Fever

Fever is one of the things our bodies can do to fight infection. It isn’t fully understood, but we know that many bacteria and viruses find the higher temperature a less appealing environment. There are many, many causes. Infection is the most common, but it can be caused by other problems as well.

In the second year of medical school, students are taught about all kinds of diseases. Some, of course, are serious, and some are usually not a big deal. Some diseases are common, and some are very rare. But nearly every student gets ‘medical student disease.‘ Day after day, they hear about exotic diseases that start…with fatigue. Then there’s the feeling that it’s difficult to concentrate. Maybe occasional headaches. They can’t help but put 2 and 2 together and end up with 73. That’s about the time when they are taught a favorite expression among doctors. ‘When you hear hoofbeats in the distance, it’s much more likely to be horses than zebras.‘ Which is simply a way of saying that when your kid gets a bloody nose, it's probably not Congo-Crimean Hemorrhagic Fever. For this reason, and as I’ve said before, it’s a mistake to ask a doctor ‘what could it be?’ That’s what medical textbooks are for, and I use them as references when needed. ‘What could it be?’ could only be thoroughly answered with zebras (all 4 kinds), camels (both kinds), and an occasional Java Rhino. Of course, your kid doesn’t have any of the vanishingly rare diseases that a single symptom—fever, for example—could possibly be.

I get a lot of calls about fever. For the most part, I can be very reassuring. It’s the body’s natural way of fighting off an infection. Fever from illness, it is generally thought, doesn’t get high enough to cause brain damage. Even a high fever (to the 105’s (41C)).

Hyperthermia can. That’s when our bodies are exposed to heat way beyond what our bodies can generate on their own. People stranded in the desert, for example--there’s a reason they call it Death Valley; or those tragic stories we read about every summer about a baby left in a car. Our bodies usually do a reasonable job in keeping us cool, by sweating. But if we get dehydrated and don't sweat enough, we could be in trouble if it were hot enough. Hyperthermia, though it does cause an abnormally high body temperature, isn't a fever.

Fever , then, doesn’t generally worry me. But what’s causing the fever? If I treat the sick child, it will be for the underlying illness, not the fever. Here's the scenario I pose to parents. If your child has a fever, but looks OK, is breathing fine and playing and active as usual, would you worry? Something is causing the fever, so I'll concede the child might be coming down with something, but that wouldn't worry me. Compare that to your child acting in a worrisome way—complaining of pain, for example, or sleeping all day and refusing to walk—but not having any fever. Is that reassuring? To me, that's much more worrisome.

So why do we treat fever at all?

There are purists out there who think that we shouldn’t treat it, and let the child’s body fight off the natural infections as millenia has designed us to. There are conspiracy theorists who believe that the companies marketing fever medicine want to support the mass delusion that fever must be treated.

For me, trying to see this from the child’s point of view, an empathic approach, is helpful. True enough, treating the fever does nothing to help get the child better faster or treat whatever illness they might have. But whenever we have a fever, we feel really bad. Sometimes fever can cause a headache, but it can certainly worsen a headache. But even without any specific symptoms, fever makes us feel sick. When we reduce the fever, we just feel better. And making children feel better is, as I look at it, an important part of my job.

I think parents with sick children often feel helpless as they watch their sick child. The fever is the only objective marker of the illness, whatever it is, and so by lowering the fever they feel like they are taking a pro-active approach. And they get positive feedback when their children perk up as their body temperatures go down.

If the child has a fever but is OK, I think it's all right to watch them and not treat the fever. If they feel awful, I would treat the fever. I don't think making the child suffer accomplishes much from a medical standpoint. But there's a few points that should be mentioned.

All kid's fever medicines are not the same. There are generally 2 choices of ingredient: acetaminophen (in Tylenol and a lot of store brands), and ibuprofen (in Motrin and a few others). They both work in most people, but it does seem that one will work better than the other in some people. Acetaminophen is safe when the directions are followed. It shouldn't be used for more than a few days, however, because at doses much higher than we should be giving, it can be toxic. Besides, if your child is really having a fever for more than about 3 days, it's probably a good idea to try and figure out what the kid has. A doctor might be able to help with that.

