Posted tagged ‘fever’

Ibuprofen or acetaminophen: Which is better for treating a kid’s fever?

January 30, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Ask babies with fever how they feel, and they’ll say… well, they probably won’t say anything, because they’re babies. But ask older kids, and they’ll look at you funny, and maybe say “Why are you asking me?” Kids these days, am I right?

Fevers make kids feel bad. Achy and miserable and bleh. So for comfort, I think it’s a good idea to treat fever in a child who’s uncomfortable. What’s important isn’t the number – how high the fever is – but how the child feels. Feeling bad? Let’s help you feel better.

(By the way, even though they make your child feel miserable, fevers will not harm your child in any way. Don’t be afraid of fevers.)

To treat a fever: first, offer extra fluids. Fevers are dehydrating, and a popsicle tastes good. Then reach for a fever reducing medicine, typically a brand of acetaminophen (like Tylenol) or ibuprofen (Advil or Motrin.) But which one’s better? A November, 2016 study in Clinical Pediatrics gives ibuprofen the edge, though not by much. Ibuprofen worked a little faster (peak effect in 90 minutes, versus 2 hours for acetaminophen), and lasted somewhat longer (by about an hour, though there was a lot of variability.) My usual advice is to use whichever one you’ve got at home and what’s seemed to work best in the past.Although serious side effects are rare, either medication can cause serious problems. Acetaminophen, especially in overdoses, is toxic to the liver (so be careful using this in a child who already has liver disease.) Ibuprofen, especially with prolonged use, can cause gastric irritation and bleeding, and rarely kidney problems. It’s important to use what you’re using correctly, at the correct dose and at the correct interval (both can safely be given every 6 hours.)

Which brings us to another idea: if either is good, can a combination of them be better? In an alternating strategy, one drug is alternated with the other, so something is given every three hours, and the same drug comes around for a dose every six. Several studies (summarized here) have shown that this can reduce fever somewhat better than either drug alone, but with a much greater chance of medication errors and overdoses. If you want to try this, write down what you’re giving and when, and make sure you (and your spouse) understand the schedule.

There are a lot of myths about fever. 98.6 F is not and has never been the “normal” temperature. Fevers, themselves, cause no harm. They also don’t help very much. In the modern world, fever is not a necessary or particularly useful part of your immune response. If a fever is making your child feel bad, treat it. With acetaminophen or ibuprofen, your choice.

Not feel good by Sophie

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“How high was the fever?” isn’t a very useful question

December 3, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

A September, 2015 study published in the Pediatric Infectious Disease Journal looked at whether fever itself – the height of a fever – is a good predictor of whether a child is likely to have a serious illness. And, once again, a common fever myth is shattered.

Researchers reviewed data from visits from children, aged 0-5 years, who presented to a pediatric hospital for fever in 2004-2006. (Yes, that was an oddly long time ago. I guess they write slowly in Australia. But in terms of the science, there haven’t been any big changes in vaccines or childhood illness since then, so I think the results are still valid.) Of the almost 16,000 fever episodes reviewed, about 1,000 children had what the authors considered a “serious infection”. That includes bacteremia (bacteria in the blood) in 64 children, pneumonia in 533, and urinary tract infection in 543. In total, only about 7% of the children had a potentially serious bacterial infection that needed to be treated. That percentage should be no surprise—we know that in the modern world, among vaccinated and healthy children, the vast majority of fevers are caused by viral infections that will get better on their own.

The authors then looked at whether the height of the children’s fever correlated well with whether or not they ended up having a serious diagnosis. They examined both the measured highest fever in the emergency department, and the parents’ self-reported “highest fever” in the last 24 hours, prior to their visit. Whichever way it was recorded, the height of the fever itself did a very poor job at discriminating between children who had and did not have a serious infection.

The statistics are complicated, and involve receiver operating curves that you may not be  familiar with—but, in the author’s words, “Measured temperature at presentation to hospital is not an accurate marker of serious bacterial infection in febrile children.”

