Michael Smith, MD (Host): This is BayCare HealthChat from BayCare Health System, and I'm your host, Dr. Mike. Dr. Juan Carlos Abanses, the Associate Director of the Pediatric Residency Program and Director of the Pediatric Emergency Department at St. Joseph's Children's Hospital, joins me today to talk about baby temperatures.

So, let's start off, very basic question, what's the normal range of temperatures for newborns and then looking at a little, into a little older child?

Juan Carlos Abanses, MD: Thank you, Dr. Mike. Thank you for having me on today. Baby's temperatures will fluctuate during the course of the day. And so their temperatures can sometimes be 96.8 or sometimes 99 degrees. The perfect body temperature is 98.7. So it's really close to 99. A lot of people worry that 99 is a fever, but it's not quite there yet. A fever is defined by 38 degrees Celsius, which is 100.4, so anything under 100.4 is still okay, even if it starts kind of creeping up to it.

Host: But that scares parents, right, 104, they're not used to that kind of level, right? So, new parents must, you know, get a little nervous at 104, huh?

Juan Carlos Abanses, MD: Well, it's 100.4 is the definition of fever. So, 100.4, correct. So, 38 degrees Celsius, so 104, I would definitely be worried about having a little baby, and that would definitely, especially for small babies, be time to come to the ER. But like I said, anything under 100.4, so technically like 99 temperatures and just right at 100.0 is still okay, although at 100.0, I start watching, once it gets to 100, it's kind of like when I start watching them really closely, but anything 99 and less is okay. But then again, some babies, it can be really problematic if they get too cold, because some babies, instead of running high temperatures, when they're real small, can actually become very cold.

So if a temperature drops down below 96.8, we worry about them also. So it's like I said, perfect body temperature is about 98.7 and if you add or subtract one degree off from that, that's about the range they should be. Everybody's temperature will fluctuate by about a degree depending on the time of the day.

Host: So if it is above normal a little bit, like when do you suggest that the parents bring the child in to see a doctor or, you know, go to emergency care?

Juan Carlos Abanses, MD: Yeah, absolutely. So, it depends really on their age. So, for example, any baby under two months of age, they just haven't developed their immune defenses well yet. They are very prone to bacterial infections. So, any temperature more than 100.4 in a baby less than two months of age needs to go to emergency room to be seen and to be evaluated.

Even going to an urgent care or a primary pediatrician's office is not going to help because they're going to need very specialized testing and a lot of different tests done for babies under two months of age. From two to four months of age, we still worry about them a lot because they haven't received their first vaccines to kind of help prevent some of the bad infections.

So we still worry about them, but not quite to the level of under two months. So a two to four month old who's got a really low grade temperature, those maybe they can call the pediatrician and maybe be seen in pediatrician's office to have the pediatrician decide whether or not they'll need to come to the ER, but definitely anybody under two months of age with a fever more than 100.4 will have to come to the emergency department. And then as kids get older, once they've had their vaccines, we start worrying about them a little bit less because they start not having as many of the troublesome, bad bacterial infections, that we used to have before. And so for an older child, I may not get worried about their temperature until it gets up above 104, 105 type temperatures. So it just kind of depends really on the age, but especially those first little babies, that two month period, any fever in them at all, is very worrisome. Needs to come to the emergency department. And that's probably one of the best things to do during that age time period is really avoid big groups of people, gatherings, those kind of things, because you don't want them to be around other people. So you really want to just avoid kind of like larger group settings, especially with those really young babies.

Host: So, let's talk a little bit about how to take a baby's temperature. You know, probably focusing more on first time parents. What are some of the options for doing that and what do you favor over other options?

Juan Carlos Abanses, MD: The most accurate, especially for the little babies, where we're most concerned about an accurate temperature is the rectal temperature. It can sometimes be thrown off with just like, if there's a little bit of poop in there, but it really is the most accurate and kind of gives us the best estimate of the baby's temperature.

And when we're having to make big decisions, like, do you need to come to the emergency department? It's the best one for little babies. And you just put it in about half an inch. And you can put a little lubrication on it and it works really good. And it's really the way that, especially for three months of age, how it should be done.

After about three months of age, you can try just using an axillary and you just kind of put it underneath their armpit. You have to be careful that obviously the clothing isn't touching. It has to be skin to skin. And so you can do that. You don't really have to add a degree because everybody always wants to add a degree that way.

