December 2003

Our doctors and staff wish all of you a very safe, happy, and healthy holiday season and a happy New Year.

Dr. Barenfeld

Fever--------------------------------------------------

Fever is defined as an increase in body temperature as a result of a change in the “set point” in the hypothalamic thermoregulatory center (say that three times fast) of the brain. A normal temperature may range from 97° F to 100.4° F, depending on a variety of factors. Generally, temperature is lowest in the morning and highest in the evening.

There are several ways in which body temperature can be measured. The best way is rectally using a lubricated thermometer inserted at least 3 cm. and left in place until the reading stabilizes, about 3 minutes. Oral temperatures are unreliable in children under 5 years of age unless the child can cooperate and keep the thermometer under the tongue with mouth closed. In general, oral temperatures are about 1° F below and axillary 2° F below rectal readings. Infrared tympanic membrane (ear) thermometers have become widely available for use. Although this method is easy and quick, issues with its reliability, especially in young children, as well as its high cost prevent recommendation of their use by the medical community.

The decision to attempt to lower body temperature rests on whether the fever is thought to be a useful defense to the body or the source of discomfort and seizure provoking. There are many myths concerning fever. Many parents have unwarranted fears of harm from the fevers that all children experience. This “fever phobia” leads to unnecessary worry and overtreatment. Myth: fever causes brain damage. This is false. Myth: untreated, fevers will keep going higher to 110° F – 115° F. False. Under normal circumstances fever will not range higher than 104° F – 106° F. Even up to 106° F fever is probably more beneficial than harmful. Myth: untreated fevers will cause seizures. Maybe. Febrile seizures occur in only 2% to 4% of children. While frightening, febrile seizures are usually brief, harmless and require no treatment. Myth: any fever is bad for you. False. The ability to produce fever is present throughout the animal kingdom. Fever turns on the body’s immune system and speeds up the production of white blood cells, antibodies, and natural infection-fighting agents. Fever also slows down the multiplication of viruses and bacteria.

The goal of treating fever then is really to make your child feel more comfortable and be less irritable. There are several ways of doing this. Since the rate of fluid loss may be increased as a result of a fever, it is important for the febrile child to receive adequate fluids. Also, an increase in fluids allows for greater heat loss from the body. Sponging with tepid water has been shown to be effective in lowering fever. When this measure is used by itself, however, body temperature quickly returns to its previous level as a result of shivering, which attempts to bring the body temperature back up to the untreated elevated set point. For this reason, sponging is considered useful only if combined with Tylenol. The combination of tepid water sponging and Tylenol may result in more rapid and effective temperature lowering than Tylenol alone, often decreasing patient discomfort and alleviating parental concern. Cold water should be avoided since it makes the child shiver and feel miserable.

Although alcohol sponging has been recommended in the past, this measure has fallen out of favor because the alcohol can be absorbed through the skin leading to low blood sugar or even coma.

The mainstay of fever reduction is through the use of medications. These are of three basic types. Acetaminophin (Tylenol, Tempra) remains the first-line choice in lowering fevers due to infection. It works well when proper dosage is given every 4 hours. It is well tolerated and comes in many different forms (liquid, chewable tablet, and suppository). Ibuprofen (Motrin, Advil) for children is relatively new on the market. Some studies seem to indicate that ibuprofen works quicker and has a longer duration of action (6 hours) than acetaminophen. However, it is more likely to cause stomach upset than acetaminophen. Aspirin is not recommended for children because of its association with Reye syndrome and other potential side effects. It is still used in the treatment of specific medical conditions.

Although fever has many benefits for our bodies, it sometimes is indicative of a serious illness. Always contact us when fever lasts more than a few days with an unknown cause. Also, any infant under 2 months of age with a temperature > 100.4° F should always prompt an immediate call to us.

Poison Policy Change------------------------------------------------

There has been a major change in American Academy of Pediatric policy in regards to treatment of poison ingestion in the home. For many years pediatricians have recommended that parents buy ipecac syrup and keep it in the home to induce vomiting in children who ingested a potentially poisonous substance. Although the efficacy of ipecac at improving outcome after childhood poisoning had not been rigorously proven and despite reports of failures, poor outcomes, and even abuse potential by those with eating disorders, the medication was widely recommended.

Recent studies have shown ipecac to be poorly effective in removing an ingested substance from the stomach and does not prevent or reduce emergency room visits. It may cause prolonged vomiting inhibiting the use of other effective treatments and in certain types of ingestions may even be harmful. Therefore the new AAP recommendation states that ipecac should no longer be used in the home. Parents should also dispose of all ipecac they already have. The first action for a caregiver of a child who may have ingested a toxic substance should be to consult the poison control center. The universal telephone number in the United States is 800-222-1222. This number should be posted near the telephone in all households with children. Common sense poison preventions include keeping all potential poisons out of sight and out of reach, and immediately closing all containers with child resistant locks after use. Never transfer a substance from its original container to an alternate one, safely dispose of all unused or no longer needed medications, and do not refer to medications as candy.