Scott Webb (Host): Though it's natural for parents, especially first time parents, to panic a bit when a child has a fever; my guest today wants us all to know that most fevers are normal, and though there are some things we can do to make our kiddos more comfortable, we rarely need to rush them to the doctor or the ED.

And I'm joined today by Dr. Dustin Monroe. He's a Pediatric Critical Care Physician with the Valley Health System.

 Welcome to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. Our podcast goes beyond broad everyday health topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. I'm Scott Webb.

Doctor, thanks so much for your time today. We're going to talk about fighting fevers in kids, high temperatures, you know, when should we worry? And I was mentioning to you that my kids are a little bit older, but I had these questions when they were younger and I'm sure lots of parents do. So let's just start out here with the most obvious one. What's a normal temperature for babies and children?

Dustin Monroe, MD: What is a misconception sometimes is that you know, fever for one person is the same as for another person. Fever is actually a pretty dynamic thing. If you look at temperatures, you know, temperature is actually a range of numbers from zero to infinity, potentially.

And fever is actually a temperature where we create a certain cutoff. And we say at this point you now have fever, and below that you do not have fever. And fever by itself is actually just a natural mechanism that occurs in our bodies when we're exposed to something, we experience illness. Our brain and our hypothalamus controls our temperature and it tells us what's a normal range.

And a normal temperature range is actually somewhere between 97 and 99 or 100 degrees. So it's a range of normal temperatures, not an absolute. We talk 98.6 is normal temperature, but it's actually a range that's normal. Fever is when we hit that set point and say, at this point, it's fever. For most people, it's about 100.4 degrees, or 38 degrees Celsius. And the reason for that is because above that, in certain ages, especially newborns and children under the age of three to six months, they can experience a lot more significant illness if the temperature is above 38 or 100.4 degrees. So it serves as sort of an alarm system to say, hey, look at me. We need to pay attention to this child and figure out, is there something that we should worry about?

Host: So when we think about temperatures and fevers, at what point do we begin to consider medications? You know, you say that a fever is kind of normal, really, because it lets us know something's going on and it may not be a big deal per se, but when do we start to think about giving meds?

Dustin Monroe, MD: Because our natural response is to have a fever when something is wrong, we want to identify what the reasons are. And then we can provide treatment to it. And the current recommendation by the American Academy of Pediatrics is that fever can become high enough that it makes kids feel run down and tired and weak. And when they feel that way, they're not as apt to provide themselves adequate hydration and they can become dehydrated because there's enough inflammation and fever happening in the body that they just are too tired to drink. So the recommendation is, whatever temperature it is actually that makes them run down and tired and not drinking well, that would be a good time to provide a fever reducer medication and do interventions that would make them feel better so that they can hydrate.

You know, and that might be different numbers for different kids. We can say that fever is 100.4, but you might have a child who's 101 temperature and is running around the house playful and happy and not really bothered by it. Do you have to give them Tylenol? And I would say, I think it's up to your discretion, but it's not always necessary to give it for a specific number.

We want to treat children based on how they're feeling. You know, I look at fever sort of as imagine, you know, a fire alarm, you know, your house, if there was a fire or not, a fire alarm goes off. It doesn't tell you how bad a fire could be or if there's actually a fire. It just alerts you to say, I should look around my house and find out what's going on.

Host: What, yeah, what's setting off the alarm? Yeah.

Dustin Monroe, MD: That's the same thing with fever treatments. You know, give Tylenol and ibuprofen or acetaminophen and ibuprofen if it makes the kids feel run down and tired. Certainly we can treat the numbers. There are some absolute numbers to try to stay ahead of it, but we shouldn't be afraid of fever.

We should use it as a way to look at the children to say something is wrong. Let's figure out what's wrong and let's make them as comfortable as possible so we can maintain their hydration and then get to that next step of deciding what do we do about it.

Host: Yeah, and you mentioned some of the OTC meds. I wanted to ask you about that. The questions that I had, and maybe still have to some, degree. Are Tylenol and Ibuprofen the same thing? Is there a difference? Can we use both? And are there any non-pharmaceutical treatments that we can use that aren't OTC things we buy, you know, at the drugstore?

