting those germs off. It also sets the body’s immune system into action.

Fever is considered  >100.4 F (38.1C)

Fever is not an illness 

it is a symptom that something else is going on that needs to be investigated.

Causes

Fever in children is most often caused by viral illnesses.

Parents tell me “I hate it when I take my child to the doctor and they tell me  “It’s just a virus.”  I think sometimes parents don’t believe that is a "real" diagnosis because the children aren't given medication. But, truly it is.

It is the most common reason for children’s fevers.  Viruses can make your child really sick. These would be illnesses such as upper respiratory illnesses (the common cold), sore throats, some ear infections, the flu, sometimes gastrointestinal viruses with vomiting and diarrhea will cause a fever. Often viruses will cause a rash - a polka dotted, bumpy, pink rash is common - either developing with the fever or as the fever subsides.

These fever viruses usually last about three days. No medication is needed for these illnesses. Viruses go away on their own, Antibiotics do not treat viral illnesses.

There are not medications that treat viruses except in very rare cases. Symptomatic treatment is all that is necessary - meaning treat the symptoms to make the child feel better until the virus goes away. Asking for medicines for viruses will not help your child get better any faster. And if antibiotics are prescribed when they are not needed, they may not work for your child when they are needed. 

Bacterial fevers happen in response to a bacterial illness.

It is hard to tell the difference in a bacterial and viral illness based on the degree of fever or even by physical exam sometimes.

Bacterial infections are such things as strep throat, urinary tract infections, some pneumonias, some meningitis (an infection around the lining of the brain) some ear infections. Sometimes test have to be done to make this diagnosis.

The degree of fever doesn’t tell you if it is a virus or bacteria. You can’t say high fevers are bacteria and low fever are viruses and, in fact, often the opposite is true. Sometimes children will run a really high fever with a virus.

You have to treat the child, not the fever.

What does that mean? Some children can be very ill and have a barely noticeable fever. Some children are barely sick and have a really high temperature.

Pay attention to how the child looks and acts, not what the thermometer says.

When do you treat fever?

Fever is not the illness. It does not hurt the child and it does not always need to be treated.

And you don’t always need to take your child to the health care provider just because they have a fever.

Check out  this cheat sheet to decide when to take your child to your health care provider 

Sometimes it is ok to let fever do it’s job.

Think of fever like the captain calling his soldiers into battle against the invading enemies.

When should you be worried about fever?

There are some times that you should  be worried about fever.

This cheat sheet gives you these guidelines in a handy printable form

Fever in infants < 3 months

Fever in infants is very concerning. Their immune system is very immature. If they are exposed to a bacteria they can become ill very rapidly and with very few symptoms. They do not have to have a very high fever to be very ill. That is why fever is such an important symptom in them.

The first sign of fever in an infant <1 month of age is an emergency. Fever in an infant less than one month will most likely result in a full workup with blood work, xrays, examination of the urine, possible spinal tap (lumbar puncture) and antibiotics.

Infants 2-3 months old will require varying degrees of exam and workup depending on symptoms, your child’s history and your health care provider’s level of concern.

As the child gets older, the level of concern gradually eases off.  Your healthcare provider will make this decision. But all fever in infants is taken very seriously.

• Do not give any baby under 3 months any medication.
• Do not wait, hoping fever will come down.
• Call the health care provide immediately for any fever >100. 4.
• If it is after office hours or the provider is not available, do not wait until the morning. Take your child to the  nearest emergency department, preferably one that specializes in caring for children. You will need to go to a full hospital, not an urgent care center - as it is likely that your child could be admitted. If you go to an urgent care center, you may have to be transferred to a full hospital.

Children who have pre-existing health conditions.

If you child has a medical condition already, particularly an immune system problem, such as sickle cell disease, cancer, diabetes, heart disease or is on a medication that affects his immune system, you should call your healthcare provider right away if they develop a fever.

In General You Should Call Your Healthcare Provider or Take Your Child To The Emergency Department in these situations: 

•  An infant less than  < 3 months  with temperature >100.4
• Child <2 years  with any fever > 24 hours
   some viruses will spike then resolve in 24 hours -  if not - needs evaluation