About 1 in every 25 kids get febrile seizures. They don’t seem to have epilepsy, but when their temperature is high enough, they have a brief seizure. It’s almost always in toddlers. As you can imagine, this is really scary for the parents. Fortunately, it’s quite common (about 1 in 25 toddlers have one), and most of those who have one never have another. The seizures do not cause brain damage, usually only last less than a minute, and usually do not mean that the child will go on to have a seizure disorder.

Every now and then, I see a child with fever who has been covered in as many blankets as the parents can manage. This is not a difference in parenting philosophy—it's just wrong. When we have a fever, our bodies are too hot. Even if we feel cold or are even shivering. In order to relieve the symptoms of fever, we have to lower our temperature. So dress your child minimally, and get rid of the heavy quilt on the bed. One of the best techniques I have found is to put the child in a bath. Not a cold bath! That would annoy anybody, especially a sick child. So draw a regular-temperature bath for them. It will still be about 20 degrees below their elevated body temperature. After soaking for 15 minutes (with you there—don't leave them alone in the bath), the water will have absorbed some of their temperature, and they will feel much better. You can do this as often as needed, without concern of overdosing.

Fever that has been relentless for more than 3 days, say 4 or 5 days, is worthy of a doctor visit. I'm still not worried about the fever causing damage, but I am concerned about finding a cause.

Elvis Presley live: Fever


Fever does, in fact, usually go up at night.

A Mistake

“Experience is the name everyone gives to their mistakes.” Oscar Wilde, from Lady Windermere's Fan, 1892


Yes, I know. Everyone makes mistakes. Every parent makes mistakes, nearly all of them invisible to a child. To a child, what we do has to be right just because we're doing it. Parenting books are filled with sure-fire techniques to get your kid to do everything from eating something besides white food to success in college. But those authors haven't met your children. Sometimes the best thing to do just isn't that clear.

Doctors make mistakes, too. In my particular line of work, I'm relieved to report, failure isn't usually associated with a really bad outcome--you know what I mean. Still, I look upon my job as making children feel better and making their lives better. I work hard at it and do my best.

Three days ago, a favorite patient came to the office with his mother. He had acquired a splinter in one of the worst places to get one, the center of the palm of his hand. It's a bad place for several practical reasons, not for elaborate medical reasons. The skin on our hands is quite thick, not quite as thick as the soles of the feet, but very thick. Unlike the soles of our feet, however, our palms are covered with sensitive nerves for feeling things. Our palms have a flexibility that makes it difficult for us to flatten our palms completely. And once we start grasping things as babies, we never stop, so the muscles of our grasp are very strong. Lastly, the palm is fully visible to the motivated child.

He had been healthy and was playful with me when they first came into the office. He was glad to show me the splinter. It was clearly visible, only about 2 or 3 mm long. But it was in an awkward position, as if it had been put straight in and then broken off at the surface. Because of this foreshortening, it was difficult to see a way to expose the deepest part of the splinter without digging a deep hole in the center of his hand. The nearest part, however, was close to the surface, and should be an easy grab with my sharpest surgical-quality tweezers. Because of the thickness of the skin in the palm, I thought I could get it on the first try without hurting him.

After about 20 minutes of the most upsetting screams possible, as this child stared at me, wearing a headlamp, using needle-sharp instruments on him, I gave up in a sweat. I had to try a different way.

I prescribed some numbing cream for him, and asked his mother to bring him back with the cream, for me to apply. The next day, I put the cream on, covered it, then wrapped his whole hand in an elastic bandage so he wouldn’t mess with the cream. He was happy to play with the office toys for about an hour. He didn’t mind the unwrapping, or cleaning off the cream. But the screaming started as soon as the tools came near him.

Granted, these are some fairly scary-looking tools. Everything was shiny and needle-sharp. We had a reasonable control ratio. (I have defined this invented term—I wonder if it’ll catch on—as the ratio of adults to the age of the child, in years. In this case, the ratio was a usually-effective 1.0: there were 3 fully grown adults to a single 3-year-old child. The 3 adults didn’t have a chance of restraining this warm and affectionate child. I though it might be helpful to use the numbness provided by the cream to allow a small injection of local anesthetic, to really be sure he wouldn’t feel anything.

I won’t keep you guessing. That didn't work, and the 3 of us never got his hand still enough even to get a good look. I never took out the splinter. Luckily, I haven’t been exaggerating about the patient’s mellow personality, and though he was absolutely impossible to restrain for even 20 or 30 seconds so I could get the thing out, he was immediately forgiving, both of me and his mother.

