February 2024

 

An article by Juan E.De la Cruz-Mena, MD, MSc, et al entitled SHORT-TERM DUAL THERAPY OR MONOTHERAPY WITH ACETAMINOPHEN AND IBUPROFEN FOR FEVER: A NETWORK META-ANALYSIS appeared in Pediatrics, Vol.154, nu 4, October 2024, pg. 60.

 

This article shows that giving a febrile child acetaminophen and Ibuprofen together is more effective at lowering the temperature. We know that giving the combination together is more effective at controlling pain. Alternating Ibuprofen and acetaminophen should be a thing of the past.

---

 

Let us take the opportunity to reprint a prior article I wrote that discusses fever and its control, and even its benefits.

 

FEVER IS OUR FRIEND: HOW COME REPTILES ARE SMARTER THAN HUMANS?

 

The iguana slithers over the floor of the jungle at a pace slower than usual. He seems less interested in the tasty hugs that dart about. A slight hissing cough can be heard coming from this sick, cold-blooded animal. The damp jungle surface, which usually is a perfect environment, has become less than ideal.

 

The foliage rustles as the lizard makes his way to a hot surface. He moves directly to the opening in the green, primeval canopy of trees and bushes made by the flowing river. Water is not what he desires, but the sun-drenched rocks that line the riverbank.

 

Instinctively this animal knows that it needs to raise the body core temperature while sick with an infection.

 

Feet patting along the surface of the muddy ground, he aims for the bright rock ahead. Beetles watch as he scurries past without even a glance their way. Feeling the warmth of the hot surface, he pauses at the base of a flat rock bathed in sunshine. A few soft coughs are emitted before the iguana scrambles up the igneous mass and comes to rest like a trout in a frying pan. Lying motionless as his core temperature rises, the animal instinctively gains satisfaction from doing something to combat his ill state.

 

Contrast that scenario with a common story played in homes throughout the world:

 

Little Mary tosses and turns in her toddler bed. Nasal discharge drips onto the surface of her pillow, and every now and then a moist cough emanates from her mouth.

 

Ruth, her mother, senses activity from the room next door. Rolling out of bed and patting barefooted into Mary’s room, she places her hand on the child’s forehead and senses heat.

 

“My God,” she says to herself. “Mary’s got a fever!” The thermometer will document this concern. A few minutes later comes the proof. Mary has 103 degrees of fever. A dose of acemetaphen is given to the child and mom starts pacing the floor.

 

Thirty minutes pass and the temperature is taken again.

 

This time it registers 103.2 degrees, “It’s going up,” she mutters. “I’ve got to get it down!” Running to the bathroom she fills the tub with tepid water. Returning to Mary’s room she proclaims to her sleeping husband, “I’ll get the temperature down. Don’t worry, Bill.” Bill rolls over; his sleep uninterrupted.

 

Mary is carried in her mom’s loving arms and placed gently in the cool water. By now Bill has awakened. The peace of the house is shattered by Mary’s screams. “No, Mommy! Get me out. It’s too cold!”

 

“What’s going on, Ruth?” Bill questions. “Mary has a fever and I must get it down.“ Blurry-eyed he staggers into the bathroom to give his support. “What can I do?” “Get the Motrin. Sometimes it works better.”

 

Retreating into the hall he realizes he doesn’t know where the medicine is kept. “Look in the high cupboard, by the kitchen sink.”

 

Together the parents manage to get some of the liquid medicine down Mary’s throat. After 45 minutes Ruth takes the temperature again. Now she is near panic. “The temperature is still 103 degrees! It’s not coming down!”

 

“Okay,” Bill says. “I’ll call our pediatrician.” Finding the phone he punches the buttons to the exchange which puts him through to the doctor.

 

“Doctor, this is Mr. Dwight. Our baby has a temperature of 103 degrees.” Silence is the response from the phone. “We’ve tried everything and nothing is getting the temperature down!” More silence prevails. “Doctor, what should we do?”

 

“Give me some history. How long has she been ill? Is she active? What symptoms does she have?” asks the doctor.

 

“I have no idea. I’ll get my wife.” Bill trades places with Ruth who is still minding the screaming child sitting in the cold water. “Doctor Jones, this is Ruth. She was fine when I put her to bed. She had a runny nose, come to think of it. I found her about 3:00 a.m. with a fever of 103 degrees.”

 

“Is she lethargic or weak?” “Hardly, Doctor. She’s fighting the cold bath like a banshee. There’s water all over the bathroom floor.” “Does she appear ill?” “If it weren’t for the fever I wouldn’t see much unusual behavior.”

 

“Okay. Let the medicine work. Get her out of the tub before she starts shivering. Dress her lightly and let her go to sleep. Check her temperature in four hours and if it is high give her another dose of fever medication. Let’s plan to see her in the office in the morning.”