Dustin Monroe, MD: Yeah, so there are two good fever reducers, you know, acetaminophen and ibuprofen. They do work a little bit different, the mechanism of action. Ibuprofen is a nonsteroid anti inflammatory medication. So they kind of work in different pathways, and the way that the body processes them after they're given, is different as well.

Acetaminophen is processed through the liver, and ibuprofen is generally processed and eliminated through the kidney. So acetaminophen needs processing through the liver before it can be excreted, and ibuprofen more gets excreted through the kidney. So the side effects of each, can be manifested if, like, for example, somebody took too much of something. Acetaminophen would manifest as liver problems and ibuprofen would manifest as potentially kidney problems and or an upset stomach.

So we want people to know what things to give and how much to give and follow the appropriate dosing guidelines. These were made over the counter because they were generally safe enough that if people read and followed the instructions, they can be administered safely at home with minimal side effects.

But that doesn't mean that there are zero side effects. So and my approach to fever if kids are run down and tired and I want to treat it, I like using acetaminophen as my initial fever treatment. I think it works really great as a fever reducer. It's very safe for all ages of children down to newborns.

But ibuprofen is generally safe, or at least studied to be safe, for kids over 6 months of age. So I like acetaminophen. It's been tried and tested. It works really well to reduce fever. And I'll give that as an initial treatment. And then, if 30 minutes to an hour later, the kids are not perked up, been hydrating, fever's still high, not coming down, then I might, at that point, dose the ibuprofen.

I think what a lot of people get into is this idea that if they had a fever, we have to viciously try to keep the fever down. Aggressively treat it. Alternating Tylenol and ibuprofen. Giving something every three hours because they had a fever. And that might be unnecessary. Again, we don't want to be afraid of the fever.

We want to treat it strategically to allow the children to feel better, to maintain hydration; while we're trying to see, do they need to get looked at by somebody or can we watch and wait and treat them at home? Certainly giving too much of anything is not a good thing. And other things that might help the non-pharmacological things like you talked about, where are like taking tepid baths might help, doing cool cloths. If you've already given a fever reducer, and they're still uncomfortable, a cool cloth on the forehead, on the neck, under the arms might help them bring down the temperature as well.

But because the body feels like something is wrong, the brain is telling the body that the temperature is supposed to be at that fever range and it's trying to fight to keep it that high. And we're trying to bring it down, but the body wants it to be high because it's fighting off something. So generally, if we're targeting treatment of how the child is feeling, we're not going to give too much, and we're not going to give things too frequently, or stress about having to give something around the clock. Somewhere between 60 and 80 percent of parents would wake their kids up in the middle of the night to dose acetaminophen, because they had a fever during the day.

Whereas, it might be better off letting them sleep, and if they wake up and they're upset, that might be a time to re-dose the medication.

Host: Let's talk about thermometers, you know, which ones really work the best and do those ear thermometers really work?

Dustin Monroe, MD: Any thermometer that gives a reading that, based on that reading, you might make decisions is okay to use. I'm fairly practical and I like to you know, get my most bang for my buck and so I might generally use the least expensive one and I like ones that I can check the temperature under the arm, in the armpit mostly, for small babies.

We need accurate temperatures because if you're under two months of age and you have a temperature of 38 degrees or 100.4, that would be an emergency and we want those babies to show up at the hospital to get evaluated because that temperature, and they might act perfectly normal, but that temperature is a trigger for us to do an investigation to look for a serious illness. And so, we do want to know and get accurate temperatures and the gold standard is a rectal temperature in small infants and babies. But under the arm for otherwise healthy kids, older kids, is generally sufficient. Doing the forehead ones is convenient because you can get a reading, but it is affected by surface temperatures, if they're sweating, if they're cold, so it's affected by external factors a lot more.

 We're trying to predict the core temperature by doing surface readings or under the arm readings or under the tongue readings. And so if your behavior might change if the temperature was elevated by a degree or two, you might want to have something that's a little bit more accurate.

