Journal of Pediatric Nursing (2014) 29, 372375
CLINICAL PRACTICE DEPARTMENT
Editor: Mary D. Gordon PhD, RN, CNS-BC
Evidence-Based Management of Childhood Fever: What Pediatric Nurses
Need to Know
Patricia Clarke MSN, ARNP, PNP-BC
University of Florida, Gainesville, FL
Received 18 February 2014; accepted 21 February 2014
CHILDHOOD FEVER IS a common occurrence and often
a grave concern to parents. Misconceptions and unfounded
fears regarding fever exist among parents and pediatric
providers alike, despite the evidence that fevers are not
harmful in most circumstances. In addition, fear of fever can
lead to aggressive and dangerous practices, including over-
dosing with antipyretics and sponge bathing with alcohol.
There is a need for pediatric nurses to understand the
physiology of the febrile response as well as common
misconceptions regarding fever in order to promote safe and
evidence based fever management for their young patients.
The Febrile Response
Avner (2009) describes fever as a complex physiologic
response. A series of actions occur within the body after
exposure to viral or bacterial pyrogens which result in
increased prostaglandin production. Prostaglandin stimulates
the hypothalamus to raise the set point of the body, similar
to raising the temperature on a central thermostat. As a result,
the body acts to raise its temperature to the new set point.
This is accomplished during the chill phase of the febrile
response. Core body temperature is increased through
vasoconstriction. Hands and feet become cool, and involun-
tary shivering generates heat production. A child will seek
warmth during this phase, such as by getting into a fetal
position under blankets. Heat seeking behavior, involuntary
shivering, and vasoconstriction aid the body in reaching the
new set point. Thus, the body becomes febrile. Body
Corresponding author: Patricia Clarke, MSN, ARNP, PNP-BC.
E-mail address: pclarkearnp@gmail.com.
http://dx.doi.org/10.1016/j.pedn.2014.02.007
0882-5963/ 2014 Elsevier Inc. All rights reserved.
Mary D. Gordon PhD, RN, CNS-BC
temperature decreases after the set
point is lowered by the hypothala- Misconceptions and
mus. Heat loss occurs by sweating,
vasodilation, and cool seeking be-
unfounded fears
havior. During this flush phase regarding childhood
the febrile child may remove fever exist among
clothes and request cool fluids. parents and pediatric
Fever resolves as the temperature providers despite the
returns to normal, either due to evidence that fevers
resolution of the illness or antipy-
retic administration (Avner, 2009).
are not harmful in
Crocetti and Serwint (2005) most circumstances.
describe fever as a well-designed
response to infection rather than an uncontrolled reaction.
Homeostasis exists during the febrile response as the body
produces cryogens which act as natural antipyretics to keep
temperature from rising to a fatal level. This is in contrast to
hyperthermia, in which the body does not have normal
thermoregulation. Hyperthermia can result from a central
nervous system insult or from being left in a hot automobile.
When hyperthermia occurs, the hypothalamus does not raise
the set point. However, the body temperature rises
uncontrollably, often with deadly consequences. In compar-
ison, fever rarely causes a temperature above 41.1 C, a non-
lethal temperature. The importance of pediatric providers
understanding the febrile response and how it differs from
hyperthermia in order to offer accurate information to parents
is obvious (Crocetti & Serwint, 2005).
Benefits and Risks of Fever
Hippocrates, known as the father of medicine, is reported to
have said, Give me the power to produce fever, and I will cure
Clinical Practice Department
all illness (Bierman, 1942). Fever therapy was used for almost
2000 years to treat many illnesses, including syphilis, gonorrhea,
rheumatoid arthritis, and asthma (El-Radhi, 2011). Fever
therapy was used successfully in children in Bellevue Hospital
in New York in the 1930s for rheumatoid illnesses (Frieden,
1939). Alarmingly, the treatment consisted of intravenous
injections of triple typhoid vaccine into the child to raise the
temperature to 105 F; the temperature was then maintained for
four hours with intermittent injections (Frieden, 1939).
The benefits of fever in both animals and humans are well
documented in the literature. Kluger, Kozak, Conn, Leon and
Soszynski (1998) describe numerous studies in which various
types of animals were injected with pathogens. The animals
that were allowed to develop a febrile response were more
likely to survive the infection than those that were administered
antipyretics and had no fever. The authors report research has
shown the febrile response to benefit both warm and cold
blooded animals, including rabbits, mice, birds, lizards,
goldfish, and even grasshoppers (Kluger et al., 1998).
