Cooked: The Risk of Fever
The text version of the podcast episode.
[00:00:42] [Music: Hot Child in the City by Nick Gilder]
Ed Les [00:01:14] That hit song by Nick Gilder is a blast from the past, released almost 25 years ago. But it's a good introduction to this first official episode of Cloudy with a Risk of Children, where we discuss the hot topic of fever in kids. The opening line of the song is a pretty good summary, I think, of how many parents feel about fever: Danger, in the shape of something wild.
Don't worry, I won't sing it: that would kill this podcast deader than a doornail before we have a chance to get rolling. But today we're going to look at why kids make a fever. Is it ever dangerous? Why should parents worry or should they ever worry? I'm Dr. Edward Les, and I'm joined by my colleague and co-host, Dr. Phil Ukrainetz. Welcome, Phil.
Phil Ukrainetz [00:01:50] Morning, Ed. Glad to be here. Looking forward to being able to reassure parents about fever.
Ed Les [00:01:55] Let's kick things off by listening to a clip from a press conference delivered by Premier Danielle Smith, the leader of our province, Alberta, in which she announces the procurement of a supply of Advil and Tylenol and in which she makes some comments around the issue of fever in children.
Premier Danielle Smith [00:02:12] What people need to know is that when their child gets sick, that they have the medication available to them so that they can treat the symptoms at home. Fever is scary for parents. If a child becomes feverish and dehydrated — I was talking to the pharmacist here — it can lead to seizures in the younger children. This is really serious if they can't get acetaminophen to bring the fever down. And that is why we want to make sure parents have access to the medication that they need because if they can't break the fever, they end up in the hospital rooms. And that is what's causing the pressure on our hospitals, not only here but across the entire country.
Ed Les [00:02:48] So a lot to unpack there. The Premier is certainly correct that for many parents fever is scary. It certainly drives a lot of traffic to our emergency department.
Phil Ukrainetz [00:02:58] Yes, Ed. I would say that three quarters of our patient presentations are fever related.
Ed Les [00:03:03] I do take some issue with the Premier's comments, however, and to be clear, I'm not taking potshots at her. She's a member of the public after all: she's not a doctor.
But it's where she says, "This is really serious if they can't get the fever down." I think she said, "If they can't break the fever, they end up in the hospital room." So there are some myths and misunderstandings, misconceptions to unpack here. And these are the sorts of things that we want to talk about today on this show.
So before we get to that, a quick comment about Celsius versus Fahrenheit. Our American audience is, of course, familiar with Fahrenheit. But many of our Canadian parents still measure temperature in Fahrenheit, too.
So just to be clear, we generally regard a fever as anything over 38 degrees Celsius, which is 100.4 degrees Fahrenheit. Forty degrees Celsius is 104 degrees Fahrenheit. And quite a high fever at 42 degrees Celsius would be approximately 107.6 degrees Fahrenheit, which I guess is not approximate — that's pretty exact. So that aside, I think it's fair to say that in general, parents find the concept of fever overall pretty scary. It's also fair to say that fever doesn't scare us.
Phil Ukrainetz [00:04:23] Absolutely.
Ed Les [00:04:24] But it used to. In fact, you'll remember Doctor William Osler — for our listeners, he is widely regarded to be the father of modern medicine. He had this to say, the esteemed doctor Osler, about 125 years ago:
"Humanity has but three great enemies: fever, famine, and war. Of these, by far the greatest, by far the most terrible is fever."
And this is from one of the giants of medicine, revered in his day as the consummate physician. So the question is, was he right?
It's important to remember that Dr. Osler practiced medicine before the role of microbes and disease was fully understood. Back in his day it wasn't really understood that bacteria and viruses were the cause of untimely demise, and so fever was often blamed.
But now we know that fever is, in fact, one of the key soldiers deployed by our immune system in the battle against infection.
Phil Ukrainetz [00:05:21] Agreed. In a very different time and very different exposure to both bacterial agents, lack of vaccinations, lack of hygiene, sanitation, the things that have markedly changed all approaches to fever and infection now. Fever was a symptom, but was not the diagnosis.
Ed Les [00:05:42] Yeah, right. But yet that notion that fever is something to worry about is deeply embedded and that's why so many parents come to see us.