Relying on the height of a fever resulted in both false positive and negative results. For instance, evaluating only those with a temperature of 100.4 or higher would still miss 1 in three serious infections. You can’t rely on high fevers as a positive predictor, either—only 1 in 6 children with a temperature of 104 actually had a serious infection.

The authors found that a few other observations could be at least somewhat predictive. Younger babies, overall, were a little more likely to have serious infections; and children who had had fevers for more than 4 days were also somewhat more likely to be diagnosed with something more serious (though I imagine those children also had more tests done, like chest x-rays. Perhaps they just found more illness when they looked for more illness.) But even when adding in considerations of age and length of illness, the height of the fever remained a poor predictor of the seriousness of the illness.

 

So what’s a parent to do?

First: prevent serious illness by making sure your children are up to date on their vaccines. We can prevent most causes of meningitis, pneumonia, blood poisoning, and other serious bacterial and viral infections with vaccines. Prevention is always better than having to evaluate and treat children in an emergency department or office visit.

Then: offer comfort care to children with fever. Extra fluids are a good idea, and if fever is causing a child to be uncomfortable, treat it. If Junior perks up and acts well after fever-reducing medication, and isn’t especially at-risk for serious infection**, treat fevers at home for a few days. If the child is getting worse, acting persistently sick, or isn’t getting better, go see your doctor. Remember: the number itself is less important than how your child feels and acts.

** This advice does not include any child less than 2-3 months old, or with an immune deficiency, or who isn’t up to date on vaccines for any reason. These kids are at much higher risk of serious or deadly infections, and shouldn’t rely on advice from the internet. Call your doctor for specific fever instructions.

 

More about fever:

What is a fever?

Why do kids get fevers?

Dispelling fever phobia

The fever action plan

 

fever rita moreno

Top ten things you didn’t know about mono. And kittens. (You won’t believe what happens next!)

January 15, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

So I noticed that blog posts cast as questions and answers, or “top ten lists”, seem to get a lot of hits. It also seems to help to include gratuitous references to high school, and pictures of kittens. And pleas to share with friends, and vague connections to charity. So let’s give it a try! If you love kittens and sunshine, be sure to share this with every human on the planet! For every share, some kind of charity will get loads of money. Probably.

Thanks to Kristi for the mono questions.

 

1. What’s mono?

“Mono” is short for “infectious mononucleosis”, a common viral infection of childhood. The “monocytosis” refers to what the blood smear looks like under a microscope– there are often a lot of white cells called “monocytes.”

Kids with mono have a wide range of illness. Some, especially younger children, are barely sick– maybe with a bit of sore throat and fever. Teenagers often fare worse, sometimes with a severe sore throat, swollen lymph nodes, fevers, and very low energy that can linger for weeks. And some people have active mono, spreading virus, with no symptoms at all.

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2. What causes mono?

Classic mono is usually caused by a virus called “Epstein Barr” (often abbreviated EBV). A very similar illness can be caused by other viruses (CMV, or acute HIV), or other infections (toxoplasmosis.)

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3. Is it true that you can only get it from kissing?

Well, maybe not only. During mono illness the saliva is loaded with mono virus, so sharing spit is the best way to give it to a friend or loved one. Mono can also spread by sharing utensils or cups, but the most efficient way to share saliva is kissing. Especially when standing upright in a high school hallway. So watch out!

Mono does not spread through casual or household contact.

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4. How long is mono contagious?

It’s likely that people are most contagious when they feel the sickest with fever– but at least some people will continue to shed EBV in their saliva for many months, maybe even a year or two. And yes, they’re contagious that whole time. Did I mention kissing in the hallway wasn’t a great idea?

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5. How long is the incubation period? I mean, how long does it take to get sick?

The incubation period varies. It’s probably in the range of 30-90 days. So when a teenager comes down with mono, it’s just about impossible to figure out who they caught it from.

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6. What’s up with the spleen thing? I don’t even know what a spleen is!

IKR! I thought a spleen was a word Shakespeare used to confuse people:

“Saint George / Inspire us with the spleen of fiery dragons!”

