Frequently asked questions about fever in children

My child’s fever won’t go away after medicine. What does this mean and what should I do?

There are a few things that you should remember:
Medicine for fever may take a while to kick in. Paracetamol and ibuprofen require approximately 30 mins – 1 hour before they have an effect. Anticipate a reduction in fever after this timeframe and not before.
Do not always expect the fever to come back down to a perfectly normal level. If your child had a 40 degrees Celsius fever before receiving an appropriate dose of anti-pyretic, his temperature will probably come down to around 38.5 degrees Celsius. Read this chapter to learn more about when, and if, to try and bring down a child’s temperature. Most of the time, bringing down the temperature is not the real goal, but rather to help improve the child’s well-being. Therefore, if the temperature has come down to a value that allows the child to feel comfortable and pain-free, there is no need to keep “going after” the fever.
When giving the right dose of medicine, it is very unlikely for the fever to remain very high. It is possible that the fever was still spiking up when you gave the child the medicine, and in between the two measurements that were taken the fever had already managed to go up a little and then back down. It is important to give the right doses (not too low and not too high), in order to maximize the potential of the medicine. You may use this chapter to find out the correct dose for your child.
Many parents see their doctor when they feel that their child’s fever is not responding to medicine. Remember that there is no evidence in the medical literature for an association between lack of response to medicine and the prevalence of severe bacterial infections.
I therefore recommend that you try and maximize the potential of these medicines by giving the right ones and the correct doses, but also to bear in the mind that in the end, temperature is just a number, and if the child looks well and is behaving normally – let him be.

My child threw up right after I gave him the fever medicine. What should I do?

In order to avoid a situation where your child receives an overdose of an anti-pyretic, make sure you wait for the right length of time to pass (the minimum required interval) before giving the drug again. Why? You can never really know whether the child vomited the entire dose or whether he had already absorbed some of it.
Nonetheless, if your child spits up the medicine immediately, you can give repeat the dose right away, provided:
The spit up happened right away, and not a few minutes after the medicine was administered.
This is a rare episode, and not something that occurs several times a day.
So, what should you do if you gave your child medicine and he spit it up a few minutes after swallowing? Consider this dose as one that the child has taken and either hope that some of it will get absorbed and that the temperature will start coming down within 30 – 45 minutes or give him/her an anti-pyretic from a different family right away (read more about the difference between paracetamol and ibuprofen here, coming soon).

How can we reduce the chances of spit-ups/vomiting after medicine?

Beyond the basics (choosing a flavour that the child likes, giving the medicine in small quantities) one can also give the medicine to the child using a syringe, while aiming it towards their cheek (and obviously not towards their throat which could lead to an immediate gag reflex).
From my own experience, being assertive with your child when it comes to medicine administration at a young age makes giving medicine at an older age much easier. Parents who hesitate with administration of drugs, especially around children who are smart and like being in control (already at a very young age), will also find it difficult to give their children oral medications at an older age. In infants and younger children one can, of-course, use suppositories instead.

Is high fever more concerning than low fever?

This is one of the more interesting questions in pediatrics.
Is there really a difference between a child with a fever of 38.5 degrees and a fever of 39.5 degrees Celsius?
The answer to this question is complex and confusing.
On the one hand, the answer is no. Medical studies have been unable to prove that the higher the degree of fever the more dangerous the child’s situation is or the higher the chances of developing a severe bacterial infection. For example, almost every child contracts Roseola around the age of one. In roseola, the fevers are very high, around 40 degrees Celsius. However, this is usually a simple viral infection, without any complications. Almost every experienced paediatrician, thought, will remember patients with severe bacterial infections, with a fever that wasn’t too high.
On the other hand, maybe the answer is yes. Two reasons for this:
In most cases where the fever is around 38.5 degrees and not more, the illness is usually not severe. These fevers may be a sign of bacterial ear infections or other mild bacterial infections, but they do not end up revealing a threatening pneumonia or other severe bacterial infections.
There is a degree of fever that is referred to as hyperpyrexia. See more about this under “Defining fever in children”. This is usually a fever of 40 degrees Celsius or more. There is an ongoing debate in the medical literature about whether such a high fever is a risk factor for severe bacterial infection. There is no clear-cut answer to this.
Practically speaking – I suggest that if your child has a high-grade fever you ‘stay on your toes’ and see a doctor earlier than you would have had the fever been lower.
Have your doctor see your child, examine him and take his recommendations.

What about low fever under 36 degrees Celsius?