So I sat last week with Dr. Otto Vanderkooi-- you know Dr. Vanderkooi?
Phil Ukrainetz [00:05:55] I know him well.
Ed Les [00:05:56] He's also a colleague of myself and Phil, but he's a pediatric infectious disease doctor at Alberta Children's Hospital. In fact, he's the chief of infectious disease and he's been plying his trade for more than 20 years, I think.
Welcome to the podcast, Dr. Vanderkooi: Let me start off by asking you how you approach parents who come to you with questions and anxiety around fever in their children.
Dr. Vanderkooi [00:06:29] So I start with normalizing the idea of fever. The perception that fever is a bad thing and is something to be avoided at all costs I think is the biggest hurdle we face each day. Fever is a natural response to infection.
Ed Les [00:06:45] So, Phil, you and I will of course say exactly the same sort of thing to parents, but one of the things we'll often get in return is, "Yes, but." And what I mean by "Yes, but" is that the parents will say this, or some version of it: "Yes, but the fever is too high."
Phil Ukrainetz [00:07:01] Right. I see it all the time. How high is too high?
Ed Les [00:07:05] I pitched that exact question to Dr. Vanderkooi. Here's what he had to say:
Dr. Vanderkooi [00:07:10] You asked the question, "Is there a fever that is too high in relation to infections?" And really, the answer to that question is no. Because the very rare fevers that really allow the fever to be a cause of problems are not caused by infection. Those are very rare circumstances where the body's ability to regulate their temperature has fallen apart. And then fevers above 42 are ones that we would consider a medical emergency.
Ed Les [00:07:37] You're talking about the kids who are, like, left in a hot car in Florida while the parents are in the casino gambling, and they come back and their kid is “cooked”?
Dr. Vanderkooi [00:07:43] Exactly. We've overwhelmed the body's regular thermostat from doing its job properly. That does not happen in an infection.
Ed Les [00:07:52] So that's environmental. And as you and I both know, there are some medications that can do that. For example, there's an anesthetic agent that can give you something called malignant hypothermia because your body's temperature goes too high. There's some drugs that you can take, overdose on, that can make your temperature go that high. But what I'm hearing you say is essentially, over 42 is possibly injurious to your body.
Dr. Vanderkooi [00:08:15] Possibly.
Ed Les [00:08:16] But parents worry. What we hear all the time, the most common narrative is, fever is harmful to my child's brain. So, under 42 degrees, no risk to the brain, essentially.
Dr. Vanderkooi [00:08:30] Essentially. And I think that is the most important take home message. It is a signal. It's like a traffic light. Less than 38, you're in the green zone. You're good to go. It's normal.
That orange zone says I'm fighting something. The amber light has come on; you're between 38 and 39 and a half, yeah, you're probably fighting some sort of an infection. By far the most common is that common viral infection which may have any number of names that we can attach to that because there's hundreds of viruses that can do that to us.
And then we hit the red light, yes, you should pay attention to me. I'm fighting something significant over 39 and a half.
Ed Les [00:09:09] I really like that analogy that Dr. Vanderkooi uses with the green light, orange light, red light approach to when you should be more concerned about fever. Really framing what the fever suggests, rather than focusing on the number itself.
Phil Ukrainetz [00:09:30] And I also like — and I don't know if you agree with this Ed — because parents will say to me, "Why does my child look worse when they're 40 than when they're 38.5 if fever is just fever?" And I would say to them that the higher the fever, often the child is trying to deal with more heat. They will look worse, but that doesn't mean they are worse. And that would become where we would use an analgesic like Tylenol or Advil to try and break the fever and see what the child looks like underlying that.
Ed Les [00:09:59] What you mean by analgesic, of course, Phil, is these medicines that we commonly known as Tylenol and Advil, painkillers, or analgesics in our language. And we'll get to quite a bit more discussion around the uses of Tylenol and Advil a bit later in this podcast. But first, I want to share something else that Dr. Vanderkooi mentioned in our interview together, where he offered his perspective, not just a doctor, but as a dad of kids himself, kids who periodically get sick and periodically have fever. Have a listen:
Dr. Vanderkooi [00:10:32] In my professional world, some of these things are very normal. I don't get excited. You'll hardly see me stressed at work. But in similar circumstances, my child, at one point while on vacation, had a fever of over 39 and a half for three days at eighteen months of age. And I'm an infectious disease specialist, a pediatrician, and a dad. Well, the dad response was far stronger than any of the others.
