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What Should I do When My Child Has a Fever
What Is Fever?
Fever is a symptom—a sign that your child’s body is fighting off an infection. Most fevers are caused by
common things like colds, ear infections, and bronchitis. Fever is the body’s way of fighting infections.
If you think your child has a fever, you should take their temperature. Temperature readings are different
depending on what part of the body you use (rectum, ear, mouth). Your child has a fever if their
temperature is above:
•
•
Rectal 100.4° F (38.0° C)
Oral (by mouth) 99.5° F (37.5° C)
•
•
Axillary (armpit) 98.6° F (37.0° C)
Tympanic (ear) 100.0° F (37.8° C)
Why Do We Treat a Fever?
Fevers are usually not dangerous for most children and infants over the age of 3 months. Most fevers do
not lead to brain damage or death. Although some children have seizures when they have a fever,
medicines used to treat fever do not always prevent these seizures. The main reason we treat fevers is to
keep your child comfortable so they will eat, drink, or sleep. If your child has a mild fever but is playing,
drinking fluids, and generally acting well, there is no reason to treat the fever. Medicines used to treat
fever do not make the fever or infection go away faster. Medicines used to treat fever may not make your
child’s temperature normal. However, you should call your doctor if your child has a fever and is less
than 3 months old, if the fever has lasted more than 24 hours, or if your child is also vomiting.
What Medicines Are Used to Treat Fever?
The most commonly used medicines to treat fever are acetaminophen (Tylenol and others) and ibuprofen
(Motrin, Advil, others). When used as recommended, acetaminophen and ibuprofen have few side effects
and are quite safe. These medicines come in drops for infants, liquid (“elixir”) for toddlers, and chewable
tablets for older children. The infant drops are more concentrated than the liquid elixir for toddlers. Do
not switch back and forth between different products or you may give your child too much or too little
medicine. Always closely read the directions on the label. DO NOT give your child aspirin for their
fever unless your doctor tells you to. Aspirin can cause serious side effects and Reye’s syndrome.
Other tips for the safe use of acetaminophen or ibuprofen include:
• To avoid making mistakes, read the label before you open the bottle, after you measure a dose, and
again before you give it.
• It is important to use the medicine exactly as you are told. Do not give more or less medicine and do
not give it more frequently than recommended.
• Many allergy, cold, and flu medications contain acetaminophen or ibuprofen. Check with your
pharmacist before combining medications.
• When giving your child a liquid medication, do not use standard tableware tablespoons and teaspoons
because they usually are not accurate. Instead, use a measuring device such as a syringe, dropper,
dosing spoon, or medicine cup.
Other Ways to Keep Your Child Comfortable
There are other ways to keep your child comfortable. These include:
• If shivering, keep your child warm until the shivering stops. If not shivering, you can remove
your child’s warm clothes and encourage them to drink plenty of fluids.
• Keep your child rested, quiet, and comfortable in a cool room.
• Place a cool washcloth on your child’s forehead or sponge them with lukewarm water. If
sponge bathing, make sure the water doesn’t get cold, and stop if your child starts to shiver.
• Never use rubbing alcohol to cool your child's skin. It can be absorbed through the skin and
harm your child.
Prepared for the subscribers of
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(Page 2 of 5)
Detail-Document #220409
−This Detail-Document accompanies the related article published in−
PHARMACIST’S LETTER / PRESCRIBER’S LETTER
April 2006 ~ Volume 22 ~ Number 220409
Antipyretics and Fever in Children
―For more information concerning dosing of commonly-used OTC medications in children see our
Detail-Document, “Dosing of OTC Products in the Pediatric Population.”
U.S. subscribers please see document #220107. Canadian subscribers please see document #220117―
Introduction
Fever is common in infants and children.
Fever is defined as an elevated core body
temperature that is often, but not necessarily, part
of the body’s defense response to the invasion of
something live or inanimate which is considered
foreign to the body.1,2
In general, fever is rarely harmful and mainly
causes discomfort.