“Haply my presence / May well abate the over-merry spleen”

But it turns out the spleen is an organ at the top left of your abdomen, usually tucked up under your ribs there. In about 40-50% of teenagers with mono, the spleen will get enlarged.

The problem, though, isn’t just that the spleen is large– it’s that rarely the spleen can rupture. And that’s really bad. A spleen rupture can occur even without mono, usually from trauma (like a car accident.) It’s thought that the enlarged spleen that can occur during mono might increase the risk of rupture, especially during tackle or rough sports (though that’s not entirely proven.) It’s also not clear if children with non-enlarged spleens are at risk for rupture during mono, or how long the risk lasts. Some people restrict everyone with mono from rough or tackle sports, regardless of spleen size; others use an ultrasound to measure spleen size (though that’s never been shown to help prevent rupture.) Should kids sit out for a fixed number of weeks, or until the spleen size returns to normal? There is no consensus on this issue. Spleen rupture itself is really quite rare, so it’s hard to do a study of the best way to prevent it.

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7. Is it true that you can only get mono once?

Yes, or at least usually. Mono caused by EBV will only happen once in most people, even though the virus itself lurks in your body afterwards. Mono-like symptoms can rarely recur at times of immune compromise. The EBV virus can resurface to cause other health problems if the immune system is really knocked out (during chemotherapy, say, or with advanced HIV infection.)

It’s also possible that other infections trigger mono-like symptoms in some people after EBV infection.

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8. Wait a minute. I’ve been tested for mono a bunch of times, and I’ve been told I had it more than once. What’s the deal?

It turns out that there are bunch of different tests for mono. Some show “past infections” that may have occurred years ago. Because you “test positive” for mono, that doesn’t mean you have acute mono right now. It might just mean you got over mono years and years ago. It depends on the test.

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9. How is mono treated?

Rest, rest, rest. Fever reducing medicine can help if fevers are making you feel bad (though the fever itself won’t hurt you.) Extra fluids, pain medicine for the sore throat, and sleep.

Rarely, steroids are used. This can help especially if the swollen glands in the throat are making it hard to drink or talk or breathe.

Fully resting at the worst part of the illness seems to help prevent mono from turning into weeks or months of malaise and low energy. However, you don’t want to rest and miss school too long– once you’re starting to feel better, try to make it back to school at least part days, and work up from there. Though rest is important, too much rest for too long leads to deconditioning and social isolation, which can make it hard to return to full activities. Teens with more-severe mono sometimes need an individualized treatment plan with a roadmap to get them recovered and back to school.

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10. Did you pad this out to ten questions?

Yes.

98.6 is average, not normal: Dispelling fever fears

November 6, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

What if I said 5’10” is the normal adult height for a male? Or a “B cup” is a normal bra size for a normal woman? Or that normal people have a skin tone the color of cappuccino, or that normal people should wear size 8 shoes? None of this makes sense. People come in all sorts of normal sizes and shapes, and almost all measurements of a person’s foot size or height or skin tone or whatever are going to be in a range of normal—from size 6 to size 13, or whatever.

It’s also wrong to say that a certain heart rate or blood pressure is normal. Your vital signs—pulse, respiratory rate, and blood pressure—vary throughout the day. There’s a range, not a single normal value. Likewise, your body temperature varies, usually falling into a range of normal values.

Normal temperatures vary from person to person, and by the time of day. Women tend to have slightly higher “normal temperatures” than men, and their measured temperatures can also change depending on their menstrual cycle. Bottom line: there isn’t a single, normal temperature for the human body.

The average human body temperature, overall, is probably something close to 98.6 degrees Fahrenheit. That means about half the time, your child will be a bit above that; at other times, below. A measured temperature above 98.6 does not mean your child is sick.

Since normal body temperatures follow a range of values, one accepted definition of fever is a temperature at or above 100.4 (some clinicians prefer 100.8). More important than the number, honestly, is how ill the child is acting and what other symptoms there are, but in any case a measured temperature less than 100.4 is not really a fever—it’s just a normal value in a normal range.

