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Wednesday, August 20, 2008

Post #10 The Changing Landscape of Fever

Fever today is not the same fever of 30 years ago.

What does this mean?

To begin with, one must understand that fever itself (for the most part) is not dangerous. Fever, defined as 100.4 degrees Farenheit or higher, is not a disease in and of itself; rather it is a symptom or a sign of an underlying disease. Viewing fever as a disease will lead to accepting common misconceptions and evoke unneccessary anxiety.

Several times a week in my office I see children with a fever reaching 104-105 degrees who recover without incident. Studies have indicated that fever itself is not worrisome until a child reaches 107 or higher. Fortunately, fever greater than 107 will usually occur only in a child with an underlying neurological deficit or, very rarely, an environmental heatstroke (e.g. being locked in a car inadvertently in the middle of a Houston summer).

When your child has a fever, his body is telling you that he is sick (or sometimes overheated by external causes). In the majority of cases, a fever indicates that your child has become infected with a germ. There are other causes of fever as well. For example, after your child has received immunizations, he may exhibit a non-worrisome fever for a day or two. In this case the body is reacting to either dead or weakened germs or germ fragments that have been purposefully introduced to create beneficial lasting immunity.

Most parental anxiety with fever revolves around the fear that there may be potential harm to the child as a result of the fever. Specifically, the parent is often worried about damage to the brain.

In truth, fever will rarely damage or hurt the child (as mentioned above), although the underlying germ causing the fever potentially could. Which is why as a pediatrician, I am seldom concerned about the fever itself; I am always far more concerned about the source of the fever. My job as a pediatrician, when presented with a febrile child, is to deduce the source of the fever and then to decide whether the source is of concern or not (and it most often is not).

If the fever is coming from a brain infection, pneumonia or kidney infection, I am very worried about the child because all of these infections are quite serious and potentially life-threatening if not treated properly. However, if the fever is coming from a cold virus or stomach virus (which is far more likely, statistically), I am not worried about the child because most of these infections resolve on their own with time and pose little to no threat to the well-being of a child.

Which brings me back to my opening statement: fever today is not the same fever of 30 years ago.

The reason is simple: vaccines. The current gamut of immunizations, while currently controversial (although the tide is finally shifting - thank goodness), are perhaps the greatest advancement of modern medicine in the past century. The vaccinations we currently administer confer protection against the deadly germs which our parents' generation grew up with. Germs which cause meningitis, diphtheria, tetanus, pneumonia, measles, whooping cough, epiglottitis . . . and the list goes on and on.

In present day, when a child who follows the recommended vaccine schedule presents to me with fever, there are many germs that I can automatically factor out while making my diagnosis. As a result of immunizations, I already know what a child CANNOT possibly have as the source of the fever. As a result, I can focus on a much more narrow list of the usual suspects as I begin my detective work.

Imagine playing the game Clue, knowing that Professor Plum, Colonel Mustard and Mrs. Peacock are already behind bars. It just makes the game that much easier (although not as easy as peeking in the envelope like my brother often did). Likewise, if I can evaluate a fever already knowing that measles, mumps and diptheria are out of the running, it makes my job a lot easier. Which is why as a pediatrician I have a leg up on my father, who had to do the same job without the benefits of many of the newer vaccines.

Of course, as antibiotic resistance is on the rise, the landscape of our usual suspects is beginning to change once again, hence the vital need for judicious use of antibiotics (but that is a topic for a separate blog). Nonetheless, fever today represents a far more limited field of possible dangerous causes than the fever of 30 years ago. That is why I sympathize when a grandmother is still apprehensive of her grandchild's fever. She lived through the years of measles, mumps and diphtheria. Many of them remember what a fever could represent in their days and understandably harbor anxiety about their grandchild's temperature.

But as a new generation grows up with a legion of vaccinated and protected children (for the most part), there will hopefully be a societal shift in the right direction concerning the fear of fever.

