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Fever Phobia

It is a mainstay of herbal and many other holistic health paradigms that fever is not an illness, shouldn't be suppressed if not absolutely necessary, and is indeed an invaluable immune response that hastens recovery, rather than threatening wellness.  This approach seems entirely at odds with the approach commonly seen in conventional medicine, which involves using antipyretic drugs (acetaminophen/ibuprofin/aspirin) to undermine the fever response and lower the temperature as the main goal of treatment.

The notions supporting the value of fever are, indeed, simple facts... not alternative medicine contrarianism, but recognized and even espoused by such mainstream medical organizations as the American Academy of Pediatrics.  And yet, in the practice of conventional medicine, fever is both feared and fought as if it were an illness rather than a vital response to one.  This phenomenon has been recognized and termed "fever phobia". 

I offer here a number of links to support and clarify this issue.  It's my belief that by educating ourselves about fever before we're in the midst of it, we can make more rational, educated decisions about the best ways to go about treating ourselves, our families and the people we work with.

Because I get more grief about my admittedly exuberant intensity on this issue, let me state very clearly:  Nothing here, either by me or the sources cited, is saying that a 104 temperature is "fine".  The idea to glean from this information is that the number on the thermometer doesn't tell us how severe and illness is, and in some cases, a 100 fever may be more severe than a 104 fever.  Look at the person with more attention and care than you give the thermometer.

More than the fever response itself, the things that need extra attention are the threat of dehydration or secondary bacterial infection.   Rather than at a specific temperature, the time to seek assistance is when you no longer feel confident to handle the situation yourself.  This is especially important in cases where dehydration has begun to occur.  Yes, there are things you can do to address dehydration at home, but no, when you have a child (or anyone with a more sensitive constitution) who is already dehydrating is not the time to be googling.

Also: if an infant has a fever, an entirely different set of issues may be at play, and I strongly encourage you to seek medical attention promptly.  Conventional medical sources say that this applies anywhere from 6 weeks to 3 months.

Two links to vitalist holistic treatment (one by Paul Bergner, one by me) follows the numerous supportive studies; do scroll all the way down to them if you want to see stuff about herbs...

 

American Academy of Pediatrics Clinical Report:

Fever and Antipyretic Use in Children
Janice E. Sullivan, Henry C. Farrar and the Section on Clinical Pharmacology and Therapeutics, and Committee on Drugs
Pediatrics; originally published online February 28, 2011
`
www.herbcraft.org/aapfevers.pdf

(this is really worth printing out to read more thoughtfully, and give to parents/clients, or to take to pediatric visits to discuss with your doc)

Some noteworthy quotes (italic emphasis mine):

"Fever, however, is not the primary illness but is a physiologic mechanism that has beneficial effects in fighting infection. There is no evidence that fever itself worsens the course of an illness or that it causes long-term neurologic complications"

"It should be emphasized that fever is not an illness but is, in fact, a physiologic mechanism that has beneficial effects in fighting infection. Fever retards the growth and reproduction of bacteria and viruses, enhances neutrophil production and T-lymphocyte proliferation, and aids in the body’s acute-phase reaction. The degree of fever does not always correlate with the severity of illness. Most fevers are of short duration, are benign, and may actually protect the host. Data show beneficial effects on certain components of the immune system in fever, and limited data have revealed that fever actually helps the body recover more quickly from viral infections, although the fever may result in discomfort in children."

"There is no evidence that children with fever, as opposed to hyperthermia, are at increased risk of adverse outcomes such as brain damage."

"Studies of health care workers, including physicians, have revealed that most believe that the risk of heat-related adverse outcomes is increased with temperatures above 40C (104F), although this belief is not justified."

"The desire to improve the overall comfort of the febrile child must be balanced against the desire to simply lower the body temperature. It is well documented that there are significant concerns on the part of parents, nurses, and physicians about potential adverse effects of fever that have led to a description in the literature of “fever phobia.” The most consistently identified serious concern of caregivers and health care providers is that high fevers, if left untreated, are associated with seizures, brain damage, and death. It is argued that by creating undue concern over these presumed risks of fever, for which there is no clearly established relationship, physicians are promoting an exaggerated desire in parents to achieve normothermia by aggressively treating fever in their children. There is no evidence that reducing fever reduces morbidity or mortality from a febrile illness. Possible exceptions to this could be children with underlying chronic diseases that may result in limited metabolic reserves or children who are critically ill, because these children may not tolerate the increased metabolic demands of fever. Finally, there is no evidence that antipyretic therapy decreases the recurrence of febrile seizures."
 