If your child has a measured temperature of 99.0 or 99.8, it’s not a low-grade fever. It’s not any kind of fever. It’s just a temperature in the range of normal, or maybe a temperature a little higher than average for that child. But it’s still not a fever. The child might still might be sick (depending on other symptoms), and might need comfort and reassurance–but don’t worry yourself or confuse the picture. A temperature in the normal range is not a fever.

More about fever in children:

What is fever?

Why do kids get fevers?

Don’t be afraid of fever

What to do when your child has a fever: The action plan

Keep your child safe from antibiotics

April 3, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Here are some facts:

Antibiotic use is the direct cause of the rise of untreatable superbugs that are killing people.

Antibiotic use is also the cause of most cases of C diff colitis in kids, a potentially life-threatening, difficult-to-treat gut disorder. Antibiotics have also been linked with recurrent wheezing  in infants and inflammatory bowel disease. They can also trigger allergic reactions that can be severe or life-threatening. (I was going to link to photos of Stevens Johnson Syndrome, but decided not to be cruel. Go ahead and Google at your risk. Don’t say I didn’t warn you.)

Here’s some more facts:

Most infections in children are caused by viral infections. This includes all common colds, most coughs, most sore throats, most nasal congestion, and most fevers. It includes most bronchitis, most pneumonia, and most wheezing. Croup, laryngitis, tonsillitis, upper respiratory infections—they’re all viral. They are caused by viruses.

There is no circumstance where any antibiotic medication helps anyone with a viral infection get better. They don’t make viral infections go away faster, and they don’t prevent the development of later bacterial infections. They just don’t work.

Even “bacterial” infections often don’t need antibiotics to get better. Most ear infections will resolve without antibiotics, and good studies have shown that antibiotics, overall, are not effective in treating sinus infections.

So: the potential for great harm. And no upside. If you’ve got an accurate diagnosis of a viral infection, you know that the antibiotics aren’t going to help. Zero benefit. Some real risk. You’d think this would be a no-brainer kind of decision.

And yet, every single day I feel this struggle with some parents who just want antibiotics. It’s really strange, in a way— I listen to the story, I do a careful exam, and if possible I get a confident diagnosis. I talk about what will help the child feel better, and red flags to look out for to contact us if things get worse. And I get back a stare. “Can’t I just get an antibiotic?” or “He needs an antibiotic for his sinus” or “My doctor just gave me an antibiotic. He has the same thing.”

It’s our own fault, I know. Doctors have been way too quick to write antibiotic prescriptions. It’s much faster to whip out the prescription pad than talk about viruses and bacteria. And, more nefariously, writing antibiotic prescriptions creates a culture of dependency that guarantees future business. Patients, at least some of them, seem more satisfied if they just get a magic antibiotic prescription. Why anger people, why fight it, why not just give out the pills and move on to the next patient? Happy parents, happy cash register.

Besides: I know there’s a good chance they’ll go right to the QuickieClinic in the drug store across the street and get their peniwondercillin prescription anyway. (And then I’ll be the one called with the weird allergic reaction or when Junior didn’t get better because he needs a “stronger” antibiotic. QuickieClinic doesn’t offer 24/7 access to their doctor. They don’t offer any access to any doctor. But I’m getting off topic here.)

Why fight it? Because I’m your kids’ doctor. I’m not here to make you happy, or give you what you think you need. I’m here to try to get an accurate diagnosis and to do the best thing for my patient. I’m here to give solid advice about how to help your kiddo feel better, and to tell you when to worry, and when not to worry. I will not always get it right, but I’m going to try my best every time, even when that means I’m not giving you the prescription you want. And I’ll be here to help when things take an unexpected turn, because symptoms and diagnoses change. I can’t guarantee when your child will get better, but I’ll do my best to do the things that can genuinely help.

