US Pharm. 2013;38(5):18-23.

Pharmacists are often questioned by parents whose children have fever. It is difficult to determine the best course of action in a busy community pharmacy, but there are some guidelines that may be followed.

Fever as a Symptom

An elevated temperature in a child may be due to overdressing the child or leaving the child in a hot place, such as a parked car.1 The former may be remedied by dressing the child more lightly, but the latter can be deadly.

If the above circumstances are not applicable, there may be a morbid underlying condition affecting the child. Fever is possible with virtually all infections, such as pneumonia, meningitis, appendicitis, skin infections, influenza, the common cold, ear infections, sore throat, sinus infections, urinary tract infections, and gastroenteritis.1

Children may develop fever after immunizations, but it generally persists for no more than 1 to 2 days. Nevertheless, postimmunization fever should be seen by a physician.1 Fever can also be caused by antibiotics, antihistamines, and seizure medications.

When to Recommend Emergency Treatment

In some situations, pharmacists should recommend a 911 call and/or an immediate trip to the emergency room.1 This is appropriate when the child exhibits any of the following: crying to the point that he or she cannot be calmed down or comforted; being difficult or impossible to awaken; confusion; inability to walk; difficulty breathing, even after the nose is cleared; blue lips, tongue, or nails; a very painful headache; stiff neck; refusal to move an arm or leg; or seizure(s).

When to Recommend a Physician Appointment

According to the National Institutes of Health (MedlinePlus), parents should call their physician immedi-ately in these situations: 1) a child aged under 3 months has a fever of 100.4˚F or above measured rectally; 2) a child of 3 to 12 months has a fever of 102.2˚F or above; 3) a child of 12 months and above has a fever of 105˚F and above (unless it reduces easily and the patient is otherwise comfortable); 4) fever in a child under the age of 2 years lasts longer than 24 to 48 hours; 5) fever in those aged over 2 years lasts longer than 48 to 72 hours; 6) the child has other symptoms of an illness that requires treatment (e.g., sore throat, ear pain, cough); 7) fevers come and go for 7 days or more, even if they are not high; 8) the child has a history of serious illness (e.g., sickle cell anemia, diabetes mellitus, cystic fibrosis, or cardiac problems); 9) the child has recent immunization(s); 10) the child has a rash, or bruises appear; 11) there is pain with urination; 12) the immune status is compromised (e.g., by chronic corticosteroid therapy, splenectomy); or 13) there is a recent history of travel to a third world country.1

Self-Care for Fever

If none of the above circumstances apply, self-treatment may be appropriate. Aspirin was once considered appropriate for fever in children, but most manufacturers no longer label it for use in those under the age of 12 years due to concerns about Reye syndrome.1 Without proper package labeling, it is not wise to recommend aspirin for children at this time. However, the pharmacist may recommend acetaminophen or ibuprofen in some circumstances.

Acetaminophen for Fever in Children

Acetaminophen has traditionally been available in several pediatric dosage forms from a variety of manufacturers. The makers of Tylenol market 160 mg/5 mL liquids as Infants’ Tylenol Suspension Liquid (labeled for those aged 2-3 years or 24-35 lb, but temporarily unavailable) and Children’s Tylenol Suspension Liquid for those aged 2 through 11 years (24-95 lb). Children’s Tylenol Meltaways 80-mg Chewable Tablets are recommended for those aged 2 to 11 years, and Jr Tylenol Meltaways 160-mg Chewable Tablets are recommended for those aged 6 through 11 years (48-95 lb).2

PediaCare and Little Remedies for Fevers also produce acetaminophen pediatric products, available as 160 mg/5 mL suspensions, one version marketed for infants and one marketed for older children.3-6

The FDA’s OTC review did not approve unsuper-vised use of acetaminophen below the age of 2 years.7 Thus, even though these products may include the word “infants” on the label, a careful inspection of the dosing chart on the boxes reveals that parents should be cautioned to consult a physician if the child is under 24 lb or under the age of 2 years. The pharmacist should question purchasers of infant fever products to ensure that a pediatrician has specified an appro-priate dosage to the parent if the child is under the age of 2 years. If the parents have not received this advice, it is prudent to ask that they contact the child’s physician and not guess at a safe dosage. For years, the makers of Tylenol supplied pediatric dosing charts purporting to provide safe doses for Tylenol in babies of any age, but the doses for those below the age of 2 years were never proven safe and effective, and these charts should be discarded.

