Has Treating Fever Burned Us?

courtesy wikimedia commons

courtesy wikimedia commons

During the days of the height of the swine flu panic, our pediatric emergency department was especially swamped, seeing several hundred children per day, usually 3-4 times our normal pediatric patient dosage per kilogram. Most everyone was a kid with a fever, plus or minus sore throat, cough, or runny nose. Part of it was sheer media-induced terror, sure. But I can’t help but wonder if another part of it was medical-induced panic: “My child has a fever, that must mean it’s serious!” (We know that there’s little to no correlation between fever and bacterial vs. viral infections.)

We are certainly notorious for this “treat the fever” business. Most of my discharge instructions include “You may give motrin or tylenol for fever or pain.” But we treat fever in our patients for different reasons than parents do: we want to improve vital signs, and see if the kid’s heart rate and respiratory rate improve once the fever is controlled; we want the kid to perk up once the fever is improved. Otherwise, we start thinking badness. (It’ll also slow their metabolic rate, leading to less dehydration and, in really frail kids, less weight loss.)

Parents treat fever for several reasons:

  • They think fever in and of itself is bad, and especially that a high fever is especially bad;
  • Often kids feel better, eat and drink better, and are less cranky without a fever.

I’m certainly not going to blame parents for bringing in their febrile child. One could argue we ourselves as emergency physicians spent a good deal of our residency just learning “sick” from “not sick” (but the experienced parent on child two or three usually figures it out pretty quickly, too). Fever is one of the simple ways to say “Hey, there’s probably an infection going on,” and we doctors are Masters of Infections ™, so it makes logical sense. Often reassurance is the most important part of the pediatric visit: I think it’s a virus, the lungs are clear, the ears are normal, and the child is behaving normally, yada yada yada.

Too often I think people also equate fever with “needs antibiotics” or “needs medicine,” for which we’re to blame as professionals as well. I once had a well-appearing, happy, normal-looking 5 year-old with an otitis media whose mother could not believe I was going to send him home with pain medicines but without antibiotics. “I have never, ever heard of such a thing,” she said, storming out at 4 in the morning, only to return with a script from her pediatrician and several choice words about me. It’s so strange that people have so little faith or respect or belief in their own immune systems — that without antibiotics, the human race would die out. We’ve also created a subculture of patients on day 3 or 4 of their cough who get a Z-Pak and then believe that the Z-Pak cured their bronchitis or URI. These are the patients who now are dependent on antibiotics for their magical antiviral properties and demand them immediately, preferring not to listen to reason, logic, or risk-benefit discussions.

It shouldn’t be up to parents to decide “sick/not sick” before coming to the ED, and if we decrease our sensitivity we just end up with more false negatives. If we tell parents not to bring kids in unless they have a fever AND they “don’t look right,” we’re going to have fewer kids overall but sicker ones who eventually find their way in.

There’s no great solution besides educating people about signs and symptoms of a potentially sick child, but we can certainly try to educate people about fevers: they’re not dangerous, they’re probably the body’s way of trying to fight off infection by “making the body work harder and faster than whatever’s attacking it” (my usual spiel), and usually we worry about children becoming dehydrated from viral infections more than the viral infections themselves. What else can we do?

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