But you know, if we're in Florida and you happen to be outside, it's just hot anyways. So it's, you just telling us what the temperature was axillary is just the easiest thing, without adding or subtracting degrees, just tell us that you took it underneath the arm and this is what the temperature was kind of thing.

And then we'll kind of go from there. There are other methods as kids get older. There's the type that you can put in the ear. That one's very quick. It works fast. The only negative is that you really can't use under six months of age because the ear canal is just too tiny in little babies. And then also in some of the older kids, if they have a lot of wax in their ear, it can kind of block because you have to angle it back towards the eardrum, which most people kind of put it straight in and not angle it back towards the eardrum, but it's trying to read the arteries on the eardrum.

So if you have a bunch of wax in the way, it can't read the temperature from that as well. A lot of people will do forehead ones, which is fine as the kids get older. The one thing about the forehead ones is that again, if you've been outside in the hot weather, it's going to read a little bit hotter.

If you've been in like a really cold room, it's going to read a little bit colder. So it's kind of a little bit more with the ambient temperature. The other thing is that because it takes the temperature so quickly, it sometimes will overestimate the height of the fever. So instead of it measuring like 103, it might measure 105.

It knows it's got a fever. So we don't mind, we kind of bring it in and kind of check them, but also realize that when it's a really high temperature, it's sometimes will overestimate it and go a little bit higher. As the kids get older, the mouth putting it underneath the tongue is a little bit more accurate.

But they have to keep their mouth closed. It needs to be under their tongue. Things that can affect that, are sometimes having had something cold to drink right beforehand, or the kid's just not keeping their mouth closed during you know, when they're trying to kind of use it. There are also those strips or discs that you can put on their foreheads.

But really those, they don't work at all. They're just very inaccurate and I would not recommend those. There are so many other ways to kind of check it that are better, that I would now recommend the strips or those little color changing ones.

Host: Yeah, I'm glad you brought that up because I'm seeing a lot of ads on the internet about these strips and discs that, it makes it so easy, but if they're not accurate, they're not accurate. When it comes to the actual thermometer, and we're talking about oral, rectal, maybe the armpits, are you good with digital or do you like the good old fashioned type?

Juan Carlos Abanses, MD: You know, nowadays, digital, the digital's have gotten pretty good. So, like I said, I'm pretty good with that. So, I think digital works really well. And the digital ones you can use rectally or orally also kind of stuff.  Now, we don't have to worry about the glass breaking or any of that kind of stuff. I just wouldn't change where they go.

Host: You mentioned with newborns, you're a little more concerned about them, when there is a fever. So, what are some of the causes in a newborn? And if somebody was to take their newborn in to see you, what kind of workup would you do?

Juan Carlos Abanses, MD: So, the things we worry about the most in newborns is that they're very prone to potentially having a bacterial meningitis. So when in mom's vaginal areas, there's a normal bacteria that happens and it's called group B strep. You can be positive in one pregnancy and negative in another pregnancy.

But that bacteria can sometimes get to the babies and cause group B strep meningitis. So the biggest thing is when they're under two months of age, we have to do some lab work.

If they're under one month of age, they have to have all the lab work done, a urine cultures to see if they have urinary tract infection. We check their blood to make sure they don't have bacteria in their bloodstream, and we have to check them for meningitis. From one month to two months of age, we don't have to check every one of them for meningitis, but if their lab work is abnormal, we follow the American Academy of Pediatrics guidelines and if they have abnormal lab work, then we have to look to see do they have meningitis and because again, one of the things is you don't want to miss a child meningitis because they will have a very difficult time and have consequences that can be lifelong and be very severe, if not life threatening.

So that's why we're a lot more careful with the little babies. They're just more prone to these bacterias that can get into their bloodstream. They're more prone to urinary tract infections, and they're more prone to meningitis. And that's why even the pediatrician's office, they'll tell you if the child's under two months of age and has a temperature more than 100.4, usually don't even come to their office, just go straight to the emergency department because we have to do very specialized testing to kind of check the babies and make sure they're okay.

Host: Right, during my time in medical school and taking pediatrics, the older kids tend to be more viral. That's correct, right? And, and what's their workup?

Juan Carlos Abanses, MD: Yeah, so it depends on the age. So most of the older kids, as they get older now, you know, especially past six months of age, and they've got their vaccines, like pneumococcal, and haemophilus influenza,these bacterias that used to be more problematic. So in the old days, we used to have to do blood work on any child that was still three months to three years of age, but now a two or three year old comes in with a fever, we don't necessarily have to do blood work on them because it's so rare now to have those bacterial infections.