• All children with any fever that repeatedly goes up to 104
  Sometimes a fever will initially spike to 104 then come down. The child may continue to run fever but not up this  high. But if fever is persistently spiking to 104 child needs to be evaluated
• Any child with persistent fever greater than 72 hours  Any fever greater than 72 hours.Viruses can last for 72 hours, but they usually resolve by then. If lasting longer than this, needs evaluation, especially if no symptoms
• Any age child who had a fever that went away but now fever has come back. Must think that child has developed an infection- possibly a secondary infection now - Call health care provider for evaluation -
• Any age child with fever and any persistent symptoms such as persistent crying, severe pain such as sore throat, ear pain, pain on urination,
• Any child who looks ill with headache, stiff neck, irritability, fussiness, won’t wake up to eat or play, decreased appetite or energy, decreased number of wet diapers, or a purple rash that is not raised ( may look like bruising or blood under the skin and does not go away when pressed on)  - this child needs urgent evaluation
• Any age child that does not feel better after treating with fever reducers or symptomatic treatment, or does not have some periods or being playful and responsive
  • child should feel better and be more active and responsibe with fever reducer. That makes you feel better about observing. Child may still be less active than normal, but should still have brief periods of normal activity. If child does not perk up with fever reducer, Is listless, does not want to eat or drink, is not urinated normally, is sleepy and does not have brief periods of playfulness. any of these symptoms are  concerning and should be evaluated right away
• Any age child  with symptoms that are not improving or are getting worse - should be evaluated
• Any child with fever >100.4 and a pre-existing immune system problem or diagnosis such as sickle cell disease, cancer, diabetes etc

 You want to place your focus on your child and his symptoms, not the fever.

You may notice that for the most part, most of those guidelines relate to time frames and symptoms, not degree of fever.

So, let's talk about Treatment of Fever.

Every fever does not have to be treated. If you notice your child feels hot and take the temperature and notice it is 100.4, you do not need to give your child a fever reducer right at that moment.

Treat the child not the fever.

You treat fever based on how your child feels.

Some children are really miserable at 101. Some are just fine at 103. If your child feels fine, then let the fever do its job.

If your child is miserable, then you need to treat them. But, is your child really miserable? There is a difference in whiny and miserable.

Here are some things to keep in mind about treatment

Treatment is only to make your child feel better.

It does not have to make the fever completely go away and

It doesn’t make the illness go away either.

the temperature does not have to come down to normal.

Sometimes parents give too much medication trying to get the temperature down.

Fever is not harmful to your child.

It is not going to give your child brain damage.

Only if your child has high temperature related to being in a hot environment like a hot car is that an issue.

Febrile Seizures (Fever related Seizures)

Parents are often afraid that a high fever will give their child seizures. Febrile seizures are seizures that are triggered by fever. They are not brought on by high fever. Children can have a seizure with any degree of fever.

They are typically related to sudden  spike in temperature. This means that the child is normal and then suddenly he spikes a temperature. Only certain children are prone to these. Sometimes there is a family history of febrile seizures. It is not the degree of temperature that causes the seizures. It is their body’s sensitivity to the fever.

Although it looks very frightening for a child to have a fever related seizure, it is not life threatening and most often the seizures arenot even treated.

Children usually grow out of these. Treating your child with fever reducers will not prevent your child from having a seizure. He either has a tendency to get them or not. If your child does have a seizure, of course, you do need to call your healthcare provider. He will be evaluated to determine the cause of the seizure and whether it is related to the fever or some other cause. A treatment plan will be given to you. But, a high fever is not the cause of these seizures. 

Treating fever

Administering  medications

Remember if your child is less than 3 months, do not give any medication for fever.

Call your health care provider immediately with any fever in this age child.

Choose the appropriate medication for your child’s age and weight.

If you don’t know your child’s weight, then use his age.

If your child is less than 2 years old, always check with your child’s healthcare provider before giving any medication.

There are two appropriate medications to treat children’s fever - Acetaminophen and Ibuprofen. Acetaminophen is available for all ages.

They each come in infant drops, liquid, chewable and tablet forms.  Acetaminophen comes in a suppository which is helpful if your child is vomiting and unable to keep down medications.

Aspirin is not an appropriate choice for children due to a dangerous complication called Reyes Syndrome that leads to swelling of the brain that children can get if they have or have had a viral illness when taking aspirin.

If your child is under 6 months and you have checked with your child's healthcare provider, you may only give acetaminophen according to your child’s weight.

Do not give Ibuprofen until your child is over 6 months of age.

What about alternating Acetaminophen and Ibuprofen?

Some people recommend alternating Acetaminophen and Ibuprofen. There are some parents and even some providers who say this works better at bringing temperature down.

There are no studies that confirm this is beneficial and this could cause the child to be accidentally overdosed. The AAP (American Academy of Pediatrics) recommends against this practice. In my past practice, I discouraged this too.

This is too confusing to keep up with which medication was given at which time and very easy to give too much medication or even give the same medication twice or too close together. And it is just not necessary.

Remember, the temperature does not have to come down to normal. The goal is not to completely eradicate the fever, only bring it down enough to make the child comfortable.

Remember when I told you that the body resets the temperature gauge to make the body unfavorable for the germs? It is just going to spike right back up until the germs are gone. And the fever reducer is not making the germs go away.