Let me conclude by noting that fever can still and sometimes does represent meningitis, pneumonia or a dangerous infection. As far as vaccines have advanced, there is still more work to be done. So when a child with a fever is acting sick (i.e. not playing, not eating, appears ill, doesn't smile, lacks energy) he or she must be evaluated by a doctor.

However, over time, with the proper communciation between a well-informed pediatrician and an attentive mother, a parent can begin to grasp when to be worried and when not to be worried. This maternal instinct can be honed over time if a mom is equipped with the right information and the proper guidance from her pediatrician.

I am proud to say that in my practice I now have many veteran mothers who don't come in for every fever (although they initially may have), but only when there is an accompanying noticeable change in the activity level of her child. I could write oodles of blogs to delineate this skill, but there is a level of understanding that can only come from repeated communication and hands-on experience.

The end result is a family that has a far lower level of anxiety about fever and a far higher understanding of what fever truly is and represents. It is a benefit to the parent and to the pediatrician alike. It saves the mom unneccesary trips to my office, copay money and frustration while it frees up my appointment slots for the kids who truly need to be seen.

There are many aspects of fever I did not cover in this blog, but hopefully this can serve as a primer in building a firmer knowledge base for the anxious parent who wants to learn more!


Miranda Heart said...

Great advice, thanks!!

I have a quick question for you. My daughter has issues with allergies leading to colds leading to problems with asthma. This usually starts after the beginning of the new year, although could pop up at any time. When would be the best time to put her on allergy meds to lower her risks?

Any help would be great, thanks.

Kathy - Maia's mom.

Peter Jung said...

Mrs. Miranda,

Allergy season tends to occur Spring and Fall. For some children just one season, others both. I would pay close attention to when Maia has issues and follow the pollen count. As the pollen count starts to gear up or she begins to display symptoms of her allergies, I would begin her medications. Even with tight control of her allergies, she will likely need preventive asthma medications if she has had recent issues with wheezing (inhaled corticosteroids). Hope that helps!

GREG said...

Hey Peter,
I was wondering whether you and your family is safe from Hurricane Ike. It must be very tough down there. Hope everything is going as smooth as they can.

Miranda Heart said...

Is this something we should be concerned about? My husband loves msn's home page and sends me health articles pretty often. He foudn this and sent it to me.

Peter Jung said...

Mrs. Miranda,

I don't know much about the "chlorine asthma risk" per say, but the concept certainly seems valid. Any irritant which is perpetually inhaled can lead to increased remodeling of the lung and hence lead to increased problems with asthma. Should this deter you from taking your child swimming. . . I think that is a family decision. However, although I might agree there are some mild asthma risks from the chlorine, I plan on letting my kids swim on a regular basis. Everything in medicine is about weighing risk/benefits, and to me the benefits of swimming (exercise, family time, learning how to swim, cooling off) outweigh the risks posed by chlorine! As for having a pool in the backyard, I'd rather not clean one. This certainly gives more weight to having a saltwater pool, but there could be undiscovered risks there as well.

Hope that helps!

Dr. Jung

mrscoop said...

My only worry is that my daughter seems to be getting a fever a month. Sometimes every two week. I keep being told it's probably a virus, but isn't that too often for fever?

Peter Jung said...

Mrs. Coop, it is typical for young children to get 6-12 viruses a year. Not every virus will come with fever, but many will. A viral infection (with fever) every month for several months in a row is not that unusual. If your child recovers quickly and overall the activity level and playfulness are normal (especially when the fever comes down with fever reducers) I think you have very little to worry about! Sounds like you probably have a judicious pediatrician who is careful about antibiotic use. :)

Anonymous said...

Being a parent to a child with PFAPA (a periodic fever syndrome) I think it would be useful for you to mention the line of PFS's as a possible periodic fever reason, especially if the fevers come regularly and without the other typical virus symptoms. Thank you! I hope you don't mind me puting a link here, it is a great source for current and updated research on PFAPA.