But for otherwise healthy kids, you can almost pick any temperature reading as long as it gives you something that you can look at to decide, should I worry? Should I get him evaluated? Should I provide some type of treatment? I think you use those readings in the context of how the child's feeling because like I said, if the temperature is 99 or 100 or 101, if the child doesn't look well, and you want to provide some relief, you might try these anti fever, anti pain medications to try to see if you perk them up.

And that might be the reason that you get them evaluated by a healthcare professional, is because they're not improving and their activity is still down.

Host: Yeah, I want to ask you, what's the threshold for when to call a pediatrician or head to the hospital? And I, you know, maybe it varies, I know that my wife and I, we had a different approach for our first baby, right, our son. By the time we got to the second one, four and a half years younger than our brother, we were a little more relaxed about things. We learned not to panic. We learned to do some of the things you're talking about today, but generally speaking, when should we call or go?

Dustin Monroe, MD: Everybody wants to know how to triage. Because, especially as a first time parent, you're nervous about everything. And you just want to know, what do I do to prevent something terrible happening to my child? The most important thing we can learn is how does our child appear?

How do they look? Are they eating? Are they drinking? Are they peeing? Are they using the bathroom? If they do have a fever and you give them a fever reducer, are they perking up? Are they hydrated? How frequently are drinking, you know, are we giving small amounts more frequently.

 How many days have you been at it? Are there other symptoms going on? Cough, cold symptoms? Have they been exposed to anything? I think certainly you need somebody to talk to, especially as a first time parent, and you might seek more medical advice as a first time parent, just so that you can get your bearings straight, to know whether or not how you feel your child looks is consistent with how a medical professional would view your child as well.

And that's learning, and that's education. That's what we're good for, is to provide reassurance. I don't think anyone should ever feel like they're going to see their pediatrician or healthcare provider, and, you know, maybe they're not walking away with a prescription or something in their hand that can make their child better, except for some of these advice things.

But I think sometimes the most important thing you get is reassurance. And to say you're doing the right thing and you're treating this the right way and we expect it to last another day or two days or three days. But if it goes beyond that, this is what we want you to do and this is what we want you to come back.

So it's okay to do that and it's okay to treat the fever before you go see the pediatrician too. I mean, we'll believe you if you come and you already gave Tylenol and the fever's gone by the time we see you. You can just tell us that, that the fever was there. It's okay to treat it. Because we want to have a discussion about what's the safe thing to do and what's the right thing to do for them and make sure they don't have infections that require some specific treatment.

So, and as you get more seasoned, I think parents don't come in as frequently for everything because they get some knowledge and experience. So, I think it's okay to always seek attention and it's okay that you don't walk away with a very specific treatment. But you should always walk away with some reassurance, some education, some learning, some empowerment to know that you're on the right track, or we need to take a different course.

Host: Yeah. I think a lot of parents worry that fevers are going to cause seizures. Can fevers cause seizures? Which kind of seizures can they cause? How bad are they? All that stuff.

Dustin Monroe, MD: Yeah, definitely they can, call it a febrile seizure. It's actually, it can be scary to look at, but it's actually a very normal phenomenon. Because children's brains are developing and if temperature reaches high enough, fast enough, it can lower the threshold where somebody can have a seizure. It's a generalized seizure, they lose consciousness, they may have shaking episodes with it, and when you check the temperatures, it can be very high, 103, 104, 105, sometimes. I've had kids with 106.9, and they can have a seizure for it. The recommendation for that is we provide supportive care, we recognize and evaluate them to see if they're normally developed children, if it was because of the fever, and then we provide reassurance. And there may be benefit to providing a single agent like acetaminophen for the next 24 hours after a seizure happened with fever.

Like, around the clock, every four hours, give acetaminophen for the next 24 hours. That can reduce the incidence of a second seizure with fever. But it doesn't mean that a child might be predisposed to epilepsy, or having recurrent seizures. They're still in the same risk as the general population for developing epilepsy.