First, some information about splinters. Usually, they have to come out. By definition, they are little irregular slivers of something, torn or broken off of something else. Broken or torn edges are rough, though you might need a microscope to see that. These rough edges can be packed with bacteria that can cause nasty infections. It’s a sign that you absolutely must get the thing out if it becomes swollen and red and painful to touch. It’s a particularly bad sign if this red/swelling/pain develops just a few hours after getting the splinter in the first place. If that happens, either get it out yourself, or if you can’t, get to an ER. In this case, there was no redness after a day when I first saw it. There was still no redness the following day. No swelling. It hurt him a little to press right on it, but not too bad.

So this was my mistake. Honestly, I don’t think it’s a mistake I make very often. I think of myself as a minimalist, using the least possible intervention that will have the best result for the child. It just looked so easy, no big deal, right there near the surface...all it would take was a few seconds of him holding still. But that’s a common error in judgement. I focused on what would be reasonable medically for all kinds of rational reasons. That wasn't an empathic approach. What was in the best interest of the child? How did he look at this issue? He certainly didn’t see it as a problem that needed what appeared to be an inappropriately serious response.

He was right. Though most splinters need to come out, what happens if they don’t? If small enough, the body’s immune system can literally digest them, and make them disappear. Sometimes, the skin will push them out over time. And sometimes the body can wall them off with scar tissue, and they are with us forever. After a really long (maybe an hour) bath, the top layers of skin on his palm might be soft enough to come off with a vigorous drying, and that might take care of it.

His mother certainly thought it needed to come out, and I did too, at the time.

It's important to try and see things from the child's perspective. It's something I consciously try to do with all my medical encounters. This time, however, not so much.

Being sensitive to the child's viewpoint is really important--but that's not the same as letting that viewpoint dictate what has to happen. Part of the price we pay for having the privileges of being grown-ups is that sometimes we have to make tough, unpleasant decisions. Just because your children would like to play on the freeway doesn't mean you should let them!

If the splinter had been infected, it would be out.

Lollipops

Let's be completely clear on this: we don't learn to like sugar. We are born with chemical receptors on our taste buds that, when they are contacted by sugar, send a signal directly to our brains. That signal does many things, including giving us a sense of well-being and relief from discomfort.

As an aside, the lab where I used to work has helped to figure out the truth about our taste buds. A brilliant scientist I worked with explains on her website that what we were taught about certain tastes having specific locations on the tongue (like sweet in front and bitter in the back) is bunk. Part of the most recent research on taste shows that there is a large genetic component to what we can and can't taste. Though our taste sensitivities can change during our lifetime, it seems that we are all born with a basic toolbox.

In the hospital, we have been using sugar water to help sick babies get through painful procedures. It really seems to help. While giving kids sugar water in the office isn't standard procedure, I think there is a medical benefit to some of the lollipops I give out.

I have posted before about 'concrete thinking' and the inability of children at certain developmental stages to predict the future and prepare for it. So an empathic approach to a child who has just had an immunization or had a splinter removed required us to see that the procedure came as an unpleasant surprise to them. They have a normal physiologic response to a sudden and unexpected painful event: shock. (It's not as bad as the shock we go into when we have an overwhelming infection, or some other really serious medical problem.) Our blood pressure drops, we feel weak, our hearts race, and our blood sugar goes haywire. In the intensive care unit, careful management of a shock victim's blood sugar can be very helpful.

After an unfortunate surprise, the lollipop causes a brief little rise in blood sugar. From a lollipop, the sugar is absorbed directly into the bloodstream through the tongue and mouth, and doesn't have to get through the digestive system, which would be much slower. So I think they get some quick pain relief like the babies as well as a rise in their blood sugar that really seems to make them feel better.

This is why I don't give out sugar-free lollipops. They just can't work the same way. (In fact, I do have some that are sugar-free for my diabetic patients. I keep them in a cabinet.)

Each Dum-Dum lollipop has less than 25 calories. Even for a kid, this isn't a significant risk for weight gain. To gain a pound, we'd have to eat about 150 of them. One lollipop will not cause tooth decay.

And, of course, there are behavioral aspects of giving out the lollipops. They are an incentive to clean up the toys at the end of a visit and something nice about going to the doctor.

(A lot of parents are concerned that the lollipop will worsen their child's hyperactivity. I have a post coming up that deals with this issue specifically.)

