This article was originally published in Lilipoh Magazine, Issue #97, Fall 2019
We lose part of our sense of control when we get sick, and no one likes that feeling. Loss of control brings fear. Illness is always a little scary because there is implicit risk of loss and incapacity and so we (appropriately) fear lasting injury. Another part of the fear we experience with illness comes not so much from injury, but from simply not quite knowing what is going to happen. Usually illness is mild, but what if it becomes life-threatening, and how are we supposed to know which illness is mild and which is dangerous? Getting professional medical advice aids in that determination, but even the medical encounter itself can bring its own set of worries—we must trust in the advice of medical providers even when we may not fully understand their decision-making process, or worse yet, not even be invited to participate in it. There are reasons to be fearful around illness on multiple levels.
A common outcome of all these fears: if we can get rid of illness symptoms on our own, even if they are mild, then life is simpler and we feel empowered. We’ve successfully stopped an illness process so that we do not have to risk.
It is probably through the interweaving of these insecurities that fever has become so strangely misunderstood. Many people today routinely reach for a bottle of Tylenol or Ibuprofen when there is any temperature elevation—sometimes even dosing medicines when the only symptom is that a child “looks flushed.” We need to work to change that. Fever has been thoroughly vilified, even though this goes against a whole body of medical research and recommendations which acknowledge the benefits of fever. Yes, having a fever does not feel very good, and yes, there are still steady streams of fearful messages which equate fever-suppression with compassionate parenting (notice that these are usually advertisements for fever-reducing medications). What has been drowned out in the midst of these fearful voices is the fact that fever is created by our body when we are ill because it is a potent tool for the immune system. Fever itself is not an illness. That needs to be emphasized again: fever itself is not an illness. Fever and inflammation are natural, intentional parts of our physiologic defense systems.
When we widely teach that elevated temperature is dangerous and that it should be quickly medicated away we are teaching to “shoot the messenger.” We need to listen better. We can be smarter than just reflexively acting out of fear—we can also learn about fever. Fear and fever present a very interesting duality.
Fear has an archetypal gesture: it works to separate things. Fear bubbles up into all different parts of our life as a method for recognizing and avoiding what could possibly hurt us. Fear always tells us it is better to just stay away, to not risk any chance of injury, illness, disorientation, or loss of control. It’s message: just don’t engage.
Fever is important because it brings qualities that are quite the opposite of fear. All processes of accentuated warmth work to bring closer connection. Warmth blurs, crosses, and dissolves boundaries. Warmth loosens and mixes—think of how cooking over a stove brings all the ingredients into closer connection with one another. Accentuated warmth, as part of an inflammatory process, aids the immune system to encounter and process what needs to change. That change may be clearing out a virus or bacteria, or it may be a splinter in your finger. Whenever we suppress warmth we limit the body’s capacity for physiologic encounter. Warmth and inflammation are quite literally the immune system’s pathways for changing what has become stuck.
How does fear act as an agent of change? It doesn’t. Fear prefers established, known patterns. Fear says avoid, avoid, avoid anything new or risky. Let’s use an analogy: if fear alone is speaking, and we had a bicycle in front of us, we would never ride a bicycle. Even if it was a situation where we already knew how to ride a bicycle and we actually did need to go from one place to another, fear tells us that we might crash and be injured and maybe even die if we take a bicycle ride, so it is better to just never let that process start. No bicycles, ever. Somehow culturally we have made a similar shift to say “No fevers, ever!”
You may ask, “Well, what happens if we suppress fever? What is the big deal? No fever = No illness.” But that logic doesn’t hold up when we take a broader, longer-term view, and in fact we learn “No fever = Rerouted illness.” Regular fever suppression stunts the development of our immunologic capacities for encounter. Encounter is an essential part of good digestive, respiratory, and immune health. Vigorous capacities for encounter mean we know how to meet and work with the world, not just avoid it. And our capacities for encounter only become stronger through practice, through the experience of actually working through febrile illnesses.