Phil Ukrainetz [00:10:55] So I have to say about being a father and being a doctor, pertinent to Dr. Vanderkooi's point, for Ed and I both with four kids each, we've watched our kids with fever. We've walked a mile in our parents’ shoes. We know that it's stressful and it's hard to also be a doctor and a father. You lose objectivity. I think the key thing we put our hats back on to say, "What would we do with our patients? What would we tell our patients and their parents and reassure them that fever isn't dangerous?"
Ed Les [00:11:23] Right. And I think it's really perfectly understandable in the modern milieu where parents have this embedded notion of fever being possibly dangerous and being able to consult Dr. Google for information that sometimes isn't really accurate information. It's understandable that we see the traffic that we do. One of the lines that I'll use with my residents at work — and you might do the same Phil — where it can seem like we’re inundated with kids with fever — I remind my residents that just because something might not seem like an emergency to us, for sure it seems like an emergency to parents. And we have to always respect that.
Phil Ukrainetz [00:12:09] And an add-on question often with parents is, "But what about seizures related to fever?"
Ed Les [00:12:16] I think few things are more frightening to parents than when your child is having a seizure. And absolutely true that for a small minority of children, small children, seizures in the context of fever is a thing. And so that's something we should talk about. And in fact, it's one of the questions I put directly to Dr. Vanderkooi last week:
Dr. Vanderkooi [00:12:37] So a febrile seizure — also talked about as a fever convulsion, is an uncommon response in about 2% of children, where with a fever they have a seizure: a seizure being an episode where they may shake. They may temporarily not be aware of their surroundings. We use the word losing consciousness. We may even see some body stiffness or eye rolling back.
And these symptoms can be very, very alarming to parents. But if they last less than 5 minutes — again, we in the medical world, you come in and the families are very excited and stressed out, but we look at them like no big deal. It's fine. And what we're seeing there is 2 to 5% of kids who may have one febrile seizure at some point in their life. It is related to how quickly the brain warms up. It is not causing damage. As that fever comes up, the body is going, wow, that's a really rapid change in how I'm used to functioning: I'm going to respond to that.
Ed Les [00:13:42] So just to emphasize Dr. Vanderkooi's comment, basically, seizures happen when the temperature in your child goes from being normal rapidly to becoming abnormal.
Phil Ukrainetz [00:13:53] And it's unique to the pediatric young brain that it doesn't weather the storm of that temperature change the way an adult brain would.
Ed Les [00:14:03] Or maybe a better way to say it is they respond differently than adults do. Their brain actually does weather the storm okay, in the sense that there isn't any harm or injury to your child. But certainly, adults don't respond to fever with a seizure response; whereas, a significant portion, up to 5% of small kids between the ages of six months and five years, do respond in that way.
And so, you and I, Phil, spend quite a bit of time on some of our shifts reassuring parents around febrile seizures. But I thought I would put the question to Dr. Vanderkooi, as to what his approach is to worried parents in this context.
Dr. Vanderkooi [00:14:42] Between six months and five years is where this phenomenon is the most common. And certainly, we would recommend that any child who has a seizure in the context of fever, there is no need to panic. If it goes on for more than 5 minutes, it is worth calling emergency medical services. If it's less than 5 minutes, once a seizure subsides, you should still seek medical care.
Ed Les [00:15:08] So to bottom line it around these types of seizures, take home message really is don't panic. These are fairly common. They don't cause harm. They should always be checked.
But one of the questions I get from parents is, "These are frightening and I hear what you're saying, but ideally, I'd love to prevent them." And so, the question that I get-- I don't know about you Phil. I'm sure you do, too — is can I give Tylenol, Advil to prevent seizure?
Phil Ukrainetz [00:15:34] Yeah. And I try and really reinforce to parents that they are setting themselves up for failure. You can't prevent a febrile seizure. You can't give enough medication early enough. You'd have to be anticipating the fever. It's not helpful. And back to the key point, febrile seizures do not hurt children.