 

“But the fever, Doctor. What about the fever?” “Don’t worry. If Mary looks normal the fever is not a real problem. In fact, it is helping her fight the infection.”

 

Why are these two situations so different? Reptiles do not have phones or medications to aid their distress. They do not have a foundation of folklore, myths, or old wives’ tales to fall back on and cloud their responses. The cold-blooded animals are simply driven instinctively to do what is best. They seek heat to raise the body temperature.

 

Why does the human body develop a fever when infection ensues?

 

Increased body temperature provokes two beneficial immunological effects: 1) the white blood cell’s ability to kill bacteria is greatly enhanced. 2) viral replication is significantly impeded.

 

Fortunately, the human body has the ability to generate it’s own heat at times of infection.

 

This saves an inconvenient trip to lay on a hot rock. The human brain has a temperature control center that works similarly to an automobile thermostat. As the temperature rises this center activates various body mechanisms to keep the vital organ systems at a safe heat level.

 

It is generally thought that temperature control center will keep the body temperature below 105.8 degrees. This level is below a fever that is intrinsically dangerous. The body systems can function satisfactorily up to and even over 106 degrees. We have learned that patients suffering a malignant hyperpyrexia attack sustain system failures when they develop temperatures in excess of 107 degrees. This tells us that deadly temperatures cannot be reached with a normal, functioning “nervous system thermostat”. A temperature over 106 degrees in a child may indicate failure of the temperature control center. That often indicates a nervous system infection, i.e., meningitis or encephalitis.

 

It is more important to assess the patient’s general condition than to rely on fever measurement alone.

 

I have seen patients desperately ill with low fevers, and those suffering from a minor viral infection with a very high fever. I can hear parents disagreeing. Their child had a fever convulsion. “Therefore, don’t tell me fevers aren’t dangerous!” It is felt that febrile seizures are associated with a rapid rise in temperature. The overall height is not as critical as the rate of rise. Without question, if you know that your child will have a seizure if the body temperature goes above 104 degrees, you will try to keep it below that threshold. Most of the time the convulsion occurs before the parent realizes the child has a fever. Fortunately, febrile seizures are short lived and pose no deadly threat to the affected child. They are more traumatic to the observing parent.

 

Assuming this is true, why give medications to lower fever?

 

Tylenol, Motrin, etc. can be given when the discomfort of the fever significantly effects the patient. Headache, muscle ache, sore throat and ear pain are good reasons to give medication, whether they lower fever or not. In the face of a serious infection, one notes the temperature is not usually reduced to the normal basal temperature of 98.6 degrees. The body does what is best, despite us.

 

I used to believe that a temperature over 105 degrees led to brain damage.

 

It was not until attending medical school that I found this statement was not true. Having talked to thousands of parents I found this myth still continues. One can understand where the panic comes from. Keep the fever below 105 degrees or the brain will be damaged! This has been the all too prevalent admonition given to inexperienced caregivers.

 

Is there any place for ice water soaks or cool water baths to control fever? Unless you are dealing with the rare condition of malignant hyperpyrexia, NEVER! A child with fever under 106 degrees never needs submission in cold or lukewarm water. These measures usually provoke shivering which in turn keeps the temperature high. It becomes a losing battle that only fatigues and torments the child.

 

In measuring body temperature remember the following:

1. Rectal temperature best assesses core temperature.
2. Forehead strips are not accurate enough and only evaluates skin temperature.
3. Axillary temperature is a poor substitute for a rectal reading.
4. Some journal articles have found electronic eardrum thermometers to be of questionable accuracy in patients under age five years.
5. If done properly, sublingual oral temperature can be accurate and within one degree Fahrenheit of rectal core temperature.

 

If you feel compelled to lower the body temperature, as in the case of the patient with a known history of fever convulsions, you should:

1. Use warm temperature bath water.
2. Wet the child as you would for a regular bath.
3. Remove him and have the baby sit on your lap, unclothed so that the water evaporates off the body—this is what causes efficient cooling.
4. If “goose flesh” occurs, or shivering is seen, dry the child off and cover with a dry towel to stop evaporation.
5. After the shivering ceases, resume the same cooling procedure again.

 

As the title of this article indicts, fever is not to be feared. It serves a useful function and can indicate when medical attention is needed.

 

It never supplants careful evaluation of the sick child, unless it reaches or exceeds 106 degrees. REMEMBER, a child with a fever of 102 degrees can be sicker that a child with a fever of 105 degrees. A temperature of 106 degrees or higher always mandates immediate medical evaluation. A concerned parent or babysitter should always seek medical attention or get professional advice if a child appears very ill or has unexplained signs or symptoms, no matter what the thermometer reads. The safest approach to this problem is the most conservative. If you think your child’s condition demands professional medical care, don’t talk yourself out of it. A phone call, a visit to your child’s physician, or a trip to an emergency room is a small inconvenience and may prevent serious complications.