A striking example of this comes from a very large study of more than 200,000 pediatric patients, including children from 34 different countries, who were asked about their use of Paracetamol (an equivalent of Acetaminophen—i.e., Tylenol) the medication commonly used for fever reduction in many parts of the world[i]. The study found that:
- “Use of paracetamol for fever in the first year of life was associated with an increased risk of asthma symptoms when aged 6–7 years,” on average, a 46% increased risk of asthma by the time a child reached first grade age. This bears repeating: giving Paracetamol for fever in the first year of life was associated with a 46% increased risk of asthma at age 6-7 years.
- But that is not all: “Current use of paracetamol [at 6-7 years of age] was associated with a dose-dependent increased risk of asthma symptoms.” In other words, the more frequently paracetamol was being given, the higher the observed rate of asthma.In fact, “high use”—defined within the study as currently using Paracetamol at least once a month—was associated with a more than 300% increase in asthma risk at age 6-7 years!
- There were similar trends for increased risks of rhino conjunctivitis (hayfever) and eczema with paracetamol use for fever.
Why should our risk of asthma be increased by use of fever suppressants? Because asthma is an illness made worse by weakened capacity for encounter. Our lungs are in contact with the world around us, through the air we breathe, all of the time. We are actually in much more continuous contact with the outside world through our breathing activity than we are through our skin or even through our digestion. Well-established external asthma triggers include pollens, grasses, pet dander, smoke, and smog, all exposures which, once we encounter them (even if we fear them), cannot simply be avoided. We have to meet them, recognize them as foreign, break them down and clear out what should not be inside of us. Even less physical asthma triggers like cold air or stress ask us to meet and adapt. Something about blunting fever stunts that developmental learning, with the potential cost of long term immunologic imbalance.
The key message here is that we need opportunities to practice immunologic encounter. This is true on multiple levels. Other kinds of research show that:
- more chances to work through inflammatory illnesses during early childhood, with fewer antibiotics and less fever suppression, are associated with a reduced risk of allergic illness later on,[ii] and
- eating off of less clean (hand-washed) dishes versus better sterilized (machine-washed) dishes is associated with lower rates of food allergies, because the plates do not get as clean when we hand wash, which means that we encounter a more regular bacterial load through our digestion.[iii]
These studies can give us courage since we now know that allowing children to experience and work through “encounter” as part of a fever, of an acute inflammatory illnesses, or of a digestive exposure, helps provide the opportunity for children to mature and refine their immune systems.
Now, the next important question: if we shift our thinking and decide that there may actually be some benefits to allowing a child to experience fever, what temperature is safe? A first helpful step is to remind ourselves that the medical definition of fever is a temperature of 100.4°F (38°C) or higher. Anything below 100.4°F, even if a child is flushed, even if a child feels warm, is not a fever. So, before we are start thinking about doing any kind of medication or intervention it is good to get out the thermometer and see what we are really dealing with.
Second, now that you have gotten out the thermometer and let’s say confirmed that yes, your child does have a temperature higher than 100.4°F, how high can you let the temperature go? Is 102° safe, 103°, 104° safe? When do you need to step in?