Treating a fever with
antipyretics assumes that fever is noxious and that
using antipyretics such as acetaminophen
(Tylenol, others) or ibuprofen (Motrin, Advil,
others) reduces or eliminates the adverse effects
associated with fever. However, neither of these
assumptions has ever been proven, especially in
older infants and children.1 In fact, fever is an
important defense mechanism in the body and
helps the body resist infection. Additionally, it
has not been conclusively proven that a core
temperature of up to 105.8º F (41° C) is harmful
in most individuals. While some may argue that
children with a history of febrile seizures derive
benefit from fever suppression, this too has not
been proven.3-5 Most children who experience a
febrile seizure have a body temperature of
102.2° (39° C) or less and tolerate even higher
body temperatures without experiencing seizures
at a later time.2 In a number of trials, antipyretics
have not been shown to prevent recurrent febrile
seizures.3-5
While fever is often considered a beneficial
response to foreign agents, it causes parental
anxiety. Crocetti and colleagues interviewed
340 caregivers of children regarding their
knowledge about fever. They found that 56% of
caregivers were very worried about the potential
harm of fever in their children, and felt that fever
could lead to a variety of sequelae including
seizures, brain damage, and death. When asked
about the lowest temperature that could lead to
harm, 76% of patients felt that a fever of
104° F (40° C) or less could be harmful, and 35%
of caregivers felt like a temperature of 100° F
(37.8° C) or less could be harmful.
In this same survey, 25% of respondents said
they gave antipyretics for temperatures of less
than 100° F (37.8° C) and 89% gave antipyretics
for temperatures of 102° F (38.9° C) or lower.
Alternating acetaminophen and ibuprofen was
reported by 27% of caregivers. Finally, 7% of
respondents thought that fever could rise to 110° F
(43.3° C) or higher if the fevers were untreated.
The authors concluded that fever phobia exists
and that health care providers should educate
caregivers about fever and its role in illness.6
Despite the protective role of fever,
antipyretics are often recommended for treatment
of fever. The primary reason to treat fever is for
patient comfort. Complete normalization of body
temperature is not necessary.
The most commonly used antipyretics include
the salicylates such as aspirin, acetaminophen, and
the nonsteroidal anti-inflammatory agents such as
ibuprofen. These agents block the conversion of
arachadonic acid to prostaglandin E2 by inhibiting
cyclooxygenase.1,2 It is thought that prostaglandin
E2 is critical in the febrile response. However,
although aspirin is a very effective antipyretic,
because of the association with Reye’s syndrome
aspirin is not recommended for use in children.
Acetaminophen and Ibuprofen
Antipyretics such as acetaminophen and
ibuprofen are the most commonly recommended
agents.
Acetaminophen (Tylenol, others) is considered
a safe and effective antipyretic agent. It is well
absorbed orally, with a maximum temperature
More. . .
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(Detail-Document #220409: Page 3 of 5)
reduction occurring at about two hours. The
manufacturer’s recommended dose is 10 to
15 mg/kg every four to six hours, with a
maximum of five doses in a 24-hour period.
However, some clinicians recommend an initial
30 mg/kg oral loading dose in order to achieve
therapeutic serum concentrations and antipyretic
efficacy sooner.7
Ibuprofen is also effective in the treatment of
fever. While nonsteroidals are associated with
serious adverse effects such as gastrointestinal
bleeding, renal failure, and allergic reactions,
these reactions are rare when used short term in
children less than twelve years.8 Even in children
less than two years of age, short courses of
ibuprofen have been shown to be remarkably
safe.8
Because of the longer duration of action,
ibuprofen can be dosed less frequently, which can
be advantageous, especially at bedtime. The
recommended dose is 5 to 10 mg/kg by mouth,
every six to eight hours. Ibuprofen is not
indicated in children less than six months of age
in the U.S. and in children less than three to four
months in Canada (varies by manufacturer).
Studies show that higher ibuprofen doses
(10 mg/kg) were more effective than lower doses
(5 mg/kg), especially at higher body temperatures
[greater than 102.5° F (39.2° C)]. Another study
found that the higher ibuprofen dose should be
used at temperatures of 101.8° F (38.8° C) or
higher.9
The question of differences in efficacy of
multiple doses of acetaminophen and ibuprofen
has been addressed in a limited number of small
studies. While ibuprofen has been shown to be
slightly more effective in a few studies, the trials
have methodological flaws making definitive
conclusions difficult. Most studies evaluate fewer
than 100 children and doses of antipyretics vary
widely. In addition, patient recruitment was often
flawed as groups were not matched at the time of
recruitment.10,11
While
an
apparent
advantage
of
acetaminophen is the availability of rectal
suppositories (especially in a child who is unable
to tolerate oral medications), problems exist.
