Summary: Determining the cause of a fever is difficult, but controlling the fever is usually not difficult. Give acetaminophen at the correct dose and remove your child's clothes. Many parents believe that children should be kept warm when they become ill, but this is not correct if they have fever. Fever means the body is too hot. By dressing children in warm clothes, the fever will increase. It is better to remove their clothes to let the heat out. Their temperature will come down and they will feel much better. You don't get sick from the wind, rain, air conditioner or fan. Most illnesses with fever are caused by germs. Ibuprofen can be combined with acetaminophen to control more stubborn fevers.
First of all, determine whether the cause of your child's fever might be serious. Contact your physician by phone or make an appointment to have your child seen by your physician. If you believe that the cause of the fever might be serious, call your physician right away or take your child to an emergency room for immediate evaluation. Determining the cause of the fever is difficult, but controlling the fever is usually not difficult.
(Note that all temperatures are in degrees F with the degrees C shown in parentheses.)
1. Give a dose of acetaminophen (common brands include Tylenol and Tempra) fever medicine every 4 hours (up to 5 doses per 24 hour day). The correct dose is very important. The dose of acetaminophen should be 4.5 to 7 mg per pound of body weight (10 - 15 mg per kg) or use the acetaminophen dosing chart below. Acetaminophen is also known as paracetamol in other countries.
2. Do not use blankets, long pants, or long sleeves. A short-sleeved T-shirt is better. Keep all the clothes off, except for a diaper or underwear if the temperature is above 102 F (39 C). It is commonly thought that when a child is ill, you must keep him/her warm. But this is not correct. Fever means the body is too hot. If you cover your child in warm clothes, your child's temperature will go up.
3. Get cool air to circulate around your child. A fan or an air conditioner would be beneficial in reducing fever. Let's examine a few myths. It is commonly thought that exposing your child will cause illness. The wind causes pneumonia. The rain causes colds. A fan causes illness and chills. An air conditioner causes colds and the flu. NONE of these are true. Pneumonia, colds and the flu are caused by germs, such as viruses and bacteria; NOT by the wind, rain, fan or air conditioner.
4. Offer liquids frequently.
5. Check your child's temperature. A normal temperature is 99.8 F(rectally) (37.7 C), 97.8 F (axillary, arm pit) (36.6 C), or 98.6 (orally, under the tongue) (37 C). Ear thermometers which measure temperature on the ear drum (tympanic membrane) usually use a "rectal" scale for younger children (in which case the normal temperature is 99.8 F) and an "oral" scale for older children (in which case the normal temperature is 98.6 F).
6. Watch your child's activity. Fussiness, which does not go away with comforting, may be a serious sign. Lethargy (drowsy and not responding to you) may be a serious sign. Call your doctor, see your doctor or go to an emergency room if there is any question.
7. Serious causes of fever cannot always be diagnosed by the doctor early on. Even if your doctor has indicated that your child's fever is not due to a serious cause, doctors cannot be correct 100% of the time. Call your doctor, see your doctor or go to an emergency room if there is any question.
Medication concentrations listed in this chapter apply to the USA only. Medications sold in other countries will often have different concentrations or different markings on their droppers.
Every 4 hours (up to 5 doses per day): Acetaminophen fever medicine doses (other names include Tylenol, Tempra, APAP, Panadol, paracetamol, etc.). Do not use aspirin unless directed by your doctor. You may choose a dose by age or weight, but dosing by weight is more accurate:
Acetaminophen suppositories are available in 80mg, 120mg, 325mg, and 650mg sizes. These are useful for children who are vomiting or for some other reason, cannot take the medication by mouth. Acetaminophen suppositories are available over the counter (available without a prescription). Ask the pharmacist where they are because they are hard to find. When using a suppository, it should be kept cold in the refrigerator because at room temperature, the suppository is too mushy to push into your child's anus. Suppositories are waxy and shaped like a bullet. Insert the suppository into your child's anus by pushing it in. The suppository will melt inside the rectum and the acetaminophen will be absorbed into the body.