The best guideline for this comes by remembering that fever is created by our body when we are ill because it is a potent tool for the immune system. Fever itself is not an illness. In other words, our immune system wants the whole body to reach a certain level of warmth and is going to create fever until that level has been reached. Unless there are outside conditions that will not allow someone to independently control their body temperature (such as being in a heat wave without any air conditioning, a hot car with the windows closed, or wearing excessive layers of clothing/too many blankets and not being able to take them off), there is no set temperature which is too high. That may sound outrageous, but this is indeed the result of a large review of the medical literature, and is summarized in the Clinical Report of the American Academy of Pediatrics on “Fever and Antipyretic Use in Children”:
Many parents administer antipyretics even when there is minimal or no fever, because they are concerned that the child must maintain a “normal” temperature. 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. Thus, the primary goal of treating the febrile child should be to improve the child’s overall comfort rather than focus on the normalization of body temperature.[iv]
The AAP report goes further:
When counseling a family on the management of fever in a child, pediatricians and other health care providers should minimize fever phobia and emphasize that antipyretic use does not prevent febrile seizures.[v]
Ah yes, another reason many people have been taught to fear fever is the risk of a febrile seizure. But seizures that come with fever are much more related to a dramatic spike in temperature than to any specific temperature, and as the report says, “antipyretic [fever-reducing medication] use does not prevent febrile seizures.” Febrile seizures occur in 2 to 5 percent of children before age five.[vi] A more effective way to avoid febrile seizures is to understand how to work with warmth. We want to avoid intervening in the wrong way at the very beginning of a fever, when the temperature is rising. A common scenario is that a child has a very hot head, but the limbs are cold. At this stage, we do not want to do things that block warmth (especially avoid things like giving them an alcohol bath, or putting a child into cold water). That’s because the immune system’s very specific goal at that moment is to heat the entire body, so it is going to create whatever temperature is necessary in order to completely warm the limbs. If we intervene and cool off the child’s limbs or chest, then the fever will spike even higher as the body furiously works hard to create more warmth, and the head (and brain) will be exposed to more dramatic temperature shifts. A better, simpler way to avoid febrile seizures is, during this first stage of fever—when the head is hot but the feet and hands are cold—put the child under warm covers and help the body warm the limbs through. Putting a hot water bottle next to the feet works very well. Knowing the natural course of a fever, as well as other gentle, natural supportive therapies, can help you safely guide a child through many common, acute illnesses with fever.[vii]
At this point you may now have a different perspective on fever. Hopefully you have less fear, and you may feel ready to work with fever in a different way. The fear voice, which says “don’t ever let you child get on a bicycle” is maybe not gone, but can be negotiated with differently. Let’s finish with some general guidelines for when it is ok to let your child practice having a fever and allow the immune system to refine its capacity for encounter:
- First, an essential caveat: any fever (100.4°F or higher) in a child less than three months of age needs to be evaluated by a medical professional. The immune system is not yet up for the task of encounter, so the research we have been discussing does not yet apply, and more significant illness needs to be ruled out in all infants younger than three months.
- Second, give your child lots to drink—water, teas, broth. Encourage regular fluid intake. It is easy to become dehydrated during a fever and dehydration increases discomfort and slows recovery. Signs of dehydration are dry lips, no tears, fewer wet diapers.
- Look for other signs of significant illness, particularly two extremes: either, when a child is in pain and cannot be consoled after providing usual comforting measures (nursing, cuddling, distraction, reassurance), or, conversely, if a child does not engage, is not responding to you normally, or is acting lethargic—these symptoms need to be paid attention to. If you see these signs, call your primary care provider and have your child looked at.[viii]
- Conversely, if your child does not seem distressed with a fever (even if it is high), allow them the space to work with the fever. Let them be. Generally healthy children over the age of two years can be given three days (72 hours) of fever if there are no other signs of more serious illness before you need to seek medical attention.[ix]Many times a fever will have completed its process in that time and you have allowed an important developmental event to take place.
Most important: use common sense. If you are unsure—ask for help. Think about this medical research and make your own “rules for the road” for fever and see what works for your family.
And let there be a little less unnecessary fear in the world. Ride a bicycle.
[i] 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. Beasley R, Clayton T, Crane J, von Mutius E, Lai CK, Montefort S, Stewart A; ISAAC Phase Three Study Group. Lancet. 2008 Sep 20;372(9643):1039-48.https://www.ncbi.nlm.nih.gov/pubmed/18805332
[ii] Lifestyle factors and sensitization in children – the ALADDIN birth cohort. Stenius F, Swartz J, Lilja G, Borres M, Bottai M, Pershagen G, Scheynius A, Alm J. Allergy. 2011 Oct;66(10):1330-8. https://www.ncbi.nlm.nih.gov/pubmed/21651566