Urinary tract infections are still very common, especially in girls, and especially if they're in diapers, because when they poop, the poop kind of goes a little bit everywhere, it can kind of get up their urethras and cause urinary tract infections. A little less common in boys. But more common in girls.

So you always worry still about urinary tract infections until they get kind of a bit older. But mostly our stuff as the kids get older tend to be more the viruses are going around. And there are so many viruses that kind of go around and everybody always asks where they get them and you can get them.

But the most common place is daycare and schools. And kids are going to get a bunch of different viruses. A normal child who is not in daycare with no other brothers or siblings is going to get sick about six to eight times a year.

A child who's in daycare or in school is going to get sick usually about 10 to 12 times a year. And like I said, most of those are going to be viruses. It's not usually an immunologic problem. Parents are always worried, “my kid's getting sick so often, they must have an immune problem.” It's not, it's just, that's how your body has to catch a lot of these little viruses over time and then you start building defenses against them and then you start getting less and less sick as they get older.

Host: It's like the idea of a little stressor is important for the immune system, right? That's how the immune system builds up its defenses and gets immune cells ready to go. But, you know, when I was a young resident, my sisters started having babies. And they would call me a lot when there was a fever, and they were always concerned about a fever in a newborn or even a little older child causing things like brain damage and stuff. What do you think about, what do you think about the things that fevers actually don't cause?

Juan Carlos Abanses, MD: So there's a lot of myths, that we see oftentimes and so one of the biggest myths is the brain damage, if the fever gets too high, that's going to cause brain damage., But really your body proteins don't start to break down until you get to about 108 to 109 degrees. And if you have a normal hypothalamus, it will autoregulate your body temperature.

And I try to explain that to parents. It's just like if you go out and eat a whole bunch of cake, your brain will send out a message that you have too much sugar to lower your sugar unless you have a disorder like diabetes. Same thing if you eat a bunch of salty fries from McDonald's. It will realize you have too much salt and autoregulate it.

Your body will auto regulate its temperature. So it tries to raise the temperature up enough to kill the virus and then it automatically starts lowering it. So I try to explain to parents lots of times that it's kind of like last time they had a fever and they were sick with some virus and had like a fever. They probably didn't feel good. They'd probably laid down on the couch. They'd want to be as active as normal. They'd lay down on the couch. And you get cold for a while, so you put a blanket on, and then you get hot, and then you take the blanket off, and then you get cold again, and then you put the blanket back on.

And that's the brain auto regulating that temperature so that it's high enough to kill the virus, but not getting too high where it's going to cause any damage to you. And so I think that's the biggest myth, is that people are afraid that if they don't treat the fever, it's going to get too high and cause brain damage, but it really doesn't.

The kids that we see that come in with the temperatures that will cause brain damage, and temperatures that high are kids who don't have a normal hypothalamus. Kids are left in cars during the summertime where their body just can't cool down because basically that car becomes like an oven. And then kids who take drugs. So a lot of the cocaine, meth, ecstasy. Those will all cause the body temperature to rise kind of stuff.

The other myth is that it will cause seizures. So a lot of people are very concerned about seizures with fevers. And we have to realize is that what we know over time is that febrile seizures are really genetic. It's not really the fever that causes the seizure. The fever is just a symptom. And if they're going to have the seizure, it happens on the first day. It doesn't happen on usually subsequent days. It happens on the first day. And the interesting thing is we have to kind of explain to people is like, if a child's going to have the flu, with the flu, they're going to have fevers for 7 to 10 days.

The fever every day is going to be 103 to 105. So they will have temperatures of 103 the first day, 104 the second day, 105 the next day, 104 the next day, and the fever continues for 7 to 10 days. But they only have a febrile seizure the first day. If the fever were what was causing the seizures, you would expect them to have a seizure every day, and they don't. It's really more of a genetic thing. We also used to think it may be because the fever got up to quickly, you know, went up too quickly, but there's kind of now, especially as we give these kids with the flu, Motrin and Tylenol and it brings it down, then their fever goes up quickly and they don't seize and they don't seize in the following subsequent days.

We're starting to find out that it looks like it's more of a genetic predisposition that the kids have. And if they don't have them the first day, you don't have to worry about it on subsequent days.