Even though the medical literature states that hypothermia (fever under 36 degrees Celsius) can be related to severe infections, in our day-to-day life, the kids we come across with records of low temperatures are usually incorrect measurements, due to technical reasons or overuse of the thermometer.
Sometimes I see children with repetitively low body temperatures (mainly in the evenings, sometimes for weeks) after they had just recovered from a febrile illness. This usually resolves spontaneously, without any treatment. Despite this, these kids should still undergo a medical examination by their physician.

What do signs and symptoms (grunting, shivers, change in colour) accompanying fever indicate?

There are some signs and symptoms to which parents and caretakers should give special attention. These include change in colour, grunting and shivers. My stand regarding these symptoms:
Grunting – this is a sound that comes out when ones let air out (exhales). In most cases, grunting is a sign of high-grade fever in certain children (we used to know that my eldest daughter’s temperature was rising because she would always start grunting). Grunting alone, is not concerning. However, grunting may also indicate shortness of breath (and in severe cases, bacterial pneumonia), pain (usually abdominal pain) or a cardiac problem (very, very rare). If the grunting child with fever is back to being cute and well-appearing when his/her fever goes away, then I’m not concerned.
If the child is grunting and ill-appearing both when he/she has fever and when the fever goes away – see a physician as soon as possible.
Shivering – when a child’s temperature starts rising, they may start to shiver. If the shivering is accompanied by teeth chattering, then this is real shivering. Again, it’s not like there is a good study out there that has found a significant association between shivering and severe infections, but I still think that if a child has shivers, they should be seen by a doctor. If the child (usually a female) has a history of urinary tract infections, then fever and shivers should raise a concern for a urinary tract infection and a urine sample should be collected.
Change in colour – it is difficult to be specific here but I’m going to give it a try:
Pallor – many children go pale when they are ill. This should certainly be checked, but it is not usually a sign of a severe infection (like a bacterial infection, for example)
Cyanosis (blue colour) – very concerning and requires an immediate examination by a physician and a measurement of oxygen saturation levels in the blood.
Jaundice (yellow colour) – with the exception of infants, this is always a sign for concern in the presence of fever and requires an immediate medical assessment.

How long can fever last in a child?

This is of course a question that the books do not have the answer to. Illnesses do not have any “common sense”.
Most of the viral infections last for a relatively short period of time (3-4 days) but some viruses may cause signs of disease and fever for a week and even longer.
Bacterial infections – these require management and antibiotics and without such treatment the fever can be very long lasting.
To summarize, there is no clear-cut answer to this. If your child has fever, I recommend you see your primary care physician after 2-3 days of fever, even if your child is well-appearing. If he/she is not well-appearing or if they develop one of the signs mentioned in the chapter “Signs that require immediate medical attention” – then see your doctor immediately.

Should I, or should I not, cover my child with a blanket when he/she has fever?

Let’s distinguish between a rising temperature and one that is going down.
When the fever is spiking up, children might shiver and complain that they are cold. At this stage, in addition to giving them medicine, you can cover your child with a blanket. After having given them the medicine, the child might start to sweat and this is a good time to uncover them or take of a layer of clothes off to allow the heat to escape the child.

Should I, or should I not, wake up my child up when he/she has fever?

This is an excellent question. There is no answer for this in the books but we can use our common sense.
In my opinion, if a child is sleeping calmly, is not irritable or in pain, and they have no history of febrile seizures – allow them to sleep and give them the medicine for fever when they wake up.
Ill remind you once again that our aim is not only to treat the fever, but also to manage the alleviate the accompanying symptoms. Therefore, if a child is sleeping it is not necessary to wake them up even if it seems like they have a very high fever.
If the child wakes up frequently, is irritable and unable to sleep well, or is in pain – wake them up and give them the medicine.
Do not give them the medicine by mouth while they are asleep!

Does tooth eruption cause fever in children?

If there is one thing I do not plan on doing is arguing with mother…
But despite what we all tend to think, lots of good studies have shown that eruption of teeth (especially the first few teeth and incisors) may cause a mild elevation in temperature in children, but not above 38 degrees Celsius.
Tooth eruption was shown to be associated with irritability, sensitivity in the gums and drooling. But not fever.
In that case, fever above 38 degrees Celsius should not be associated with tooth eruption but should trigger a physician to search for the real cause (usually an infection, viral infection for the most part) of fever in the child.

Should I give my child medicine for fever when his/her teeth are erupting?

As I just mentioned in the previous question, tooth eruption does not really lead to a “real” fever. Nonetheless, tooth eruption does cause the child a tremendous amount of suffering and uncomfortableness. Therefore, one can certainly give these children medicine such as paracetamol and ibuprofen if they are suffering.
Most parents give one dose before bedtime during the rough nights. It’s totally okay to do that.