Some people cut suppositories in half if only half the dose is desired. For example, if your child's dose is 160 mg, it sounds like a good idea to cut the 325 mg suppository in half instead of giving two 80 mg suppositories. However, the medication is not always distributed evenly inside the suppository, so by cutting a suppository, you may be giving too much medicine or not enough.
Some common questions about fever control:
What if my child feels chilly or has chills with fever? Shouldn't I keep my child warm?
It is normal to feel chilly when you have fever even though the skin is hot. This is true for adults as well. If you cover your children with warm clothes, their temperature will stay high and they will still feel chilly. If you take off their clothes, they will lose heat, their temperature will come down, then they won't feel cold any more. Again, taking off their clothes will not cause them to become ill.
How should fever be measured?
Rectal temperatures are the most accurate method of measuring temperature in young children, but it is uncomfortable and potentially harmful to measure rectal temperatures frequently. Doing rectal temperatures too often may cause small rectal tears.
Oral temperatures are very accurate in older children who can hold a thermometer under their tongue for several minutes. Make sure they do not drink cold or hot liquids prior to taking the temperature, since this will cause an incorrect temperature measurement.
Axillary (under the arm) temperatures are not very accurate, but they are still good enough in most instances at home. Ear thermometers (tympanic temperature) are more accurate than axillary, but they do not correlate perfectly with rectal and oral temperatures. Skin temperature strips or disks that are placed on the forehead with colored temperature indicators are not very accurate, but they are usually good enough for routine home use. An experienced hand placed on a forehead, cheek or back is often a good screen to determine if there is a fever, but it would be difficult to get a number for a temperature measurement this way.
If you're going to purchase a thermometer, do not purchase a mercury glass thermometer. These are too slow and they often break. Electronic thermometers with digital readouts are only about $6 now. They are much faster and they don't require shaking before use.
Use simple methods of measuring temperature for most instances. If you are concerned about your child's temperature or you plan to call your physician, you should get an accurate temperature (oral, rectal, or ear) to report to the doctor. Oral temperatures are very accurate in older children. Rectal temperatures are most accurate in young children. Ear temperatures are good enough as long as you take it two or three times to make sure you are getting a consistent result.
How does fever control in adults differ from children?
The skin of adults is thick, while the skin of children is thinner. Notice that when you carry a child, you can feel the heat of his/her body against you. This is because their skin is thin and the heat goes through their skin very easily. When adults have fever, most of the extra body heat is lost through the lungs by breathing. When children have fever, most of the extra body heat is lost through the skin and lungs. If we cover up children when they have fever, this will block heat loss from the skin and the fever will build to a higher temperature. Since adults don't lose much heat through the skin, it doesn't matter if they are wearing warm clothes and blankets.
Recall the last time you had a fever. No matter how many blankets you covered yourself in, you still felt cold. It is normal to feel cold until the fever comes down. Fever reduction medications such as acetaminophen and ibuprofen will usually bring down the fever to resolve that cold, chilly feeling. Since this relies mostly on medication and less on skin exposure, it doesn't matter how much clothes or how many blankets adults have when they have fever.
But it does matter for children. Since the skin of children is thin and significant heat loss occurs through the skin when they have fever, it is very important to keep their clothes off when they have fever. Most small children should be wearing a short sleeve T-shirt and a diaper. Pants, socks, long-sleeves and sweaters are the wrong thing to do when trying to control fever. If the temperature is above 102 F (39 C), they don't need a shirt either. In this case, remove all their clothes except for the diaper.
Why do children feel cold when they have fever?
Fever results in a disruption of normal body temperature regulation and sensation. It is normal to feel cold (chilly) when fever is present. Even though they complain of feeling cold, fever means that the body is too hot. Putting clothes and blankets on them makes their temperature higher and they will still feel cold. Taking their clothes off causes them to feel cold for a while, but when their temperature comes down, they will no longer feel cold.
What about sponging?
Some physicians suggest sponging: a) Fill the bathtub with lukewarm water which is cooler than the skin. b) Place your child in the tub and sponge your child for 30 minutes. c) Do not use alcohol. However, sponging has not been shown to be better than merely taking off your child's clothes. Sponging is hard work for parents (30 minutes of time) and children generally don't like it. Why not just take off your child's clothes and let him play in a cool room. This is much easier and it is just as effective as sponge bathing.