El-Radhi (2011) discusses multiple studies which support
the concept that fever is beneficial in humans. For example,
research has shown fever slows the replication of bacteria
and viruses in the body. In addition, the febrile response is
known to enhance the bodys ability to fight infection by
increasing phagocytosis and T-lymphocyte activity. There
have been reports of Hodgkins disease going into remission
after an acute fever secondary to measles infection. Other
studies have shown that febrile illnesses early in childhood
may provide protection against allergies and cancer in
adulthood. Finally, fever may enhance the bactericidal
activity of penicillin (El-Radhi, 2011).
Risks of fever include increased metabolic demand, mild
dehydration, and discomfort. These effects are generally
mild and easily tolerated by most children. In addition, some
children are at risk for febrile seizures, which are benign.
However, some children cannot tolerate the increased
metabolic demand that fever brings. These include children
with pulmonary or cardiovascular disease, critically ill
children, or children who are immunocompromised
(Avner, 2009). In these children, even moderate fever should
be treated aggressively (Schmitt, 1984).
Fever Phobia
Barton Schmitt M.D. is a pediatrician who first coined the
term fever phobia to describe the misconceptions about
fever he observed in the parents of his patients (Schmitt,
1980). Common misconceptions he reported include: the
belief that temperatures in children will rise uncontrollably if
not treated; fever causes great harm, including brain damage
and death; and, fevers should be treated aggressively
(Schmitt, 1980). Crocetti, Moghbeli, and Serwint (2001)
studied parents knowledge and management of fever twenty
years later to determine if attitudes and practices had
changed. The authors found fever phobia persisted and in
373
some ways had worsened. In comparison to Schmitts study,
more parents listed seizures as a harmful effect of fever, were
likely to wake children from sleep to check temperature, and
administered antipyretics or sponge baths for normal
temperatures (Crocetti et al., 2001).
Studies have shown that there are ethnic and cultural
differences regarding knowledge and management of fever in
the United States. Cohee, Crocetti, Serwint, Sabath, and
Kapoor (2010) studied treatment of childhood fever among
Caucasian, African American, and Latino parents and found
that although all ethnic groups were likely to over treat fever
with acetaminophen, African American parents were more
likely than the other groups to over treat with ibuprofen. In
addition, Latino parents were more likely to identify afebrile
temperatures as fever, and African Americans were least likely
to worry about brain damage or death as a result of fever
(Cohee et al., 2010). Rupe, Ahlers-Schmidt, and Wittler (2010)
found Latino parents to be more likely than Caucasians or
African Americans to report the beliefs that fever can rise
uncontrollably if untreated and fever can cause death. Crocetti,
Sabath, Cranmer, Gubser, and Dooley (2009) found mis-
conceptions regarding fever in Spanish-only speaking parents.
More than half the parents believed fever could cause brain
damage or death, and 90% of the parents were reportedly very
worried about fever (Crocetti et al., 2009).
Fever phobia has also been reported by researchers in
multiple countries. Tessler, Gorodischer, Press, and Bilenko
(2008) compared attitudes about fever in traditional Bedouin
parents and westernized Jewish parents in Israel and found
the Bedouin parents more likely to believe fever can cause
brain damage and death compared to the westernized
Jewish parents. Walsh, Edwards, and Fraser (2008) report
Australian parents over treat fever with antipyretics, indicate
normal temperatures as fever, and believe moderate fever can
cause harm. Fever phobia and excessive treatment of fever
has also been identified in the United Kingdom (Purssell,
2008); Japan (Sakai & Marui, 2009); Canada (Karwowska,
Nijssen-Jordan, Johnson, & Davies, 2002), and Italy
(Impicciatore, Nannini, Pandolfini, & Bonati, 1998).
Parents are not alone regarding fever phobia and
aggressive treatment of fever. The belief among nurses and
doctors that fever is harmful and necessitates treatment has
been widely reported (Karwowska et al., 2002; Poirier,
Davis, Gonzalez-Del Rey, & Monroe, 2000; Sarrell, Avner
Cohen, & Kahan, 2001; Walsh, Edwards, Courtney, Wilson,
& Monaghan, 2005; Wright & Liebelt, 2007). Parents
receive confusing messages from health care providers about
the dangers of fever and the need for treatment which may
exacerbate their fears (May & Bauchner, 1992).
Antipyretics
As previously noted, when pyretics enter the body
prostaglandin production is elevated, stimulating the
hypothalamus to raise the set point. As a result, body
374
temperature is increased and fever ensues. Acetaminophen
and ibuprofen work by impeding the cyclo-oxygenase
enzyme, which transforms arachidonic acid to prostaglan-
din (Avner, 2009). The decrease in prostaglandin produc-
tion leads to a lowering of the set point and resolution of
fever (Avner, 2009).