Ed Les [00:15:51] So really the only way in which you could theoretically at least prevent a seizure from happening in the context of fever is if you were giving your children regular Tylenol and Advil when they don't have a fever, almost as a fever preventative, which of course is not a logical thing to do.
Phil Ukrainetz [00:16:09] Agreed. And the risk of harm from the medication is higher than the risk of harm from a febrile seizure.
Ed Les [00:16:15] Right. So that's a good segue to the whole topic of Tylenol and Advil and Motrin (acetaminophen and ibuprofen) and when they should be used. Again, here's Dr. Vanderkooi:
Dr. Vanderkooi [00:16:29] Only use Tylenol if the fever and the symptoms are causing discomfort to the child.
Ed Les [00:16:35] Right. So, treat the child but not the fever, is kind of what your message is.
Dr. Vanderkooi [00:16:38] Correct. Don't worry about the number. Look at your child. If they're playing happily and they've just got snot running down their face and they've got a low-grade fever, leave them be.
Ed Les [00:16:46] But, of course, parents use Tylenol and Advil all the time. And I wonder sometimes when parents come to our emergency department and come to the triage desk, their child's often sick with fever, our triage nurses — who are supremely skilled and just excellent — often reach for Tylenol and Advil and medicate those kids who are crying and irritable when they first show up in the emergency department. And I wonder sometimes whether parents derive the wrong idea from that, despite the best efforts of our nurses.
Phil Ukrainetz [00:17:16] Right. And I guess what I would hope, not to let a teachable moment to a parent go by, would be that the nurse would say, and they probably do this more than we think, "I'm giving this because your child's uncomfortable. Your child looks maybe listless or a bit fussy and they're uncomfortable. So, I'm going to treat their pain and discomfort and that's also going to help." So, you see how the child looks once the fever is broken and helps so that the physicians looking at the child post pain medication.
Ed Les [00:17:48] Right. So, I put this question to Dr. Vanderkooi. Is it critical that we use these medications when our kids are sick?
Dr. Vanderkooi [00:17:55] No. I know at my house trying to sometimes find the Advil or Tylenol is the challenge. The adults like their Advil after sports. But the kids in general, if it's a low-grade fever — yeah, they felt warm, put them to bed and rest them. We don't run for it because it makes no difference.
Ed Les [00:18:16] It makes no different to their recovery from illness?
Dr. Vanderkooi [00:18:20] Correct. Their recovery from illness is neither shortened or lengthened.
Ed Les [00:18:24] So Dr. Vanderkooi, if we are using Tylenol and Advil, kind of by the logic we’re spooling out here, does that actually then get in the way of the immune response, if we don't allow the fever to do its work?
Dr. Vanderkooi [00:18:39] That has been a worry on and off in both infection studies as well as in vaccine or immunization studies. And to date, if you look at the vast majority of all of the data that we can get our hands on, there is no effect on the course of an infectious illness or, like I said, the immune response or the protection you get from a vaccine, whether or not you use medication such as Advil and Tylenol in response to fever.
Ed Les [00:19:09] Right. So just to be crystal clear, it's perfectly okay to use Tylenol and Advil intermittently when your kids are sick to make them more comfortable. You don't need to worry that you're interfering with the immune response. Is that right?
Dr. Vanderkooi [00:19:22] That's 100% correct.
Ed Les [00:19:24] One of the things that's confusing for parents — we field a lot of questions around this — is around dosing. And it's confusing, unfortunately, because the medications that are available for babies and for children have different concentrations. So, for example, babies will have a liquid medication, Tylenol that has a certain concentration. And I don't expect our listeners to internalize these numbers, but just for illustration, it will be 80 milligrams in one mL. So, 80 milligrams/mL; whereas, the children's version of liquid Tylenol is a different concentration entirely, which is — and again, don't internalize this — 160 milligrams per five mLs. And so, the dosing for parents can be pretty confusing.
Phil Ukrainetz [00:20:12] Never mind for U.S. listeners that five mLs is a teaspoon and one mL is one-fifth of a teaspoon. And then you're converting the milligrams. It's confusing.
Ed Les [00:20:24] And so Dr. Vanderkooi also shared some comments with regard to dosing for simplicity's sake for parents, just to take the worry out of it with regard to the different concentrations, because it can be quite confusing for parents.