Pharmacists should be aware of a seemingly anomalous situation in regard to pediatric acetaminophen products. FeverAll suppositories are available in a range of strengths, including one 80-mg acetaminophen product, FeverAll Infants’ Strength. The product carries labeling for those aged 6 to 36 months, and the Web site contains the phrase “approved for infants as young as 6 months of age.”8,9

If oral acetaminophen is not proven safe or effective for unsuper-vised self-care in infants under 2 years, by what line of thinking is a suppository proven safe and effective for babies as young as 6 months of age? An FDA Web site lists the product as approved, giving credence to the manufacturer’s assertion that it is, indeed, proven safe and effective, despite the seeming discrepancy.10 The regimen for those aged 6 to 11 months is one suppository every 6 hours, with a maximum of 4 doses in 24 hours. For those aged 12 to 36 months, the regimen is one suppository every 4 to 6 hours, with a maximum of 5 doses in 24 hours.9

Pediatric Warnings on Acetaminophen Products

When patients contemplate use of pediatric acetaminophen products, pharmacists should point out numerous warnings and precau-tions.11 The products warn against use in children with liver disease without a physician’s approval, and also caution that liver disease may occur if the parent administers more than 5 doses in 24 hours (the maximum daily amount), or gives them with other medications containing acetaminophen. A specific, separate label asks parents to question their physician or pharm-acist if they are not sure whether any medications the child is taking contain acetaminophen. Labels caution parents not to give the products to children who are allergic to acet-aminophen or who are taking warfarin. Parents are urged to discontinue the product and seek physician care if the fever worsens or lasts more than 5 days, if new symptoms occur, or if redness or swelling is present. Parents are also instructed to dose by weight rather than age when possible and to recap the bottles tightly to maintain child resistance.11 It should be noted that these products do not carry any indication of a specific temperature beyond which a physician should be consulted, making the MedlinePlus suggestions good guidelines to follow.1

Ibuprofen for Fever in Children

The only other nonprescription ingredient proven safe and effective for fever in children is ibuprofen. It is available as a 50 mg/1.25 mL liquid under the trade names Infants’ Motrin Concentrated Drops and PediaCare Infants Fever Reducer Concentrated Oral Suspension, both labeled for children 6 through 23 months of age.12,13 It can also be purchased in liquids for older children (2-11 years) containing 100 mg of ibuprofen per 5 mL. Examples of these products include Children’s Motrin Suspen-sion Liquid and PediaCare Children Fever Reducer.12,14

Pediatric Warnings on Ibuprofen Products

Ibuprofen pediatric fever products also carry a host of warnings the pharmacist should be aware of.12-14 Parents are warned that ibuprofen can cause an allergic reaction, with possible onset of hives, facial swelling, asthma (wheezing), shock, skin reddening, and/or blisters. In these cases, use should be discontinued and a physician contacted immediately. The product may cause stomach bleeding, with increased risk if the child has had stomach ulcer or bleeding problems, is taking an anticoagulant or corti-costeroid, takes other medications containing prescription or OTC NSAIDs (e.g., aspirin, ibuprofen, naproxen), or exceeds the suggested time of administration. It should not be used if the child has ever had an allergic reaction to any other product for pain or fever, or during the period before or after heart surgery.

Parents should ask a physician before use in the following situa-tions: 1) the stomach bleeding warning applies to their child; 2) the child has a history of stomach problems (e.g., heartburn); 3) the child has problems or serious side effects from taking any pain reliever or fever reducer; 4) the child has not been drinking fluids; 5) the child has lost a lot of fluid due to vomiting or diarrhea; 6) the child has high blood pressure, heart disease, liver cirrhosis, or kidney disease; 7) the child has asthma; or 8) the child is taking a diuretic.

Parents should ask a pediatrician or pharmacist before use if the child is under a doctor’s care for a serious condition or is taking any other drugs. Parents should give ibuprofen with food or milk if stomach upset occurs. The risk of stroke or heart attack may be increased if the suggested dose is exceeded or the drug is taken for longer than directed. Parents should cease use and speak to a physician if the child does not experience any relief within the first 24 hours of treatment, if fever or pain gets worse or lasts more than 3 days, if redness or swelling is present in the painful area, if new symptoms appear, or if the child has signs of stomach bleeding, such as feeling faint, vomiting blood, passing bloody/black stools, or experiencing stomach pain that does not get better.

Parents must follow dosing directions exactly. For instance, the dosing directions for Infants’ Motrin are 1.25 mL for those aged 6 through 11 months (12-17 lb), given every 6 to 8 hours and no more than 4 times daily.12

Avoid Alcohol Baths

Some well-meaning parents may decide that an alcohol bath will be helpful for lowering fever in children, i.e., by covering the child’s body with isopropyl or denatured ethyl alcohol. They may also add alcohol to water and sponge it onto the child. Any such intervention is dangerous. The child may absorb the isopropyl or ethyl alcohol and its chemical denaturant. They may also breathe in the alcoholic fumes. Parents should be strongly urged to avoid giving alcohol baths.

PATIENT INFORMATION

What to Do When Your Child Has a Fever


Is a Mild Fever Dangerous?

Fortunately, most fevers are harmless. In fact, when a child develops a fever, he or she is using an important defense against infection. This is because infections survive best at normal body temperature. When the temperature goes up, the invading organisms do not survive as well, and the child overcomes the infection earlier. For this reason, older infants can develop high fevers when they experience minor illnesses.