You want a burger your way? Go to Burger King. You want a quick antibiotic prescription? Go to the retail clinic in the drug store, or one of those docs or practitioners who see 60 kids a day. You want someone to use their professional skills and judgment to help your child? Find yourself physicians who’re stingy with the prescription pad.

FDA warns of acetaminophen causing severe skin reactions

August 6, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

I’ve said in many times here, but it’s worth saying again: any medicine (any real medicine, let’s leave placebos out of this) can cause adverse reactions, and sometimes serious adverse reactions. Even good old Tylenol (acetaminophen), said the FDA in a warning this week.

It’s not time to panic. Serious skin reactions to acetaminophen are really, really rare—the FDA’s warning mentioned 107 serious skin reactions, including 12 deaths, from 1969 to 2012. Considering that millions of doses of acetaminophen are given to children yearly, your child’s risk of this kind of reaction is miniscule.

Still, acetaminophen, like any other drug, really should only be used if needed. It’s great for reducing fever—but that’s really only necessary if the child isn’t feeling well. Fever itself is harmless. But I do recommend using acetaminophen (or ibuprofen after age 6 months) is a child with a fever feels sick and uncomfortable. Acetaminophen is also effective for treating pain, and can safely and effectively be given even before painful experiences, or regularly for a few days when you know there is going to be pain.

About those skin reactions: almost any drug can rarely cause serious skin reactions that can lead to significant skin loss, almost like a large burn. These reactions are probably more common with anti-epilepsy medications and some antibiotics (like Bactrim), though even then they’re quite rare. Still, the most important steps are to 1) avoid medication unless it’s needed; and 2) if there is a worrisome rash, stop taking the medication. The medicine-rashes that are most serious include blistering or painful skin, or reactions that include the lips or eyes, or any widespread rash that’s worsening. If your child has a rash on a medication, contact the prescribing doctor’s office to discuss what you’re seeing and whether stopping the medication is needed. When in doubt, it’s usually best to stop the medicine—though of course that depends on what the medication is for. Call or see your own doctor for advice.

Even though it’s overall a very safe and useful medications, there are other rare problems with acetaminophen. Even relatively small overdoses can cause severe liver toxicity, especially in those with pre-existing liver disease. And there are some links to the use of acetaminophen and asthma (though this is still unclear.)

The FDA is going to require a warning about these skin reactions on all prescription medicines containing acetaminophen, and will “request” that manufacturers include this warning on over-the-counter preparations. That label is going to get crowded!

Can acetaminophen cause asthma?

May 28, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Tylenol (acetaminophen) replaced aspirin as everyone’s favorite pain reliever-fever reducer in the 1980’s, when aspirin was linked to a rare fatal liver disorder called Reye’s Syndrome. Acetaminophen is very widely used now, even in newborns, and is considered safe as, well, something very safe. Except maybe it isn’t.

Some evidence is adding up that acetaminophen could be linked to the rising rates of asthma in the developed world. There’s a certain biologic plausibility to it—acetaminophen depletes the body of glutathione, which may prevent that molecule from stopping inflammation in the lungs. And several epidemiologic studies, and at least one randomized trial from 2002, have seemed to confirm the link. The positive evidence for the association was summed up in this New York Times article from 2011.

However, a more recent NYT article, this one from last week, refutes the claim. The article quotes the author of an as-yet-unpublished study who says that it’s not the medications like acetaminophen that increase asthma risk, but common upper respiratory infections—which are often treated with Tylenol. If this author is correct, the acetaminophen is going along for the ride, but isn’t itself causing the asthma.

That’s science for you. A whole lot of studies, and we’re still not sure.

What I am sure of is this: all medicines, if they’re biologically active at all, have side effects. There is just no way around that. If someone is trying to sell you a perfectly-safe “medicine”, it isn’t a medicine. It’s a placebo.

No medicine ought to be taken unless it’s needed, and when doctors and patients think about the risks and benefits of any medication, we ought to figure in at least a little fudge factor for possible risks we don’t even know about yet.

Related posts:

Tylenol versus Motrin

Acetaminophen safety alert (2009)