Host: Oh, I think that's going to make a lot of parents feel a lot better about a fever in their child. So if you are a parent and your newborn or little older kid has a fever, but it's not at those levels you've mentioned, how should they treat this at home?

Juan Carlos Abanses, MD: So again, under two months of age, I would tell you, don't treat it. Come straight to the emergency department. In the two to six months of age, they can give Tylenol and they can give Tylenol and call their pediatrician, talk to their pediatrician via the phone and see what the pediatrician would like them to do.

We don't recommend ibuprofen under six months of age because there's a theoretical risk of increased bleeding with it. So we recommend just Tylenol until six months of age. After six months of age, they can give Tylenol and Motrin. But the interesting thing about it is what I try to teach parents is that the fever is actually doing a lot of good things to the body.

So the fever is actually helping to boost the immune system. It's actually helping to release interferons. It increases our white blood cells that help kill the infections. It sets the body's metabolism. It slows the growth of bacteria or viruses, and it prevents the spread of disease. So it's actually the fever is actually trying to kill off the virus.

So what I try to tell parents is, in an older child, so again, past six months of age kind of thing. What I'm looking for is trying to keep the child more comfortable than trying to get rid of their fever. You don't have to necessarily break the fever. So for me, the most important thing is I tell them like if the child has a 102 fever, but is running around playing, jumping on dad's back and just playing and having a good time, leave them alone.

That way their body will naturally kill off the virus a little bit quicker. If the fever is 101, but the child feels miserable and achy and that doesn't feel good, I tell them to give the child a little Tylenol or ibuprofen. The other important thing is, a lot of people, will give the children baby aspirin, and baby aspirin, it's a misnomer, it's aspirin should never be given to a child, because it can cause bleeding problems, and if they catch the flu, it can cause Reyes syndrome, where their brain swells, and their liver goes into permanent failure, so, aspirin is something to never give children. So we sometimes will see parents wanting to give them baby aspirin, but baby aspirin is kind of a misnomer. It's really relating to the size and the amount of the aspirin and not for it to be really given to children. So that's the other thing that I would tell people to avoid.

And the other thing I try to tell people is, again, if the child's sleeping comfortably, and they're sleeping, and they're taking a good nap or something like that, and they have a little bit of fever, but they're comfortable, there's no need to really wake them up to make them take the medication because it's been four to six hours kind of thing.

Again, the key for me in those older children is to help them be comfortable. Get as much rest and encourage lots of fluids because as a child does have fever, it does increase their metabolism. They use up more fluids. Just like if you go on a hot day, you have to drink more. When your body's hot, you have to drink more.

So I really try to encourage lots of fluids and drinking lots of fluids. But really the key is keeping that child more comfortable.

Host: You know, Dr. Abanses, I knew you were going to be full of great information and I really appreciate this. Let's wrap this up and kind of give us your take home message for parents with kids with fever. Like, what do you want them to leave this podcast with?

Juan Carlos Abanses, MD: I think the most important thing is, especially under two months of age, we really worry about the fever. So if they have any fever more than 100.4, they need to come to the emergency department. But because of that, try to avoid big groups, gatherings, that kind of stuff. We don't want your child to potentially be around someone that is having the beginning of some kind of illness and you just don't know about it.

They just don't have the immune system to fight the stuff off as much. So especially in those first couple of months of life, try to avoid the big gatherings, try to avoid all the people kind of touching or kissing on the baby. Let the babies kind of develop their natural immunity. As a child gets older, once they're older, not to be quite as afraid of the fever.

Like I said, that older age, the fever tends to be a natural way of the body's defense, to kind of help them. Now, if the fever is lasting more than five days, I'm going to tell you they need to be kind of seen. It's still probably more viral kind of thing, but we do worry about other illnesses at that point in time.

But usually the most important thing is going to be that as rule, young babies, we worry about them a lot because it's more bacterial infections that we're worried about. As they get older, the majority of the things causing those  fevers tend to be more of those viruses and those viruses usually have to kind of run those courses.

We have to sometimes check them for other things, but the majority of time it's going to be a little virus and it just needs to run its course.

Host: Fantastic. Dr. Abanses, I'm going to thank you for joining me today. This was great information and that wraps up this episode of BayCare HealthChat. Go on over to the website at BayCare.org for more information and get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other BayCare podcasts.

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