The recommended dose of acetaminophen is 10 to 15 mg/
kg per dose every 4 to 6 hours with a maximum dosage of 90
mg/kg/24 hours; onset of antipyretic action is 3060 minutes
(Sullivan & Farrar, 2011). Ibuprofen is considered safe to
give to children above 6 months of age. The dosage is 10 mg/
kg per dose with a maximum of 40 mg/kg/day; antipyretic
action is as effective as or more effective than acetaminophen
(Sullivan & Farrar, 2011).
Although both drugs are considered safe when given
correctly, toxic effects can occur with more frequent doses or
higher doses than recommended. Hepatotoxicity can occur
with an acute overdose of acetaminophen, while chronic
overdose can lead to acetaminophen-related hepatitis
(Sullivan & Farrar, 2011). Nephrotoxicity can occur with
ibuprofen. Those at highest risk for developing renal
insufficiency are infants under 6 months of age, children
with dehydration or cardiovascular disease, or those taking
other nephrotoxic medications (Sullivan & Farrar, 2011).
Alternating acetaminophen and ibuprofen to reduce fever
is a widely used practice among parents and often
encouraged by nurses and doctors (Sullivan & Farrar,
2011). According to Sarrell, Wielunsky, and Cohen (2006),
alternating antipyretics significantly decreases fever com-
pared to monotherapy. However, the regimen is controver-
sial. Sarrell et al. (2006) warns against alternating
medications, as it may increase parents fever phobia and
the risk for overdose. The American Academy of Pediatrics
(AAP) cautions providers who recommend alternating
antipyretics to give thorough instructions to parents to
avoid dosing incorrectly (Sullivan & Farrar, 2011).
Finally, antipyretics have been administered by parents
and health care providers alike to prevent febrile seizures.
However, the evidence has consistently shown that admin-
istration of antipyretics do not prevent either fever or febrile
seizures (Fetveit, 2008). Febrile seizures are a common
occurrence in early childhood and are not associated
with brain damage or increased mortality (Shinnar &
Glauser, 2002).
The evidence suggests the focus of management of the
child with fever should be on relieving discomfort,
avoiding dehydration, and observing the child for signs of
serious illness, such as difficulty breathing, rash, decreased
urination, and diarrhea or blood in the stool (Crocetti &
Serwint, 2005). Sponge bathing with alcohol to reduce
fever can cause toxicity as the alcohol may be systemically
absorbed; therefore the practice should be avoided
(Schmitt, 1984). In addition, sponge bathing with cold
water is ineffective because it is uncomfortable and can
lead to shivering, resulting in a higher temperature
(Schmitt, 1984).
Clinical Practice Department
Applying the Evidence to Practice
Pediatric nurses are in a unique position to talk to parents
about fever. It is imperative that nurses have knowledge of
the febrile response, benefits of fever, and safe management
of fever. Nurses should discuss what beliefs parents have
about fever so that misconceptions can be identified. In
addition, nurses ought to be aware that misunderstandings
about fever may vary among ethnic and cultural groups;
therefore, information should be given in a culturally
sensitive manner. If parents express concerns about detri-
mental effects of fever, the difference between hyperthermia
and fever should be discussed, as well as the benefits of fever
in fighting illness. While febrile seizures are frightening to
witness, parents need to know that they are benign and
cannot be prevented with antipyretics.
Dangerous practices to treat fever need to be identified
and discussed with parents. These include sponge bathing
with alcohol and overdosing with antipyretics. Parents need
to understand the different dosing regimens of acetamino-
phen and ibuprofen. In addition, they should understand that
many over the counter products contain ibuprofen or
acetaminophen; if administered, they may unwittingly
overdose their child. Alternating antipyretics should be
discouraged due to the risk of confusion and error.
Fever is usually the result of benign viral illness. For
healthy children, the benefits of fever usually outweigh the
risks. Nurses can educate parents to focus on the comfort of
the child by offering fluids and removing extra clothes. The
child should be observed for signs of serious illness.
Antipyretics should be given carefully with the objective of
improving the comfort of the child rather than decreasing
the temperature. The desired outcome of parental education
is to limit fever phobia while promoting safe management
of fever.
References
Avner, J. R. (2009). Acute fever. Pediatrics in Review, 30, 513, http://dx.
doi.org/10.1542/pir.30-1-5.
Bierman, W. (1942). The history of fever therapy in the treatment of disease.
Bulletin of the New York Academy of Medicine, 18, 6575.
Cohee, L. M. S., Crocetti, M. T., Serwint, J. R., Sabath, B., & Kapoor, S.
(2010). Ethnic differences in parental perceptions and management of
childhood fever. Clinical Pediatrics, 49, 221227.
Crocetti, M. T., & Serwint, J. R. (2005). Fever: separating fact from fiction.