And so we don't have to treat those with medications. Meaning, they don't need daily medicines to suppress the body's ability to have seizures, we just treat the fever at that point. Now parents all the time worry that if there's fever it's going to suddenly spike high enough where you're going to have a seizure and so we need to aggressively treat the fever.

I don't think it's actually possible to probably prevent it from happening because I think the temperature change is so fast. I do think that if the child is, you know, sick and ill looking, it's okay to treat it. But to feel like you're going to be able to prevent it, I think is, is not the right strategy.

I think recognizing it and seeking treatment and getting reassurance that it's seizure due to fever, and then doing fever treatment for the next 24 hours is going to be helpful. And we provide a lot of education and reassurance when they come into the hospital after one of these episodes. And it's important to get that kind of feedback and discussion about what to expect, because it could happen again.

You know, if you're under six and you had a febrile seizure, you could have another one with a subsequent fever, and that doesn't mean that that's a bad thing. That just is part of the process of growing and developing and having our brains develop, but we can handle it differently the next time it comes around. But it can be a scary thing. It's not so common that I think everyone needs to walk around worried about it, but we do recognize it and we want people to feel like we can talk about it and have these sort of strategies after we see these episodes of how to keep them from happening again within a short period of time.

Host: Right. Want to give you a chance here at the end. I think we've covered this, but let's go back over this again. When should a parent worry about a fever?

Dustin Monroe, MD: So I would be worried anytime the fever is persistent beyond a few days, if there are symptoms that accompany the fever that are worrisome. So children becoming dehydrated, if breathing becomes labored, or their activity level doesn't perk up with fever treatment, you know, where they're laying there, they're tired, they're less active, labored breathing; these things I would be concerned about and want to have a good evaluation and assessment to decide if any additional things are needed to be done, either testing or treatments.

I would also be concerned if, you know, with five days of fever and unusual rashes, things like that would be something that needs more intervention. You know, we look at are they ear pulling? Are they complaining of sore throat at certain ages. These things we can do tests to provide treatments that might help the condition that's causing the fever get better so that the fever will resolve with adequate treatment.

That's what I think medical professionals try to do is make assessments. Is it okay to provide supportive treatments? Do we need to do prescriptions? Do we need to decide that the patient needs to go into the hospital for IVs or oxygen? Things that you can't do at home. And I think well appearing kids that perk up with fever treatment can be watched for a while at home.

And if they manifest any of those things, I would, you know, go to the pediatrician or if it's more urgent to come down to like we have here at the Valley Hospital, we have a pediatric emergency room that's well equipped to make those assessments and help families triage in the middle of the night, early in the morning, middle of the day.

I think they do a really good job down there of helping families recognize, you know, what's going on and how can we treat it. We went through years of education to understand these things. And, I always say parenting is hardest job that you have for which you receive the least amount of education and training.

And we really are not trained to be able to understand everything that's going on with our kids. I have three kids of my own and I don't always have the answer to everything, but it's about observing and, you know, worrying and doing assessments, providing an intervention and seeing if those interventions make improvements or not.

And then we can take the next level and see our pediatrician or come down to the hospital for more urgent things. So that we can make sure that the kids are on the right path for improvement. We're always happy to help in any way.

Host: Yeah. That's perfect. I mean, as you said earlier, over time, we parents, we begin to develop some seasoning and some understanding and maybe we're better with the second one but we don't know everything. We don't receive much training. We don't know everything. It's why we have, great experts like yourself, pediatricians, hospitals, all that good stuff. So thank you so much for your time today. You stay well.

Dustin Monroe, MD: Thank you.

Host: And for more information about Children's Health at Valley, please visit valleyhealth.com/children'shealth.

And if you found this podcast helpful, please share on your socials and check out our entire podcast library for topics of interest to you. And thanks for listening to Conversations Like No Other presented by Valley Health System in Ridgewood, New Jersey. For more information on today's topic or to be connected with today's guest, please call 201-291-6090 or email valleypodcast@valleyhealth.com. I'm Scott Webb. Stay well.