Myths about Fever
Barton D. Schmitt, MD
` http://www.rchsd.org/pediatrichousecalls/symptomchecker/feversystoms/fevermythsabout/index.htm


Misconceptions about fever are commonplace. Many parents needlessly worry and lose sleep when their child has a fever. This is called fever phobia. Overall, fevers are harmless. Let the following facts help you put fever into perspective:

Myth: My child feels warm, so she has a fever.
Fact: Children can feel warm for a many reasons such as playing hard, crying, getting out of a warm bed or being outside on a hot day. They are “giving off heat”. Their skin temperature should return to normal in 10 to 20 minutes. Once these causes are excluded, about 80% of children who feel warm and act sick actually have a fever. If you want to be sure, take their temperature. The following are the cutoffs for fever using different types of thermometers:
` Rectal, ear or temporal artery thermometers: 100.4 F (38.0 C) or higher
` Oral or pacifier thermometers: 100 F (37.8 C) or higher
` Under the arm (Axillary or Armpit) temperatures: 99 F (37.2 C) or higher
 

Myth: All fevers are bad for children.
Fact: Fevers turn on the body's immune system and help the body fight infection. Fevers are one of the body's protective mechanisms. Normal fevers between 100 and 104 F (37.8 - 40 C) are actually good for sick children.

Myth: Fevers above 104 F (40 C) are dangerous and can cause brain damage.
Fact: Fevers with infections don't cause brain damage. Only body temperatures above 108 F (42 C) can cause brain damage. The body temperature climbs this high only with extreme environmental temperatures (for example, if a child is confined to a closed car in hot weather).

Myth: Anyone can have a febrile seizure (seizure triggered by fever).
Fact: Only 4 percent of children can have a febrile seizure.

Myth: Febrile seizures are harmful.
Fact: Febrile seizures are scary to watch, but they usually stop within 5 minutes. They cause no permanent harm. Children who have had febrile seizures do not have a greater risk for developmental delays, learning disabilities, or seizures without fever.

Myth: All fevers need to be treated with fever medicine.
Fact: Fevers only need to be treated if they cause discomfort. Usually fevers don't cause any discomfort until they go above 102 or 103 F (39 or 39.5 C).

Myth: Without treatment, fevers will keep going higher.
Fact: Wrong. Because the brain has a thermostat, fevers from infection usually don't go above 103 or 104 F (39.5- 40 C). They rarely go to 105 or 106 F (40.6 or 41.1 C). While the latter are "high" fevers, they are harmless ones.

Myth: With treatment, fevers should come down to normal.
Fact: With treatment, fevers usually come down 2 or 3 F (1 or 1.5 C).

Myth: If the fever doesn't come down (if you can't "break the fever"), the cause is serious.
Fact: Fevers that don't respond to fever medicine can be caused by viruses or bacteria. It doesn't relate to the seriousness of the infection.

 

Myth: Once the fever comes down with medicines, it should stay down.
Fact: The fever will normally last for 2 or 3 days with most viral infections. Therefore, when the fever medicine wears off, the fever will return and need to be treated again. The fever will go away and not return once your child’s body overpowers the virus (usually by the fourth day).

Myth: If the fever is high, the cause is serious.
Fact: If the fever is high, the cause may or may not be serious. If your child looks very sick, the cause is more likely to be serious.

Myth: The exact number of the temperature is very important.
Fact: How your child looks is what's important, not the exact temperature.

Myth: Oral temperatures 98.7 to 100F (37.1 to 37.8C) are low-grade fevers.
Fact: These temperatures are normal variations. The body's temperature normally changes throughout the day. It peaks in the late afternoon and evening. An actual low-grade fever is 100 F to 102 F (37.8 - 39 C) .

SUMMARY: Remember that fever is fighting off your child's infection. Fever is one of the good guys.