Masking the fever is not helpful. You need to know how the child really feels. Just treat the fever enough to make the child not miserable. You may be masking the real symptoms that are causing the fever too. Your child may have an ear infection but you may be masking the pain and he can’t tell you.

 Use an appropriate medication dropper

Use the medication dropper that came with the medication to dispense the fever reducer if possible. 

It will have the most accurate measurements on it. 

.

Never use a kitchen teaspoon to dispense any medication. The size of kitchen measuring spoons vary and you can overdose your child.

Ask your pharmacist for a measuring device if you need one.

Only give the recommended dose in the recommended time frame. Don’t give more often that what it says. Write down the time you gave it because it is easy to forget when children are sick and you are tired.

Other ways to treat fever

Make sure you keep your child well hydrated - fever can cause fluid loss that causes dehydration.  

Lots of fluid can be just as helpful as a fever reducer. Give extra breast milk or formula for infants under one, an oral electrolyte solution, such as pedialyte for babies over one and low sugar sports drinks are good choices for older children.   

Dress them in lightweight clothing.

.

Things to Avoid

Trying to prevent fever by treating your child if they have a “low grade” fever and you "think that they are getting a fever" or "feel warm". Only treat true fever. It is important to know what the temperature is.

Waking your child up at night to give them fever reducers if they are asleep. They need their rest more than fever medication. You do not need to give the medicine “around the clock” to keep the fever away.

Giving your child an ice bath to try to bring the fever down quickly. This is not recommended - this will cause chills and shivering which will cause the fever to spike higher. (I know this used to be done but it is not recommended any longer).

 It is ok to give a bath if your child has a fever. A regular bath will not hurt a child who has a fever. Some cultures think this is true.

But it is not necessary to give a bath specifically to bring down fever. Remember that children lose a lot of heat through their skin and they get chilled very easily.

So, just taking their clothes off will cool them off.  But, If they get too cold they will shiver. Shivering spikes temperatures higher. (And it makes them uncomfortable and they will cry and they are already unhappy and we don't want to cause more misery!)

Don’t bundle up. Your grandmother might tell you that they need to be bundled up in blankets. This is going to cause them to get overheated and cause their temperature to go higher. I know sometimes they say that they are cold when they have a fever and they want a blanket. Just put a light covering on them.

 Ok, there you have it. Fever can be very frightening for parents but if you keep these principles in mind, you should have a little more peace of mind. 

The most important principles to remember are:

Fever is not the illness and does not always need to be treated.

Remember to treat your child not the fever.

Fever can be your child’s ally in the fight against illness.

Armed with your guide which you can download here and your own healthcare provider's instructions, try to determine whether to be worried.

 What are the things you want to look at to determine if you can watch and wait or have your child evaluated right away?

Is your child less than 3 months old?

Does your child have a pre-existing medical condition?

Either of these conditions require evaluation right away.

Can you see a reason for the child’s fever - a runny nose, a cough? A child with cold symptoms who is still active and playful is much less worrisome than a child with fever and no symptoms. It is always better to have a source for the fever.

Is your child getting better? Or Worse? A child who had a fever and some cold symptoms but is getting better and no longer has fever is much less worrisome than a child who had fever for a few days that went away and now has fever again.

Is your child crying persistently? Or happy? Fever in an unhappy child needs to be checked out.

If you give the fever reducer, does the fever come down? Is your child happy and playful? That is less worrisome than a child who does not perk up. Children can look very ill when their temperature is up but look much different when the temperature comes down.

 
Does your child look ill? Does your child have an unusual rash that does not go away when you press on it? Does it look like blood under the skin or bruising?  If your child not eating or drinking well? Does your child have decreased wet diapers? Anything out of the ordinary or worrisome needs to be checked out.

It is always best to use your judgement as a parent. If you are uneasy or concerned about your child, have your child evaluated by your healthcare provider. Sometimes your parental intuition is best. But, sometimes your fear causes you to react and it helps to have some guidelines to follow.

These guidelines will help give you a place to start the next time your child has a fever.

Use these, along with your healthcare provider’s instructions, understanding that guidelines are just that, something to guide you. They never take the place of decisions or evaluation made between you and your own healthcare provider.

If you would like education, encouragement and guidance as you walk through this journey of parenthood, join other parents just like you in our Private Facebook Group where you can meet others with the same questions, concerns, joys and struggles who support each other every day. We would love to have you. You can continue the conversation there about fever and other concerns about your child. See you there. 

Mini-Disclaimer

This information is being provided to you for educational and informational purposes only. It is being provided to you to educate you about caring for your baby and as a self-help tool for your own use. It is not medical advice. This information is to be used at your own risk based on your own judgment. For my full Disclaimer, please go to https://www.dreambabycafe.com