“The fever does not go down” is the concatenation of five words that any pediatrician hears the most times during their professional practice. Considered in humans as the temperature of 38°C or more, it has always been the workhorse of children’s health. Also the headache of more and more mothers and fathers. Despite being a fundamental part of our defense system against infections, lowering fever is often considered the goal to beat, even by prescription. But that trend is changing. Today, most specialists in child health insist that fever should not be lowered at all costs (it is there to help), but rather treat the discomfort that it may cause in girls and boys.
“It is the most frequent reason for which they come to the emergency room,” says Paula Vazquez Lopez, president of the Spanish Society of Pediatric Emergencies (SEUP). “Fever doesn’t cause brain damage, or death, or anything. It is good that they have a fever because it is our body’s way of defending itself against viruses and bacteria,” adds this pediatric emergency specialist at the Gregorio Maranon Hospital in Madrid. “Even having it high, or that it doesn’t go down well, doesn’t mean that this infection is more or less important,” she explains to the parents. In fact, she continues, “I’ll give you the example of the flu: it’s a virus infection that causes a very high fever, lasts several days and is very difficult to bring down, but it’s not serious.”
According to Juan Carlos Molina, a pediatrician at the emergency department of the Nino Jesus Children’s Hospital, also in Madrid, “our parents and grandparents accepted fever more as something natural. But now there is “feverphobia, an undirected or meaningless fear,” says the specialist. “Parents often want to treat the thermometer, they are concerned about much more than the general condition. I tell them that the goal is for them to be well, that we give them antipyretics so that the child is more comfortable”.
Indeed, fever serves “to help us activate our body’s defenses”, as the Spanish Association of Primary Care Pediatrics (AEPap) explains on its website. By itself, this scientific society emphasizes, “it does not cause damage to neurons or of any other type and the complications, when there are any, are due to the cause of the fever, not to the fever itself.” His decalogue of fevera downloadable document aimed at families in Spanish, Catalan, Basque and Galician, agrees with the paediatricians consulted: “You only have to use medicines for fever if there is discomfort or pain.”
In addition, this decalogue clarifies that “neither the degree of fever nor the response to treatment guides us about the severity of the infection or whether it is caused by viruses or bacteria.” The AEPap insists on hydrating well and not covering or undressing the child too much, and advises against household measures such as “the use of damp cloths, alcohol scrubs, showers or baths. Treatment of fever does not modify the evolution of the infection. The important thing is the treatment of the infection that causes it, in the event that it has it ”, emphasize these experts.
“You have to change the chip that you have to lower it based on the number that the thermometer puts; you have to do it according to how the child is, ”says Vazquez Lopez. It is also not necessary to give medicines to prevent reactions to the vaccines, such as fever or inflammation in the area of the puncture. “I am many years old and before, every time we vaccinated, we said: in case you have a fever, give it to prevent Apiretal [paracetamol]. But it has been seen that it is not indicated”.
What is the ‘fire in the body’ worth?
Strictly, we consider fever or pyrexia (of pyros, fire in Greek) at a body temperature of 37.5°C or more, but values between 37°C and 38°C are usually called low-grade or tenths. Under normal conditions, the thermoregulatory center of the hypothalamus keeps us at between 35°C and 37°C, the ideal range to develop physiological functions. However, certain substances act as pyrogens: they stimulate this thermostat at the base of the brain to raise the temperature, which “decreases the reproduction of microbes and increases the inflammatory response”, as described on the Hospital Clinic de Barcelona website. “When there is a fever, the immune defenses and the mobility of the leukocytes improve, products that are more toxic to the bacteria are generated”, explains Molina.
Pyrogens can be exogenous substances (microbes and their toxins) or endogenous (molecules that our immune system uses to communicate, such as cytokines or prostaglandins). When leukocytes detect the pyrogens of a germ that infects us (which in children are usually viruses), they release cytokines into the blood that alert the biological thermostat to raise the temperature. This is achieved by increasing metabolism, reducing blood flow to the skin, which causes paleness and a feeling of cold, and producing muscle contractions, the classic shivering. Once the hypothalamic thermostat returns to the normal range, one feels hot and sweats to reduce the temperature, which explains the various symptoms of febrile syndrome.
The measurement should be made with an electronic contact thermometer, advises Molina. “Ear ones and infrared ones that you put on the forehead are not very reliable.” Although in older children the axillary measurement is sufficient, in children under one year it should be taken in the rectum. “The rectal temperature is between 0.5°C and 1°C higher than the axillary one, but closer to the real one”, observes this expert. This precision, he clarifies, is necessary in young infants, especially in children under three months, in whom the risk of serious infections increases and tests that are rarely done in older children with good general condition may be required.