 

 

Fever phobia: misconceptions of parents about fevers.
Schmitt BD.
Am J Dis Child. 1980 Feb;134(2):176-81.
` http://www.ncbi.nlm.nih.gov/pubmed/7352443


Abstract Eighty-one parents bringing their children to a hospital-based pediatric clinic were surveyed about their understanding of fever. Most parents were unduly worried about low-grade fever, with temperatures of 38.9 degrees C or less. Their overconcern was designated "fever phobia." Most parents (52%) believed that moderate fever with a temperature of 40 degrees C or less can cause serious neurological side-effects. Hence, most parents treated fever aggressively: 85% gave antipyretic medication before the temperature reached 38.9 degrees C and 68% sponged the child before the temperature reached 39.5 degrees C. A review of the literature showed that the only serious complications of fever were febrile status epilepticus and heat stroke, two rare entities. The great concern of parents about fever is not justified. Health education to counteract "fever phobia" should be a part of routine pediatric care.

Parental Fever Phobia and Its Correlates
Michael S. Kramer MD1, Lenora Naimark BA1, , Denis G. Leduc MD1
PEDIATRICS Vol. 75 No. 6 June 1985, pp. 1110-1113
1 The Department of Pediatrics and Epidemiology and Biostatistics, McGill University Faculty of Medicine, Montreal


Parents of 202 young febrile children were surveyed about their knowledge, attitudes, and fears concerning fever and its treatment. Forty-eight percent of the parents considered temperatures less than 38.0C to be "fevers", 43% felt that temperatures less than 40.0C could be dangerous to a child, 21% favored treatment for fevers less than 38.0C, and 15% believed that, left untreated, temperature could rise to 42.0C or higher. Fifty-three percent advocated waking a febrile child at night to administer antipyretic therapy. Young age of the child was associated with a preference for use of acetaminophen over aspirin and, unexpectedly, with a higher parental threshold for consideration of fever. The higher their child's temperature at the time they were questioned, the higher the minimum temperature that parents considered a cause for concern. Surprisingly, higher socioeconomic status was not associated with a lesser degree of fever phobia. In fact, parents of higher socioeconomic status were more concerned about the risks of brain damage or seizures as sequelae of fever than were parents of lower socioeconomic status. It is concluded that undue fear and overly aggressive treatment of fever are epidemic among parents of infants and young children, even among the highly educated and well-to-do. Considerable effort will be required on the part of pediatricians and other child health workers to reeducate these parents about the definition, consequences, and appropriate treatment of fever.

Fever Phobia: The Pediatrician's Contribution
PEDIATRICS Vol. 90 No. 6 December 1992, pp. 851-854
Ariane May MD1, Howard Bauchner MD1
1 From the Department of Pediatrics, Division of General Pediatrics, Boston City Hospital and the Boston University School of Medicine, Boston, MA.

` http://pediatrics.aappublications.org/cgi/content/abstract/90/6/851


Fever phobia, the exaggerated fear of fever, is found among parents of all socioeconomic classes. Pediatricians may inadvertently contribute to fever phobia if their practice and educational message are incongruent. To determine how pediatricians treat fever in their practice, the authors sent a self-administered questionnaire to a sample of members of the American Academy of Pediatrics who lived in Massachusetts. Pediatricians were asked (1) how dangerous they believed fever to be, (2) how they treated fever in their practice, and (3) what types of educational information they gave families regarding fever. One-hundred seventy-two of the 234 (74%) eligible pediatricians returned the survey; 151 were completed. Sixty percent of the respondents were male, and 75% practiced some form of primary or episodic care. Ninety-eight (65%) believed that fever itself could be dangerous to a child, with 58 (60%) of the original 98 citing that a temperature of 104F or greater could lead to complications such as seizures, brain damage, or death. In practice, 108 (72%) always or often recommended treatment to reduce fever and 96 (89%) of the 108 did so at temperatures between 101 and 102F. One hundred thirty-one (88%) respondents agreed that a sleeping child with fever should be left undisturbed. One hundred twenty-one (80%) pediatricians always or often tried to educate families about fever during sick-child visits, yet only 38% addressed the dangers of fever. It is concluded that (1) many pediatricians believe that fever (with no underlying treatable cause) greater than 104F could lead to serious complications and (2) most pediatricians educate families about fever predominately during sickchild visits. Pediatricians may be contributing to fever phobia by presenting mixed messages to parents about fever—for example, by prescribing antipyretics for children with temperatures between 101 and 102F while recommending that a sleeping child with fever be left undisturbed and by failing to address parental concerns about fever during all types of pediatric visits.

Fever Phobia Revisited: Have Parental Misconceptions About Fever Changed in 20 Years?
PEDIATRICS Vol. 107 No. 6 June 2001, pp. 1241-1246
Michael Crocetti*, Nooshi Moghbeli*, and Janet Serwint
From the * Department of Pediatrics, Johns Hopkins Bayview Medical Center, and The Johns Hopkins Children's Center, Baltimore, Maryland.