What if the fever doesn't go down well or the fever recurs before the next dose of acetaminophen is due?
Such fevers that are more difficult to control are more worrisome than fevers that are easy to control. Contact your doctor for advice. Once you have determined that the cause of the fever is not serious, the best way to control difficult fevers, is to add ibuprofen. Refer to the paragraph about ibuprofen below.
How should ibuprofen be used to control fever?
Ibuprofen liquids are now available without a prescription. Some believe that ibuprofen is a better fever medication than acetaminophen. This may be true, but they are roughly the same. Although ibuprofen tastes better, acetaminophen is currently felt to be safer. The side effects of each medication are discussed in the next question below.
In my opinion, ibuprofen should not be used as the first drug to be used for fever. Since ibuprofen has more side effects than acetaminophen, acetaminophen should be used first. In difficult fevers, ibuprofen should be added to acetaminophen so that BOTH medications are used together. The dose of ibuprofen is 4.5 mg per pound of body weight (10 mg per kg) every 6 hours. Some physicians recommend giving acetaminophen alternating with ibuprofen every 3 hours. Others recommend giving acetaminophen every 4 hours AND ibuprofen every 6 hours. This latter method requires more organization because the ibuprofen doses may coincide with an acetaminophen dose or it may be due between acetaminophen doses. Whenever two or more medications are being used, it is a good idea to write down the medication times when they are given to help keep track of the medications. It is very easy to forget when the next dose is due without writing it down.
Using ibuprofen together with acetaminophen is much more effective at controlling fever than one of these fever medicines alone. As the fever resolves, ibuprofen can be discontinued. If the fever continues to resolve, then acetaminophen can be discontinued as well.
What is the difference between acetaminophen, aspirin and ibuprofen?
Acetaminophen is the safest of these three medications. Acetaminophen is a very effective fever medication. Its main side effect is liver injury when given in high doses or in an overdose. The usual dose is 10-15 mg per kg (4.5 to 7 mg per pound) while the toxic overdose amount is more than 140 mg per kg (64 mg per pound). However, liver injury can occur at lower doses if several high doses are given several times in a row or if the doses are given too frequently. There is some controversy over exactly what the dose acetaminophen should be. The dose above and in the dosing chart is the standard recommendation.
Aspirin is the oldest of these three medications. Aspirin is a very effective fever medication. However, aspirin is no longer recommended for routine use because it has too many side effects. Aspirin causes stomach upset. It may cause ulcers and bleeding in the stomach. It is also a very strong anti-platelet drug. Platelet are cells in the blood that cause blood to clot. Without platelets, we would bleed very easily. Taking aspirin results in easy bruising. What if you took aspirin and then broke your arm? It would probably bleed more and cause a larger blood clot around the broken bone. What if you unexpectedly needed surgery after taking aspirin? For example, if you developed appendicitis or if you got injured in a car accident, you would bleed excessively during surgery.
Aspirin has also been associated with Reye's syndrome which is a very serious rare disease that can result in lethal brain swelling. For these reasons, aspirin is no longer recommended for children except in special circumstances. You should not give aspirin to your children unless your physician specifically recommends this for a special reason. A significant overdose of aspirin can be lethal.
Ibuprofen is a very effective fever medication, which is related to aspirin. Both of them belong to a drug class called NSAID (non-steroidal anti-inflammatory drug). Ibuprofen can cause stomach upset, bleeding and ulcers, similar to aspirin, but this effect is not as severe compared to aspirin. Ibuprofen is also anti-platelet, but this effect is not as severe as with aspirin. Ibuprofen has not been linked to Reye's syndrome, but ibuprofen is a relatively new medication, so it's possible that there are some undiscovered rare side effects. Significant injury from an ibuprofen overdose is very unlikely, other than stomach upset, bleeding and ulcers.
Some physicians recommend using ibuprofen routinely for fever. My opinion is that acetaminophen should be used routinely for fever because it is safer than ibuprofen. Fever is very common and fever medications are commonly used. Ibuprofen should only be used together with acetaminophen when acetaminophen alone is not able to control fever well
What is the best dose of acetaminophen to use?