And from when would it be a problem? As Molina explains, temperatures above 41°C or 42°C are more dangerous, especially if they are maintained. “But in these cases there is talk of hyperthermia and in children it is exceptional. It occurs due to high exposure to the sun, such as heat stroke, or poisoning from certain medications ”, settles the expert.
Unfounded fear of febrile seizures
“Another thing that scares mothers and fathers are seizures,” recalls Vazquez Lopez. Indeed, a small group of infants and young children (about 4%) have a genetic predisposition to seizure with fever. But lowering it early does not prevent it, insists the AEPAp. Although pediatric assessment is always recommended after a seizure in the context of fever, “do not insist on lowering it so that it does not happen,” reiterates the president of the SEUP. “In most cases you don’t have to do anything, they last a few seconds. They disappear with age because the brain matures and there is no need to take any medication to prevent them”, reassures the specialist.
“Not all children are going to have them, even if they have a very high fever,” says Molina. “There is a genetic predisposition, many times the parents have already had it. In this case, they understand it better.” As this pediatrician clarifies, “some end up being epilepsy when the children are older, but it is very rare, around 1 or 2%.” In any case, he adds, “it’s very difficult to avoid them, they don’t bother to give antipyretics or apply cold measures. There is no need to do any treatment different from that of a child who does not have febrile seizures.
The usual medications for children with fever and malaise are paracetamol, which is analgesic and antipyretic, and ibuprofen, which is also anti-inflammatory. They do not cure the infection, but they do help the child feel better. “When the febrile process is due to significant inflammation, such as acute otitis media or adenitis [una adenopatia muy inflamada], I prefer ibuprofen”, says Molina. “But for temperature control, both are the same.” As this specialist recalls, although the practice of alternating or combining them is widespread, there is no evidence that this is more effective, as stated in a review published in Evidence in Pediatrics.
“Many doctors indicate it [alternar antipireticos]but it has not been shown to be more effective in reversing fever and leads to errors, either due to overdosing or underdosing”
Juan Carlos Molina, emergency pediatrician
Furthermore, doing so increases the risk of dosing confusion and the risk of side effects. “Many doctors indicate it, but it has not been shown to be more effective in reversing fever and it leads to errors, either due to overdosing or underdosing. One must be given on schedule and the doses can be raised a little or the administration intervals shortened, but it is not appropriate to combine one and the other sequentially”. Vazquez Lopez tells the parents this way: “sometimes I tell them that, occasionally, they can give the other one, but the ibuprofen-paracetamol-ibuprofen-paracetamol regimen is totally discouraged. Many times it is the pediatricians themselves who set this guideline, but alternation must be avoided”.
Nor are traditional remedies a good idea, such as putting children in cold or warm water. “Instead of promoting the well-being of the child, they promote discomfort. And, if they work, it is very transitory, we do not recommend them ”, highlights Molina. Even less common practices in other cultures, such as rubbing with alcohol. “They are dangerous because they burn and irritate the skin a lot; and alcohol can also be absorbed through it, intoxicating the child”. At other times, he overdresses himself. “With several shirts it is more difficult for me to lose heat. We say that you be with little clothing, in a cool, well-ventilated place, that you drink liquids, but putting them in the bathtub has gone down in history ”.
When fever is important
“Most febrile processes in children last 3 or 4 days, but there are viruses with which they last up to a week, like the flu,” Molina points out. Although, in general, a child with a fever can be monitored and treated at home, a duration of more than five days justifies a visit to the pediatrician. “Fever for an infection is good. You have to downplay it, but you have to know when to consult”, emphasizes Paula Vazquez Lopez. This specialist lists alarm signals to go urgently, in which the two pediatric medical societies, the AEPap and the SEUP, agree: “That the child has a bad color, that he is pale, with mottled skin, with an ugly color; when spots appear on the skin that do not disappear under pressure; if your eyelids or lips swell; if he has difficulty breathing; if he is dizzy, unresponsive, irritable, drowsy, or having seizures; In these cases, they have to go immediately to the emergency room”, warns the expert.
“And when do they have to go, but not by calling 112 and in a calmer way? If they are infants under 3 months old or if the fever is associated with any skin or behavior alteration, even if they are not very bad, ”advises Vazquez Lopez. A separate case are children without defenses or those not vaccinated, the pediatrician qualifies. “Immunosuppressed people do not have a fever, especially those with cancer, who do not have this defense mechanism. Therefore, we must always be more careful with them.” Also with unvaccinated girls and boys, especially if they are under 3 months old. “You always have to ask if they are vaccinated against pneumococcus, meningococcus and haemophilus, which are going to give us potentially serious invasive bacterial infections. If they do not have vaccines, the protocol for action in the event of a fever without a source is a little more aggressive ”.
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Source: EL PAIS