` http://pediatrics.aappublications.org/cgi/content/abstract/107/6/1241

Objectives. Fever is one of the most common reasons that parents seek medical attention for their children. Parental concerns arise in part because of the belief that fever is a disease rather than a symptom or sign of illness. Twenty years ago, Barton Schmitt, MD, found that parents had numerous misconceptions about fever. These unrealistic concerns were termed "fever phobia." More recent concerns for occult bacteremia in febrile children have led to more aggressive laboratory testing and treatment. Our objectives for this study were to explore current parental attitudes toward fever, to compare these attitudes with those described by Schmitt in 1980, and to determine whether recent, more aggressive laboratory testing and presumptive treatment for occult bacteremia is associated with increased parental concern regarding fever.

Methods. Between June and September 1999, a single research assistant administered a cross-sectional 29-item questionnaire to caregivers whose children were enrolled in 2 urban hospital-based pediatric clinics in Baltimore, Maryland. The questionnaire was administered before either health maintenance or acute care visits at both sites. Portions of the questionnaire were modeled after Schmitt's and elicited information about definition of fever, concerns about fever, and fever management. Additional information included home fever reduction techniques, frequency of temperature monitoring, and parental recall of past laboratory workup and treatment that these children had received during health care visits for fever.

Results. A total of 340 caregivers were interviewed. Fifty-six percent of caregivers were very worried about the potential harm of fever in their children, 44% considered a temperature of 38.9C (102F) to be a "high" fever, and 7% thought that a temperature could rise to 43.4C (110F) if left untreated. Ninety-one percent of caregivers believed that a fever could cause harmful effects; 21% listed brain damage, and 14% listed death. Strikingly, 52% of caregivers said that they would check their child's temperature 1 hour when their child had a fever, 25% gave antipyretics for temperatures <37.8C (<100F), and 85% would awaken their child to give antipyretics. Fourteen percent of caregivers gave acetaminophen, and 44% gave ibuprofen at too frequent dosing intervals. Of the 73% of caregivers who said that they sponged their child to treat a fever, 24% sponged at temperatures 37.8C (100F); 18% used alcohol. Forty-six percent of caregivers listed doctors as their primary resource for information about fever. Caregivers who stated that they were very worried about fever were more likely in the past to have had a child who was evaluated for a fever, to have had blood work performed on their child during a febrile illness, and to have perceived their doctors to be very worried about fever. Compared with 20 years ago, more caregivers listed seizure as a potential harm of fever, woke their children and checked temperatures more often during febrile illnesses, and gave antipyretics or initiated sponging more frequently for possible normal temperatures.

Conclusions. Fever phobia persists. Pediatric health care providers have a unique opportunity to make an impact on parental understanding of fever and its role in illness. Future studies are needed to evaluate educational interventions and to identify the types of medical care practices that foster fever phobia.fever, fever phobia, child, children, antipyretics, sponging, health care practices.
 

Acetaminophen (not just Tylenol) isn't as safe as you may think...

From a different angle, there is a strong epidemiological like between the use of Acetaminophen (Tylenol in the US, Paracetamol in Europe) and asthma.  A detailed article from the American Academy of Pediatricians can be found here:

The Association of Acetaminophen and Asthma Prevalence and Severity
John T. McBride
Pediatrics; originally published online November 7, 2011; DOI: 10.1542/peds.2011-1106


An excerpt:

"The epidemiologic association between acetaminophen use and asthma prevalence and severity in children and adults is well established. A variety of observations suggest that acetaminophen use has contributed to the recent increase in asthma prevalence in children:

(1) the strength of the association
(2) the consistency of the association across age, geography, and culture
(3) the dose response relationship
(4) the timing of increased acetaminophen use and the asthma epidemic
(5) the relationship between per-capita sales of acetaminophen and asthma prevalence across countries
(6) the results of a double-blind trial of ibuprofen and acetaminophen for treatment of fever in asthmatic children
(7) the biologically plausible mechanism of glutathione depletion in airway mucosa.

Until future studies document the safety of this drug, children with asthma or at risk for asthma should avoid the use of acetaminophen...