Contemporary Pediatrics, 22, 3442.
Crocetti, M., Moghbeli, N., & Serwint, J. (2001). Fever phobia revisited:
have parental misconceptions about fever changed in 20 years? Pedia-
trics, 107, 12411246.
Crocetti, M., Sabath, B., Cranmer, L., Gubser, S., & Dooley, D. (2009).
Knowledge and mangagement of fever among Latino parents. Clinical
Pediatrics, 48, 183189, http://dx.doi.org/10.1177/0009922808324949.
El-Radhi, A. S. (2011). The role of fever in the past and present. Medical
Journal of Islamic World Academy and Sciences, 19, 914.
Fetveit, A. (2008). Assessment of febrile seizures in children. European
Journal of Pediatrics, 167, 1727.
Clinical Practice Department
Frieden, E. (1939). Fever therapy for children. The American Journal of
Nursing, 39, 762767.
Impicciatore, P., Nannini, S., Pandolfini, C., & Bonati, M. (1998). Mothers'
knowledge of, attitudes toward, and management of fever in preschool
children in Italy. Preventive Medicine, 27, 268273.
Karwowska, A., Nijssen-Jordan, C., Johnson, David, & Davies, H. D. (2002).
Parental and health care provider understanding of childhood fever: a Canadian
perspective. Canadian Journal of Emergency Medicine, 4, 394400.
Kluger, M. J., Kozak, W., Conn, C. A., Leon, L. R., & Soszynski, D. (1998).
Role of fever in disease. Annals of the New York Academy of Sciences,
856, 224233, http://dx.doi.org/10.1111/j.1749-6632.1998.tb08329.x.
May, A., & Bauchner, H. (1992). Fever phobia: The pediatricians
contribution. Pediatrics, 90, 851854.
Poirier, M. P., Davis, P. H., Gonzalez-Del Rey, J. A., & Monroe, K. W.
(2000). Pediatric emergency department nurses' perspectives on fever in
children. Pediatric Emergency Care, 16, 912.
Purssell, E. (2008). Parental fever phobia and its evolutionary correlates.
Journal of Clinical Nursing, 18, 210218, http://dx.doi.org/10.1111/j.
1365-2702.2007.02077.x.
Rupe, A., Ahlers-Schmidt, C. R., & Wittler, R. (2010). A comparison of
perceptions of fever and fever phobia by ethnicity. Clinical Pediatrics,
49, 172176, http://dx.doi.org/10.1177/0009922809336208.
Sakai, R., & Marui, E. (2009). Fever phobia: Can we blame the trend to nuclear
family or having a single child? Acta Paediatrica, 98, 405407.
Sarrell, M., Avner Cohen, H., & Kahan, E. (2001). Physicians, nurses, and
parents attitudes to and knowledge about fever in early childhood.
Patient Education and Counseling, 46, 6165.
375
Sarrell, E. M., Wielunsky, E., & Cohen, H. A. (2006). Antipyretic treatment
in young children with fever. Archives of Pediatrics & Adolescent
Medicine, 160, 197202.
Schmitt, B. D. (1980). Fever phobia: misconceptions of parents about
fevers. American Journal of Diseases of Children, 134, 176181.
Schmitt, B. D. (1984). Fever in childhood. Pediatrics, 74, 929936, http://
dx.doi.org/10.1111/j.1651-2227.2008.01097.x.
Shinnar, S., & Glauser, T. A. (2002). Febrile seizures. Journal of
Child Neurology, 17, S44S52, http://dx.doi.org/10.1177/
08830738020170010601.
Sullivan, J. E., & Farrar, H. C. (2011). Fever and antipyretic use in children.
Pediatrics, 127, 580587, http://dx.doi.org/10.1542/peds.2010-3852.
Tessler, H., Gorodischer, R., Press, J., & Bilenko, N. (2008). Unrealistic
concerns about fever in children: the influence of cultural-ethnic and
sociodemographic factors. The Israeli Medical Association Journal, 10,
346349.
Walsh, A. M., Edwards, H. E., Courtney, M. D., Wilson, J. E., &
Monaghan, S. J. (2005). Fever management: pediatric nurses
knowledge, attitudes and influencing factors. Journal of Advanced
Nursing, 49, 453464.
Walsh, A., Edwards, H., & Fraser, J. (2008). Parents childhood fever
management: community survey and instrument development. Journal
of Advanced Nursing, 63, 376388.
Wright, A. D., & Liebelt, E. L. (2007). Alternating antipyretics for fever
reduction in children: an unfounded practice passed down to parents
from pediatricians. Clinical Pediatrics, 46, 146150, http://dx.doi.org/
10.1177/0009922806293922.