Why You Probably Shouldn’t Break a Fever
The first time my son was sick with a fever he was warm, weak, and just miserable. Naturally, I reached for the Tylenol, but I was slow in doing so—having learned that it’s not always good to break a fever—so I put it back in the cabinet. After hours of checking his temperature and seeing him in this discomfort, I began to worry about whether the fever would cause seizures or even brain damage. I gave in and within 20 minutes the Tylenol had brought him back to his typical, jovial self.
He was happy and I was relieved but I wasn’t sure whether I made the right decision. I’ve heard that fevers can be good and I know there are so many side effects of medications, even as benign as Tylenol. So did I make the right decision? I went on a deep quest to find out.
This article is meant to dispel the myths, misconceptions, and fears surrounding fevers in order to provide the best approach for our kids. It’ll provide evidence-based practices for treating fever in your children. Learning this now, when your child doesn’t have a fever, is important. When we’re armed with good information we can tamp down the emotional decision-making in times of stress and amp up the logic-based parts for better outcomes.
Should you break a fever? Myths, fear, and culture.
Back in 1980, the pediatrician Dr. Scmitt coined the term “fever phobia” to describe the misapprehension that parents and doctors had regarding fevers. This phobia leads to treating a fever that’s not only generally very safe but is beneficial to the body. In the decades since this fear and anxiety haven’t gone anywhere but up.
One cross-sectional screen of parents found that they all treat fevers with acetaminophen “too frequently.” A separate study found that both the parents and pediatricians used multiple types of medication (ibuprofen, acetaminophen, steroids, etc.), to reduce the body temperature “with the aim to prevent febrile convulsions, despite the fact that all these practices are discouraged by the current guidelines.” And in an interview study comparing parent responses to the research, they found widespread use of medications to lower fevers with the aim of preventing seizures even though this doesn’t work. In short, treating the standard fever is more related to dogma than evidence-based practice.
There are two main reasons parents give their kids medication for fevers:
Poor health literacy is common in healthcare providers, caregivers, and patients. With a lack of consistency regarding evidence-based education and recommendations on fever management strategies, it’s no wonder that parents still use medication inappropriately when their child has a fever.
There’s a general fear that leads to overmedication, however, it’s not usually fear of the fever itself but of the repercussions of the fever. As a child’s internal temperature rises so does the fear that this will lead to convulsions, seizures, brain damage, and death. This fear has been found to be most common in highly educated mothers.
Why do we get fevers?
Our immune system is constantly in standby mode. It’s on the lookout for that next viral or bacterial invader and when that time comes it strikes with full force. One of the tools in the immune system’s toolbox is the fever. A fever is not an illness but rather a response to one.
This use of heat to raise the temperature of the body at the onset of an infection isn’t limited to humans–all vertebrates do it. Interestingly, some animals, such as birds, are like humans and this occurs naturally. For other animals, like lizards, this isn’t naturally occurring and they will actually seek out a heat source to induce this effect.
In humans of all ages, the body is a finely tuned machine that’s constantly seeking balance in all things from blood sugar to electrolyte balance to body temperature. Body temperature varies from person to person, hour to hour, and even by age. The average body temperature is 98.6°F but it’s lowest around 6 am and highest around 4-6 pm. Children ages 18-24 months tend to have the highest normal body temperature which hovers at about 101°F. (source)
Adults have a much easier time regulating their body temperature compared to children. Our best evolutionary adaptation to this is sweating and as adults, we sweat easily (sometimes too easily). Children, however, don’t sweat nearly as easily, and simple things like playing, running, and even wearing warmer clothes can spike their body temperature.
While these can temporarily raise body temperature, things like bacterial and viral infections (e.g. common cold, ear infections, UTI) are the most common reasons for a fever. Other, less common things that might cause a fever are dehydration and sunburn and in very rare cases things like pneumonia, appendicitis, or allergic reactions to foods or medication.
When children come down with any of these threats then their immune system may release cytokines (in particular interleukin-1). This cranks out prostaglandins in the hypothalamus which creates a higher “set point” temperature in the body in an effort to kill the threat.
The benefits of this higher body temperature are that it “augments the performance of immune cells, induces stress on pathogens and infected cells directly, and combines with other stressors to provide a nonspecific immune defense.” (source)
A rise of even just a few degrees has the ability to halt the issue in a relatively short time. In fact, intentionally causing a fever, a.k.a hyperthermia, is used to treat different types of cancer and even a one degree rise has been shown to reduce virus replication by a factor of 200. This adaptive immune system response of a fever is actually a great sign telling us that our body is working well to keep us healthy.
While there are countless examples of the benefits of fever it was Dr Julius Wagner-Jauregg who was one of the first to put this to the test for treating the neurological effects of syphilis. For this work, he won a Nobel Prize back in 1927.