Most of the children in my office are not getting any kind of painful procedure. It's for them that I think the lollipops are most important. It's a reward for good behavior, a way of noticing that they did everything right (or even mostly). It is one of the great failures of parenting that we don't catch our children being good. We point out, sometimes angrily, when they don't do what we want. But somehow we have the irrational expectation that when they're doing what they should, they are somehow rewarded for it. In fact, the child can often feel that you're not noticing them being good, but their misbehavior really gets your attention. In my office, I notice their good behavior, explicitly point out one or two things they did that were good, and reward them for it. Since I can't give them the most treasured reward—a parent's attention—I have to get by with candy on a stick. Besides, they taste really good.





The photograph at the top is from my collection and is by Weegee.

The Bridgeport Paradox: Black and White in the Delivery Room

Connecticut is one of the richest states in the United States. Most of its many wealthy people live on the 'Gold Coast' which is within commuting distance to New York City and is along the shore of Long Island Sound. The richest county in Connecticut is Fairfield county, where low-density communities are filled with some of the most expensive private homes in America.

There are no major hospitals in these affluent towns, owing to their low population density. So when the rich and famous need a hospital, they go to the nearest major medical center, Bridgeport Hospital.


Bridgeport is an island of poverty in this sea of wealth. A booming 19th-century industrial town, it gradually ran out of most manufacturing jobs decades ago. It has double the state's average rate of people living in poverty, and triple the rate of the poorest poor—people living at less than 50% of the poverty rate.

When I did my required training rotation through Obstetrics, I was assigned to Bridgeport Hospital. It's a big urban medical center, with a busy Labor & Delivery ward. Almost all of the Obstetricians in the area had luxurious private offices located in the adjoining wealthy communities, where they served an exclusive clientèle, mostly white. For deliveries, however, even the fancy doctors used the great facilities at Bridgeport (in private rooms). Some of these doctors in private practice, along with the doctors on staff at the hospital, also worked with the patients from Bridgeport, mostly women of color. Most of these patients didn't have private insurance, and sometimes didn't have insurance at all. These patients often had less prenatal care, and less access to medical care in general for any of their other medical needs. Many had complex social issues associated with poverty which complicated their care.

In this context, I expected that the wealthy, private-paying patients with their private physicians would somehow get better treatment and have an easier time. For many types of medical problems, this seems generally to be the case, and I expected it at Bridgeport Hospital, where the stark contrasts in patient resources are dramatic.

The experience of my first day has remained deeply etched in my memory. I was told to wait at the nurse's station of the obstetrics ward. The screaming started within minutes of my arrival. It was the most disturbing sound I had ever heard. Clearly screaming in severe pain, the halls were filled with this sound which came from behind a closed door. I was new there, but I asked the nurse sitting next to me, who was browsing through a catalog for scrubs with cartoon characters, if we should go in there and help. She was very kind and explained that the obstetrician was already in the room and the woman had said that she didn't want any interference or medication. Within a couple of hours of this, a new patient was wheeled in to another private delivery room. With her was her husband, her doctor, and her personal secretary. After getting settled, the personal secretary left the room and sat in the waiting area. A second source of intense and disturbing screaming started coming from this room, too. Now there were two.

Before lunch, an ambulance brought in one of the local women, and the nurse sitting next to me dropped her catalog (by now she had moved on to a shoe catalog), and prodded me to come along. I didn't do anything at my first delivery, but I watched a very skilled doctor give this woman an epidural anesthetic. A couple of hours went by before she had her baby, which is about the most fabulous thing a person could witness. She pushed and was awake and happy when the delivery nurse put her new baby into her arms.

I don't know what happened in those private rooms, as I was never invited in. But this experience was repeated nearly every day I was there. I asked one of the obstetricians about it. She told me that many of her private patients refused all medications and wanted what she called the 'full experience' of childbirth and motherhood. She said this wasn't often the case with the inner-city mothers she treated in the hospital. She never really thought about it, and tried to give her patients what they requested.

So much suffering, both medical and otherwise, falls heaviest on the poor. What I witnessed was counter-intuitive: the rich were enduring unspeakable pain, and the poor were not. I'm not an obstetrician, but I do look upon my job as trying to ease suffering if I can. Were the poor women getting better advice than money could buy? Maybe they just had more common sense.