There is some controversy here. The dose given in the dosing chart is the standard dose of 10-15 mg per kg (4.5 to 7 mg per pound). Some experts suggest that this dose does not get a high enough level in the bloodstream. Doses of up to 20 mg per kg per dose have been recommended in some reports. However, other experts have cautioned that harmful toxic effects on the liver may be possible at these higher doses of acetaminophen.
Harmful effects on the liver occur when acetaminophen is broken down by the body into smaller compounds. A few of these compounds are harmful for the liver. A normal liver can detoxify these compounds and remove them from the body so that liver injury normally does not occur. But if the liver is weakened or the amount of acetaminophen taken is excessive, the liver cannot keep up, and the toxic compounds build up to injure the liver. The liver is necessary for normal body function, so a significant overdose of acetaminophen which causes liver failure can be lethal.
Most children have healthy livers. For healthy patients, the toxic dose of acetaminophen is estimated to be over 140 mg per kg (64 mg per pound). This is far greater than the normally recommended dose of acetaminophen and even the high dose of acetaminophen (20 mg per kg) is much lower than this overdose level.
However, when high doses are given frequently, the level of acetaminophen can build up and accumulate to toxic high levels. Also some patients with liver disease (hepatitis, liver fibrosis, etc.) have a weakened ability to detoxify and remove the toxic breakdown compounds of acetaminophen. Such patients with already weakened livers are unfortunately more likely to suffer additional liver injury if they take too much acetaminophen. Acetaminophen dosing in children with abnormal livers should only be prescribed by liver specialists.
Given the controversy of dosing acetaminophen where some experts believe the dose should be higher and others who feel that the high dose is too dangerous, it seems wisest to use the standard dose that is recommended in the table. Realize that acetaminophen has been given to children many times for many, many years with only a few cases of unexpected harmful effects. Acetaminophen at the standard dose appears to be very safe.
Why does acetaminophen taste so bad?
Try to dissolve a tablet of acetaminophen in a tiny cup of water. You will find that it does not dissolve well. To make a liquid form of acetaminophen, a "solvent" (such as alcohol) must be used to dissolve the acetaminophen. Solvents taste bad because they are chemical liquids like alcohol, acetone, gasoline, benzene, kerosene and paint thinner. Many brands of acetaminophen may state "alcohol free", but some other "solvent" (which tastes just as bad) must be used to dissolve the acetaminophen. Acetaminophen itself tastes bad. Try sucking on an acetaminophen pill to see how bitter it tastes. Taste the acetaminophen liquid yourself and you will now appreciate why it tastes so bad.
But there is good news!! Acetaminophen liquid is now available in a "suspension." Suspensions don't need solvents because the medicine is not fully dissolved. Instead, the medicine is suspended in a thick sweet goop similar to molasses, gravy, cream or ranch dressing. The acetaminophen taste can be drowned in the sweetened suspension. If you're willing to pay more for a better tasting form of acetaminophen, try the suspension products and taste the difference for yourself. I've found the suspension form of acetaminophen to taste substantially better than the other forms. Chewable tablets taste very good too. Young children are too young to take chewable tablets, but you should try to get them to take these once they are three years old. Chewable tablets are much easier to give than liquids.
Ibuprofen tastes much better than acetaminophen. But this is largely because liquid ibuprofens are almost exclusively available as sweet flavored suspensions. What a good idea!! It tastes much better this way.
Is it possible to overdose on fever medicines?
As noted earlier, it is possible to overdose on acetaminophen, but the overdose level for healthy children is very high so overdose is not very likely. For severe acetaminophen overdoses, an antidote is available to reduce the harmful effects of the overdose, but the antidote must be given early, before liver damage begins. Overdosing ibuprofen is not likely to do any harm other than its known side effects on the stomach and platelets. Aspirin overdose can be severe and lethal, but the overdose level is a high dose that is not likely to be taken accidentally, so most aspirin overdoses are intentional suicide attempts. Treating an aspirin overdose can be very difficult.