A fever is considered (source):
Children (0-12 months): 100.4°F or higher (taken rectally)
Children and adults: 101.3°F or higher (taken orally)
Are fevers dangerous?
Fevers are not only generally very safe but they’re a sign of a strong and healthy immune system. A fever has been considered an adaptive, protective, and self-limiting response for thousands of years. It’s only in recent years, with the use of medication, that fevers have been considered harmful.
Most fevers in children are a response to viral illnesses. Fevers tend to stay in the 101°F-104°F degree area—high enough to kill the invaders but low enough to not have any long-term issues. They typically last 2-3 days and they’re typically not harmful.
So how common is it that children with a fever need a healthcare provider? “Only about 1 out of 100 children with fever have a serious medical problem that needs to be treated by a doctor. In most cases bacterial infections such as pneumonia are then to blame.” (source and source)
So what is the best approach to managing a fever?
Should You Break a Fever? The Two Approaches
Fever approach 1: antipyretics
Unfortunately, our immune system doesn't ‘t work like a laser with pinpoint accuracy, zapping away every threat. Instead, it must go with the carpet bombing strategy with ramifications that can be felt throughout the body. We experience muscle aches, headaches, chills, sweating, and a loss of appetite among other uncomfortable things. This prompts us to reach for the Tylenol and voila, we feel better in no time. This is the first approach: antipyretic (Greek for “against fire”).
There are three types of OTC meds used as antipyretics: acetaminophen (Tylenol), NSAIDs (non-steroidal anti-inflammatory drugs) like ibuprofen (Advil), and salicylates (like aspirin).
The main issue with the antipyretic approach is that these fever-reducing medications reduce the impact of the fever which was called in to fight the illness in the first place. As a result, the threat stays in the body longer, potentially looms larger, and you stay sick for a longer period of time. It’s like reducing the number of firefighters sent to a fire. Yes, the fire will still eventually go out but it will take much longer.
Then there are the side effects of the medications.
The research on treating fevers with medication
Feel free to skip this section and scroll to the next but I thought it was worthwhile to list the evidence against the use of medication for fevers here.
Since fevers are so common and easy to objectively define in the hospital, particularly in the intensive care units (ICU), they’re an easy place to perform good research.
A 2001 randomized study in the Archives of Internal Medicine broke up 38 surgical intensive care patients into two groups: antipyretic and external cooling without meds (e.g. cooling blankets and ice packs). Each of these patients had a fever but they did not have neurotrauma or severe hypoxemia (low oxygen levels). They measured the fever and discomfort levels. The researchers concluded that “Letting fever take its natural course does not seem to harm patients with systemic inflammatory response syndrome or influence the discomfort level and may save costs.” There was no significant difference in the recurrence of the fever, infection, hospital or ICU length of stay, or mortality.
A 2006 randomized prospective study in Surgical Infections divided up 44 patients with fevers in the trauma intensive care unit into two groups. The aggress group got 650mg of acetaminophen 650 mg every 6 hours if their temperature was above 101.3F and the permissive group had no meds unless their temperature was above 104 degrees F. After about a year the study had to be stopped because there were seven deaths (!) in the aggressive group and one death in the permissive group. They simply concluded that “Aggressively treating fever in critically ill patients may lead to a higher mortality rate.”
A 2015 randomized control study in the New England Journal of Medicine broke up 700 intensive care unit (ICU) patients into two groups. One group received 1g of intravenous acetaminophen (Tylenol) every 6 hours and the other group received a placebo every 6 hours. They concluded that using acetaminophen to treat a fever didn’t reduce the number of ICU-free days. There was also no significant difference in the hospital length of stay or the mortality rate.
According to this 2015 review in the Journal of Thoracic Disease states that “The only clinical condition with abundant evidence to support aggressive antipyretic treatment is in acute brain injury. Even the management of febrile seizures in the pediatric population has moved away from antipyretic use as prophylaxis since fever reducing drugs do not reduce seizure recurrence.”
A 2020 article written in the midst of the pandemic and published in the Journal of the Royal Society of Medicine agrees. “In this moment of uncertainty and crisis, it may be proper to break cultural habits and advise against the use of antipyretic drugs for at least a few days after the onset of symptoms.”
A 2020 thesis titled, “The impact of fever and its treatment in critically ill children” assessed the relationship between fevers and mortality rates of children in the ICU. The author concluded, “Fever was similarly associated with improved survival in children with infection.”
A 2021 review in Evolution, Medicine, and Public Health supported the idea that an antipyretic approach is not good if the fever is due to COVID either. “During pandemic COVID-19, the benefits of allowing fever to occur probably outweigh its harms, for individuals and for the public at large.”