...Between 1991 and 1993 the Boston University Fever Study randomly assigned nearly 84,000 febrile children aged 6 months to 12 years to receive, as necessary, low-dose ibuprofen, high-dose ibuprofen, or acetaminophen (12 mg/kg per dose) in a doubleblind fashion. Of these children, 1879 with preexisting asthma were nearly evenly assigned among the 3 groups. For asthmatic children with a respiratory infection, the subsequent need for an outpatient asthma visit was 2.3 times higher in those treated with acetaminophen (95% CI: 1.26–4.16), and the risk was dose-dependent. Because there was no placebo control, it is theoretically possible that this outcome was a result of a protective action of ibuprofen, but the acetaminophen dose dependence, the lack of dose dependence for ibuprofen, and the availability of other evidence that acetaminophen exacerbates asthma make this explanation unlikely.

` http://pediatrics.aappublications.org/content/early/2011/11/04/peds.2011-1106.full.pdf

another study found an epidemiological link between using Acetaminophen to treat fevers and asthma:


Association between paracetamol use in infancy and childhood, and risk of asthma, rhinoconjunctivitis, and eczema in children aged 6—7 years: analysis from Phase Three of the ISAAC programme
Prof Richard Beasley DSc a , Tadd Clayton MSc b, Prof Julian Crane MBBS c, Prof Erika von Mutius MD d, Prof Christopher KW Lai DM e, Prof Stephen Montefort PhD f, Alistair Stewart BSc g, for the ISAAC Phase Three Study Group


An excerpt:
"205,487 children aged 6—7 years from 73 centres in 31 countries were included in the analysis. In the multivariate analyses, use of paracetamol (acetaminophen) for fever in the first year of life was associated with an increased risk of asthma symptoms when aged 6—7 years (OR 146 [95% CI 136—156]). Current use of paracetamol was associated with a dose-dependent increased risk of asthma symptoms (161 [146—177] and 323 [291—360] for medium and high use vs no use, respectively). Use of paracetamol was similarly associated with the risk of severe asthma symptoms, with population-attributable risks between 22% and 38%. Paracetamol use, both in the first year of life and in children aged 6—7 years, was also associated with an increased risk of symptoms of rhinoconjunctivitis and eczema...


Use of paracetamol in the first year of life and in later childhood, is associated with risk of asthma, rhinoconjunctivitis, and eczema at age 6 to 7 years. We suggest that exposure to paracetamol might be a risk factor for the development of asthma in childhood."

` http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61445-2/fulltext

And (if that's not distressing enough), Tylenol is just really decidedly toxic.  That's not an overstatement; it's the most dangerous drug over the counter in the US (some sources will ciote aspirin, but aspirin deaths are frequently linked to intentional suicide attempts, whereas Tylenol/Acetaminophen deaths are usually unintentional overdoses.

Propublica did a great story; I especially like the picture oriented tools that allow you to just click on box labels to see whether you're taking too much acetaminophen (it's in a LOT more products than Tylenol):
` Part 1
` Part 2

This American Life did a great radio show based off the Propublica article that you can listen to here:
` This American Life: Use Only as Directed
 

Risks of Fever Suppression...
 

Population-level effects of suppressing fever
David J. D. Earn, Paul W. Andrews and Benjamin M. Bolker
22 January 2014 doi: 10.1098/rspb.2013.2570 Proc. R. Soc. B 7 March 2014 vol. 281 no. 1778 20132570

 

Fever is commonly attenuated with antipyretic medication as a means to treat unpleasant symptoms of infectious diseases. We highlight a potentially important negative effect of fever suppression that becomes evident at the population level: reducing fever may increase transmission of associated infections. A higher transmission rate implies that a larger proportion of the population will be infected, so widespread antipyretic drug use is likely to lead to more illness and death than would be expected in a population that was not exposed to antipyretic pharmacotherapies. While the data are incomplete and heterogeneous, they suggest that, overall, fever suppression increases the expected number of influenza cases and deaths in the US.

` http://rspb.royalsocietypublishing.org/content/281/1778/20132570.abstract

A "layperson's" summary of that study can be found here:
Fever Treatments May Cause More Flu Deaths

 


 

Holistic Perspectives on Fever

Treatment of Acute febrile Disease (paul bergner)

 

The Energetics of Fever (jim mcdonald - thanks to John Gallagher at HerbMentor.com for offering this up to the public at large)

 

You can also buy an audio recording of my holistic immunity class (over 4 hours, with about 30 pages of written info included) that covers this information in depth here.
 

jim mcdonald

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