Rectal administration of acetaminophen often
leads to erratic absorption with peak levels
varying by as much as nine-fold and often does
not reach therapeutic concentrations. In addition,
the time to peak is substantially longer when
compared to the time to peak of orally
administered acetaminophen. Consequently, the
American Academy of Pediatrics discourages its
use.12
Alternating Acetaminophen and Ibuprofen
When fever reduction is inadequate with
maximal doses of either acetaminophen or
ibuprofen
monotherapy,
some
clinicians
recommend alternating acetaminophen and
ibuprofen.
While this is commonly
recommended, there is surprisingly little
published information to support this practice.
Clinical trials evaluating this practice suffer from
many flaws.13-16 Trials evaluating the efficacy of
combination
therapy
for
resistant
high
temperatures are needed before this practice can
be routinely recommended.
Alternating antipyretics can be considered
when children experience breakthrough fever
before another dose of the same antipyretic can be
given. For example, ibuprofen can be given every
six to eight hours. However, fever sometimes
reoccurs after three to four hours, before
ibuprofen can be safely given again. In this
scenario, acetaminophen can be given three to
four hours after the ibuprofen dose.
There are a variety of regimens which can be
used, but care must be given to avoid giving the
medications on the same schedule (i.e., every four
hours). In a survey of pediatricians, 50% of the
161 respondents recommended alternating
antipyretics. The most commonly cited regimen
was a regimen of acetaminophen every four hours
with ibuprofen every six hours. This would entail
giving a dose of acetaminophen at times
0 and 4 hours, ibuprofen at time 6 hours,
acetaminophen at time 8 hours and potentially
both at time 12 hours.13 This regimen could cause
confusion in some caregivers and potentially lead
to overdose. Alternatively, regimens utilizing
these medications at a fixed dosing interval (i.e., a
regimen where these medications are given every
six hours, so either acetaminophen or ibuprofen is
given every three hours or every eight hours, so
either acetaminophen or ibuprofen is given every
four hours) have been used. Care should be given
to avoid exceeding five doses of acetaminophen
or four doses of ibuprofen in a 24-hour period.
Caution should be used in alternating
antipyretics in infants and children at risk for renal
failure, such as those with mild to moderate
More. . .
Copyright © 2006 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
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(Detail-Document #220409: Page 4 of 5)
dehydration.12 There is a case report of acute renal
failure associated with alternating antipyretics in a
dehydrated child. The authors hypothesize that
the synergistic and additive mechanisms of action
and toxicities of acetaminophen and ibuprofen can
predispose these individuals to adverse effects.14
Nonpharmacologic Treatment of Fever
In the majority of cases, antipyretics are the
most convenient method of reducing fever.
However, sponging is a useful alternative to
antipyretics in children who are allergic to an
antipyretic or if they cannot tolerate it.
Additionally, sponging can be used in
combination with antipyretics.
Common
situations when sponging can be considered
include:17
• Fever is making the child uncomfortable
• Temperature is over 104° F (40° C)
• The child is unable to tolerate oral
medications
When sponging is used, the child should be put
into a tub of one to two inches of tepid water
[85° to 90° F (29.4° to 32.2° C)]. Colder water is
uncomfortable and can lead to shivering which
can further elevate body temperature. The water
should be spread over the trunk, arms, and legs,
using a sponge or washcloth. Water evaporates
from the skin surface and cools the body, usually
within thirty to forty-five minutes. The room
should be kept warm, about 75° F (23.9° C).
Alcohol should not be added to the water since it
can be inhaled or absorbed through the skin
leading to adverse effects such as coma.17
Other nonpharmacologic methods which can
be utilized in a child with a fever include keeping
the child lightly dressed, encouraging extra fluid
intake, and avoiding overexertion. 17
used
instead
of
children’s
suspension
(160 mg/5 mL), or an adult strength tablet
(325 mg) is used instead of children’s chewable
(80 mg) or junior strength tablet (160 mg).
Caregivers should understand the differences
between the products and the importance of using
a calibrated measuring device to administer liquid
medications.
Finally, many combination products contain an
antipyretic.
If a child is getting multiple
medications for a variety of symptoms, caregivers
may unknowingly give more doses of an
antipyretic than recommended. Caregivers should
be warned that many preparations contain an
antipyretic and that simultaneous use can be
dangerous. They should be instructed to read the
entire label of any over-the-counter product,
especially those recommended for cough, fever, or
headaches or other painful conditions. If their
child is receiving an antipyretic and they are
concerned about duplication of therapy, they
should ask the pharmacist before purchasing or
administering any over-the-counter product.