The evidence is clear that the use of medication to reduce a fever is generally not beneficial. In the patients studied in the above research, not only is there no significant advantage to using medication but there can be a huge downside.
The side effects of medication
The other issue with this approach is that antipyretic medications have toxic effects like all medications. Here are the main side effects of some of the most popular medications used for fevers.
Acetaminophen (a.k.a Tylenol or paracetamol) is the most popular antipyretic and analgesic (pain reliever) medication in the world. It’s been shown to negatively impact the immune response of the body. There are also case reports and evidence that suggest that giving multiple doses of acetaminophen at just slightly higher doses than the recommended maximum amount can cause liver failure. Other side effects of acetaminophen are red, peeling or blistering skin, rashes, hives, itching, swelling, and difficulty breathing or swallowing.
NSAIDs (e.g. Advil), another series of drugs commonly used with fevers, also have side effects. The most common ones are acute kidney injury and gastrointestinal bleeding. Other side effects of NSAIDs include dizziness, sleepiness, headaches, nausea, abdominal discomfort, heartburn, and diarrhea.
Aspirin has been linked to Reyes syndrome, a very rare condition typically occurring in children that causes the brain to swell and the liver to lose function after a viral infection. The FDA recommends that “aspirin should not be used in children or teenagers for viral infections, with or without fever, because of the risk of Reye's syndrome with concomitant use of aspirin in certain viral illnesses.” As a precaution, we do not use it with our children at all.
It’s important to note that while this information can be alarming, these medications are very common and generally safe when the recommended dosage is given and when they’re used for short periods of time. As the old adage goes, “the dose makes the poison.” Talk to your healthcare provider about using any medications with your children. Use a reputable site like drugs.com or talk to your pharmacist to learn more about medications prior to giving them to your children.
There are no universal antipyretic guidelines
Given that fevers are so common and medications are so often used to treat fevers, you’d think that there’d be a universally accepted approach to treating a fever. Nope.
A systematic review analyzed 74 national and international guidelines for the use of antipyretics for fever in children. The recommendations for when to provide medications ranged from 100.4°F to greater than 104.9°F. That’s an enormous range! They stated, “There is no recommendation on which all guidelines agree, and many are inconsistent with the evidence–this is true even for recent guidelines.”
This lack of consensus on antipyretics makes it obvious that there’s insufficient evidence and agreement to provide a clear-cut protocol for managing a fever with medication. The evidence doesn’t support their use for the general fever and as a result, guidelines are created based not on science but based on non-clinical factors such as tradition, anecdotal information, cultural norms, and emotions. That being said, it’s important to take into consideration the information and evidence to optimally treat a fever.
Fever approach 2: let it ride
The other strategy is to let the fever run its course, often referred to as the “let it ride” approach. It’s as simple as it sounds but it’s not easy.
Commercials, the advice of friends, and our past experiences make the fever equation seem like it’d be a no-brainer: child has fever → I have fever-reducing medication → give meds → child looks and feels better. But given the research and the recommendations of the medical community, using restraint with providing medications for the general fever, through this “let it ride” approach, is often the best approach.
Having a sick kid is never easy but having the knowledge that this is best for the health of the child always helps. Your child is going to have a fever. How you manage it in theory and how you manage it in the moment are often two totally different avenues. Do your research, talk to your significant other and your doctor before fevers occur, and come up with an approach for when the time comes.
How to treat a fever
Here are some best practices for treating children (above the age of 3 months) with fevers:
Monitor the symptoms (concerns include rashes, severe headaches, and a stiff neck–see below for more information).
Monitor the behavior (concerns include not maintaining eye contact and constant crying–see below for more information).
Keep the child hydrated.
Don’t dress the child too warmly.
Avoid or limit external cooling techniques (a bath, cold packs, wet towels, etc.). It has mixed results in the literature with modest results at best.
Don’t use antipyretics with the sole purpose of reducing body temperature. If your child is uncomfortable to the point of causing health issues such as not drinking water then consider antipyretics.
Combination therapy, which is alternating acetaminophen and ibuprofen, may be the best approach. Do not give aspirin due to the risk of Reye’s syndrome.
We use the brand Genexa for acetaminophen because it doesn’t contain dyes, artificial preservatives or fillers, and it uses organic agave syrup instead of high fructose corn syrup.
Contact your healthcare provider if you have an intuition that something more severe is occurring.
Seek medical assistance if any of the below situations or symptoms arise.
“Time, rest and loving care are usually the best remedies.” -Institute for Quality and Efficiency in Health Care (IQWiG)
These are general guidelines. Talk to your doctor and come up with guidelines that work for you and your family that align with your own mental well-being.