Dr. Vanderkooi [00:20:38] If you have any concerns about what the intermittent and appropriate amounts are, pay close attention to the label or talk to your pharmacist or doctor about how should I use this medication? Because just like anything else in the medical world, too much can cause problems in and of itself. So, making sure you do it right, because more is not necessarily going to give you more benefit, but it may actually cause you harm.
Ed Les [00:21:06] So that's an important point; right Phil? That is that when your kids are sick, don't get too carried away with the Tylenol and the Advil.
Phil Ukrainetz [00:21:13] Remember, they're comfort measures. They're supportive measures. They make you feel better. They don't change the course of the disease.
Ed Les [00:21:20] Right. One of the things I've said to parents over the years is that no child has ever been harmed by a fever. But believe me when I tell you that there have been people and kids harmed by too much Tylenol or too much Advil.
Phil Ukrainetz [00:21:35] Absolutely.
Ed Les [00:21:36] Now, another question that comes from parents often is whether or not they can use their own Advil and Tylenol for their children, given the shortages that we've all been experiencing.
Again, I consulted Dr. Vanderkooi: Is there a difference between kids’ Advil and Tylenol? While we're talking about this topic, if you're going to use it, is there something unique about kids’ Tylenol as opposed to adult Tylenol? Is it a different drug?
Dr. Vanderkooi [00:22:00] They're identical in terms of the effect of medication that's in them. In children, we have created products that might be in a liquid format so it's easier for young children to take. It might be in a chewable format so it tastes better and the kid can chew on it. But at the end of the day, Tylenol, the generic name acetaminophen, is what is the effect of compound in all three of those formulations or style of medication.
Ed Les [00:22:29] So whether it's children's liquid or children's chewable tablets or adults, the pill that you swallow, Tylenol is Tylenol. Acetaminophen, acetaminophen, acetaminophen, right?
Dr. Vanderkooi [00:22:38] Correct.
Ed Les [00:22:39] And the same thing is true for Advil or ibuprofen.
Dr. Vanderkooi [00:22:42] A hundred percent. Correct.
Ed Les [00:22:43] So really the same medicine, Phil, but worth emphasizing to parents to be careful of the dosing, because clearly the strength and the concentration of the adult medications are different than what we see in the kids’ medicines, which in general are easier to administer to the small kids because they taste good and they're easy to swallow if they're liquid and easier to swallow if they're chewable tablet.
There's been a move lately because of the recent shortage for pharmacies to compound the adult medications into more palatable forms for kids. And so that's certainly one option for parents.
Another one of the things I'll share, just to drive home the importance of fever and so that I can help parents kind of climb off the ledge with regard to trying to exterminate the fever when they see it… I'll say there's two periods of life when fever doesn't reliably come to our aid. So, when you're a newborn, for sure in the first month of life — when the biological machinery, so to speak, it's bright and shiny but it's just getting up to speed — those really small babies they don't reliably make a fever when they get an infection.
Phil Ukrainetz [00:24:09] And I like to keep it simple for parents and I say under three months. Let's just take that whole super-young category of children. That's a good time to get your child looked at sooner than later.
Ed Les [00:24:20] Absolutely. Because related to what I just said, when those really young kids get an infection, they are more at risk. They're a bit more vulnerable than children over three months, certainly than older children, than adults.
And then the other time in life when fever doesn't come along and help us fight off infection, that's at the other end when you're old and your biological machinery is older and getting rusty and the wheels are coming off. And then you'll be like an 82-year-old man with pneumonia, a bacterial infection in your lung, and you don't make a fever. It's one of the reasons why they get so sick: they get something called sepsis, and they can actually die from that.
So, I use those examples just to drive home the importance of fever as an aid to helping us getting better.
Phil Ukrainetz [00:25:14] Agreed. And on that note, with children and adults, I'll often say — because you have parents present with a child with a fever, parents are very worried about the child — and I'll say to them: Incredibly you can treat this fever that your child has similar to how you treat it as if you had a fever as an adult. So, if you had a low-grade fever but didn't feel that bad, you might just lay down and relax. If your fever got high enough, you're starting to feel uncomfortable, you would go take Advil, Tylenol to help relieve your symptoms. You can treat your child the same way you would treat yourself. They are not different species.