Elevated temperatures may not be due to infection. Perhaps the infant is overdressed or wrapped in a hot, tight blanket. Trapped body heat causes the temperature to rise. The remedy here is to remove the blanket and/or some outer clothing to allow cooling.

Your child may experience convulsions caused by the fever, known as febrile seizures. Most of the time these seizures are of no consequence, end quickly, do not cause any permanent harm, and do not mean that your child has developed epilepsy. However, seizures are a medical emergency, and your child should be seen by a doctor to rule out any possible complications.

Eating and Drinking While a Fever Is Present

Allow the child with fever to drink plenty of fluids. However, if the chosen fluid is fruit juice (e.g., orange or apple juice), it is best to dilute it with an equal amount of water. Popsicles and liquid Jell-O are good choices, and if the child is vomiting, they are particularly useful.

The child with fever can eat, as long as he or she is not forced to do so. Bland foods such as bread, crackers, pasta made with refined white flour, and refined hot cereals (e.g., oatmeal, cream of wheat) are usually well tolerated.

Nonprescription Medications

You must be extremely cautious in using nonprescription medications to lower a child’s fever. A good general guideline is to take a child 3 months of age or less to a physician when the temperature is 100.4˚F or above when measured rectally; when the fever is above 102.2˚F in a child aged 3 to 12 months; and when older children have a fever of 105˚F and above.

Consult Your Pharmacist for Advice in Treating Fever

Aspirin is a bad choice for relief of fever and should be avoided unless a physician advises its use. Acetaminophen should not be used in those under the age of 2 years, and ibuprofen drops should not be used for fever in children under the age of 6 months. Acetaminophen drops should be used no longer than 3 days, and ibuprofen products no longer than 3 days (or 24 hours if they do not provide any relief).

Every nonprescription product has a long list of warnings and precautions on its box. You should carefully read each of these before purchase and/or use of the product. Failing to do so can expose your child to serious adverse reactions. Dose the product exactly as directed, and use only the dropper or measuring device that comes with the product.

Remember, if you have questions, Consult Your Pharmacist.

REFERENCES

1. Fever. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/003090.htm. Accessed March 29, 2013.
2. Tylenol. Children’s dosage guide. McNeil Consumer Healthcare. www.tylenol.com/children/subchild. Accessed March 29, 2013.
3. PediaCare Infants Fever Reducer/Pain Reliever with Acetaminophen with a dosing syringe! Prestige Brands, Inc. http://pediacare.com/Products/pediacare-infants-fever-reducer-pain-reliever-with-acetaminophen.aspx. Accessed March 29, 2013.
4. PediaCare Children Fever Reducer/Pain Reliever Acetaminophen Oral Suspension. Prestige Brands, Inc. http://pediacare.com/Products/pediacare-childrens-fever-reducer-with-acetaminophen.aspx. Accessed March 29, 2013. 
5. Little Remedies for Fevers Infant Fever/Pain Reducer. Prestige Brands, Inc. http://littleremedies.com/products/fever_and_pain/fever_and_pain_reliever. Accessed March 20, 2013.
6. Little Remedies for Fevers Children’s Fever/Pain Reducer. Prestige Brands, Inc. http://littleremedies.com/products/fever_and_pain/childrens_pain_reliever. Accessed March 20, 2013.
7. Reducing fever in children: safe use of acet-aminophen. FDA. www.fda.gov/ForConsumers/ConsumerUpdates/ucm263989.htm. Accessed March 29, 2013.
8. FeverAll. Another way to put fevers to bed. Actavis Mid Atlantic LLC. www.feverall.com. Accessed March 29, 2013.
9. FeverAll. Dosage and labeling information. Actavis Mid Atlantic LLC. www.feverall.com/About/dosage-information. Accessed March 29, 2013.
10. Infants’ FeverAll. Drugs@FDA: FDA approved drug products. www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.DrugDetails. Accessed March 20, 2013.
11. Infants’ Tylenol Oral Suspension Liquid. McNeil Consumer Healthcare. www.tylenol.com/children/orasus_prod_inf#. Accessed March 29, 2013. 
12. Infants’ Motrin products. McNeil Consumer Healthcare. www.motrin.com/product_links/20?val=overview#. Accessed March 29, 2013.
13. PediaCare Infants Pain Reliever/Fever Reducer IB Ibuprofen Concentrated Oral Suspension. Prestige Brands, Inc. http://pediacare.com/Products/pediacare-infants-fever-reducer-pain-reliever-with-ibuprofen.aspx. Accessed March 29, 2013.
14. PediaCare Children Pain Reliever/Fever Reducer IB Ibuprofen. Prestige Brands, Inc. http://pediacare.com/Products/pediacare-childrens-fever-reducer-with-ibuprofen.aspx. Accessed March 29, 2013.
15. Paediatric Death Review Committee and Office of the Chief Coroner, Province of Ontario. Fever and irritability in a four-and-a-half-month-old infant. Paediatr Child Health. 2002;7:53.

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