When to contact your healthcare provider
Babies & Toddlers
Call your child’s healthcare provider if:
0-3 months: A rectal temperature of 100.4°F or higher.
3-6 months: A rectal temperature higher than 102°F (or a lower temperature that seems uncomfortable) in babies 3-6 months old.
7-24 months: A rectal temperature higher than 102°F lasting longer than a day.
Children
Call your child’s healthcare provider if your child:
Has a fever higher than 104°F. This could indicate something more severe such as poisoning, a severe infection, or heatstroke.
Has a fever and is less than 3 months old.
Has a fever lasting more than 3 days (72 hours).
Has a fever above 100.5°F for 3 weeks or more, even if there are no other symptoms.
Is listless, confused, or can’t maintain eye contact.
Refuses to drink water.
You think your child needs to be seen.
When to go to the hospital or call 911
Infants, Adults, and Children
Anyone with these symptoms should go to the hospital or call 911:
Has trouble breathing
Is not moving
Is not waking up
Has a seizure
Is irritable and vomits repeatedly, or has a severe headache.
Has a rash
Is confused
Has persistent vomiting or diarrhea or signs of dehydration
Has severe headaches
Cannot stop crying
Has a stiff neck
Moderate to severe abdominal pain
What I do
These meds to reduce a fever seem harmless. After all, nearly every parent I know uses them, doctors recommend them, and I’ve had gallon's worth of Tylenol as a kid. Yet, the research points in a different direction.
I knew some of the information above before diving into the topic however, the deeper I went with the research the more alarming the concerns that rose to the surface. Since this, I’ve changed my approach to how I treat fevers (in kids and in myself). I now almost always go with the ride-it-out approach. I try to avoid the meds and, instead, I monitor the symptoms and the temperature while making my kids comfortable and keeping the environment around them low-key, happy, and fun. The exceptions are few and far between but it’s primarily been when my kid can’t fall asleep or is drinking way less than normal in which case we use the brand Genexa for acetaminophen.
I can’t say that anytime I’ve done this it’s been easy but it has gotten much easier. Based on everything I know the end justifies the means and my kids are better off for it.
Takeaway
When a child has a fever, parents tend to give meds and the kid feels better. This reasoning comes down to a few main factors: what our parents did for us, cultural norms, what our friends and family do, what our healthcare providers recommend, and even basic emotions like fear and anxiety that may not be present outside of the moment but skyrocket when that thermometer blinks red. Not everyone knows that there are disadvantages to giving kids medication but even once we learn that we shouldn’t break a fever, we often still do it. I survived, it’s instant relief, and maybe that fever will lead to seizures, brain damage, or something worse. Here you go.
Fevers, however, are a purposeful and important tool that our immune system uses to suppress the threat (typically a bacterial or viral invader). Fevers are typically harmless and very rarely result in any significant health concern. This use of medication to reduce the general fever, referred to as antipyretics, is not only unsupported in the research but the use of these medications can cause more harm than not using it. A good approach to managing a fever is to let the fever run its course or “let it ride.”
That being said, it’s important to talk to your healthcare provider if your child exhibits any of the rare situations that would require more immediate action (see the list immediately above).
FAQ
Can a fever cause brain damage?
It’s very unlikely for a fever to cause brain damage. A fever that reaches 108 degrees or higher, however, can cause brain damage. This is very rare and tends to happen when the surrounding environment is warm such as when a child is left in a hot car. (source)
Does a higher temperature mean a worse illness?
The number does not correlate to the severity of the illness. Some kids have a serious illness and no fever and others have a minor illness with a higher fever.
Will medication prevent a febrile seizure?
Unfortunately, antipyretics don’t prevent febrile seizures. There is no compelling evidence that the use of any medication reduces these seizures. One of the reasons is that febrile seizures tend to occur at the onset of the fever meaning meds wouldn’t effective in preventing them. (source)
Does a fever cause a seizure?
Febrile seizures are fevers or convulsions triggered by a fever. They tend to happen in children when a child has an ear infection, a cold, or the flu. Most of the time this seizure lasts a few minutes at most. They do not cause any long-term health issues or brain damage. About 2-5% of children less than 5 years old will have a febrile seizure and 40% of them will have another seizure. (source)
What should I do when my child has a febrile seizure?
Start by prioritizing your child’s safety. Make sure there is nothing in their mouth. Put your child in a safe position in an open area on the ground or the floor to prevent hitting something or falling and hurting themselves. Don’t hold the child or restrain them.
Time how long the seizure lasts and if it’s longer than 5 minutes then call 911. If your child has symptoms of meningitis after the seizure (stiff neck, extreme lethargy, and vomiting) then seek medical attention. (source)
Does teething cause a fever?
No. Teething can slightly raise the temperature of the baby but not to the point of a fever.