Users of this document are cautioned to use their own
professional judgment and consult any other necessary
or appropriate sources prior to making clinical
judgments based on the content of this document. Our
editors have researched the information with input
from experts, government agencies, and national
organizations. Information and Internet links in this
article were current as of the date of publication.
Project Leader in preparation of this DetailDocument: Neeta Bahal O’Mara, Pharm.D.,
BCPS
References
1.
Preventing Overdoses of Antipyretics
Overdoses of antipyretics can occur for a
variety of reasons. Some overdoses occur in
children whose caregivers feel that “if some is
good, more is better.”
Some caregivers
administer extra doses or higher doses than
recommended if the fever is not reduced as
expected.
Parents should understand that
temperature normalization is not the goal, but
rather patient comfort.
Another reason for unintentional overdose is
giving the wrong formulation. For example,
concentrated infant drops (80 mg/0.8 mL) are
2.
3.
4.
5.
Plaisance KI, Mackowiak PA. Antipyretic therapy:
physiologic rationale, diagnostic implications, and
clinical
consequences.
Arch
Intern
Med
2000;160:449-56.
Mackowiak PA. Concepts of fever. Arch Intern Med
1998;158:1870-81.
Offringa M, Moyer VA. Evidence based
management of seizures associated with fever.
BMJ 2001;323:1111-14.
American Academy of Pediatrics. Committee on
Quality Improvement, Subcommittee on Febrile
Seizures. Practice parameter: long-term treatment
of the child with simple febrile seizures. Pediatrics
1999;103:1307-09.
El-Radhi AS, Barry W. Do antipyretics prevent
febrile convulsions? Arch Dis Child 2003;88:64142.
More. . .
Copyright © 2006 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
(Detail-Document #220409: Page 5 of 5)
6.
Crocetti M, Moghbeli N, Serwint J. Fever phobia
revisited: have parental misconceptions about fever
changed in 20 years? Pediatrics 2001;107:124146.
7. Treluyer JM, Tonnelier S, d’Athis P, et al.
Antipyretic efficacy of an initial 30-mg/kg loading
dose of acetaminophen versus a 15-mg/kg
maintenance
dose.
Pediatrics
2001;108.
http://pediatrics.aappublications.org/cgi/content/full/
108/4/e73. (Accessed March 8, 2006).
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younger than two years old. Pediatrics
1999;104,e39.
http://www.pediatrics.org/cgi/content/full/104/4/e39.
(Accessed March 8, 2006).
9. Bell EA. Pediatric Ambulatory Care. In: Schumock
G, Brundage D, Chapman M, et al. eds.
Pharmacotherapy Self-Assessment Program, 5th
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of Clinical Pharmacy, 2006:137-43.
10. Perrott DA, Piira T, Goodenough B, Champion GD.
Efficacy and safety of acetaminophen vs ibuprofen
for treating children’s pain or fever. Arch Pediatr
Adolesc Med 2004;158:521-26.
11. Goldman RD, Ko K, Linett LJ, Scolnik D.
Antipyretic efficacy and safety of ibuprofen and
acetaminophen in children. Ann Pharmacother
2004;38:146-50.
12. American Academy of Pediatrics. Committee on
Drugs. Acetaminophen toxicity in children.
Pediatrics 2001;108:1020-24.
13. Mayoral CE, Marino RV, Rosenfeld W, Greensher
J. Alternating antipyretics: is this an alternative?
Pediatrics 2000;105:1009-12.
14. DelVecchio
MT,
Sundel
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Alternating
antipyretics: is this an alternative? Pediatrics
2001;108:1236-37. (letter to the editor)
15. Sarrell EM, Wielunsky E, Cohen HA. Antipyretic
treatment on young children with fever:
acetaminophen, ibuprofen, or both alternating in a
randomized, double-blind study. Arch Pediatr
Adolesc Med 2006;160:197-202.
16. Nabulsi M, Tamim H, Mahfoud Z, et al. Alternating
ibuprofen and acetaminophen in the treatment of
febrile children: a pilot study [ISRCTN30487061].
BMC Med 2006;4:4. [Epub ahead of print]
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http://www.biomedcentral.com/1741-7015/4/4.
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ub_cat=1. (Accessed March 8, 2006).
Cite this Detail-Document as follows: Antipyretics and fever in children. Pharmacist’s Letter/Prescriber’s Letter
2006;22(4):220409.
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