Ed Les [00:25:52] Right. And related to that you will know — from your own experience and I know from my own experience with my man colds — that no matter how much Advil and Tylenol you take, you can't erase all of your discomfort. And the same thing applies to our kids. Advil and Tylenol are designed to provide relief from discomfort, but you can't relieve all of their miserableness — and nor should you try.
There's a well-known children's book called Going on a Bear Hunt that I sometimes use as analogy or metaphor for parents when I'm talking to them about their children's illness. As many of our listeners are aware, the basic story plot is some kids go hunting for a bear and encounter all kinds of obstacles; whereupon, they conclude that they can't go over the obstacles, can't go under, but they simply have to go through them and so then they proceed. And I think that's a pretty good analogy for what is the case with most child illness in the sense that you can't go over it, you can't go under it, you simply have to go through it. There's some discomfort involved, but for the most part, thankfully, most of our kids pull through just fine.
[00:27:13] So, Phil, we've powered through a lot of stuff today. I think maybe at this juncture we'll hammer home some take-home points. Given the title of this podcast, perhaps we'll call them “Rays of Sunshine”. But in any case, let me just hit some bullet points: take-home, these key messages:
[00:27:34] First of all, no child has ever been harmed by a fever.
Secondly, fever doesn't cause brain damage or any other injury to the body.
Third, there's no such thing as a fever that is too high.
Fourth, fever is a healthy response to infection. Fever is your friend not your fault.
Fifth, fever seizures or febrile seizures, while they're scary, they're benign, meaning they're not harmful. But absolutely when they happen, your child should always be seen by a doctor.
Sixth, it's perfectly okay to give Tylenol or Advil, acetaminophen or ibuprofen, to your kids when they're sick to make them comfortable. But treat the child, not the fever. Pay attention to fever as parents. You want to know within a day or two why they have a fever. And you also want to know in a reasonable amount of time that the fever is going to go away. We usually say about four or five days.
Seventh, just to be clear with regard to the littlest ones — so kids under three months — if they have a fever, those are a higher risk group and in general it's good advice to seek the attention and the advice of a medical professional.
And finally, the last point, I would say just common-sense things: We should use the very good tools we have at our disposal — get your children vaccinated and teach them how to wash their hands.
Phil Ukrainetz [00:28:57] Interesting, Ed. The final point you have there, I have to say, is the primary difference between what the father of modern-day medicine, William Osler, that case we gave where he said fever was the biggest threat to mankind, and the difference we have now-- and I completely agree with you-- are get vaccinated, wash your hands, which is sanitation and hygiene-- all simple things that all of us can do. Stay at home when you're sick, which is common sense. Don't share your secretions. So, in our case, our kids’ hockey, soccer, water bottles. And then I'd say a final point, in a small proportion of the cases, is the gift of antibiotics, that modern day medicine has found antibiotics to be used strategically in the right situations.
Ed Les [00:29:44] Thanks, Phil. That's a great segue to our next episode where we discuss the so-called risk of antibiotics. As you and I both know full well, antibiotics have been an enormous blessing to humankind with regard to stamping out disease. But there are some downsides to how we've been using antibiotics in the modern era, and that's what we're going to tackle next time in an episode titled Drugged: The Risk of Antibiotics.
[00:30:21] Now, this is the point at which we would open our listener mailbag and respond to any feedback and suggestions that we've received. But given that this is our first official episode, we don't have anything in our mailbag yet. And so, if you have any feedback or criticism, feel free to send it to us at: feedback@riskofkids.com and we'll open that letter box on future shows and respond to feedback that we receive.
[00:30:51] A huge thank you to my co-host, Phil, for joining me today. And a big shout out to Dr. Otto Vanderkooi for his wisdom and his insights. We hope you'll join us for the next show. We'll sign off with another oldie but goodie, the unmatchable Peggy Lee. Take it away, Peggy.
[00:31:22] [Music: Fever by Peggy Lee]
Ed Les [00:31:35] Thank you for listening to Cloudy with a Risk of Children, hosted by emergency physicians Dr. Edward Les and Dr. Phil Ukrainetz.
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