Facing Alternative Fever Facts

“He’s been running a fever today —99 to 99.4 degrees— and has been a little fussy with a lot of runny nose and cough,” the mother told me.

More misinformation about fever, I thought to myself, as the child ran around the emergency department exam room.

“We generally consider fever to be 100.4 degrees or higher,” I said in my kindest voice.

The mother cut me off. “No. Ninety-nine degrees is a fever, I know it,” she said with indignant force.

I felt as if I’d been suddenly shifted into a universe of alternate facts.

Years of practice have honed my discussion points addressing the many myths about fever, but such frank disagreement about the actual number was new.

I vented to my husband that night. “I mean fever is pretty straightforward — almost binary. You have it, or you don’t. I wish thermometers were like pregnancy tests: just yes or no.”

He laughed.

“We don’t care as much about how high it is. It’s more about how many days it’s been, how the child looks overall, other symptoms, and other medical history that puts the kid at higher risk,” I continued.

“But I think a lot of people don’t know any of that,” he replied. “They don’t really understand fever and when it matters. I think they see it as almost symbolic: a sign of sickness, something doctors will pay attention to.”

“Good point. I mean you could fill a thick book with all the misconceptions about fever,” I continued. “It can feel hard to confront them without coming across as condescending or alienating. ”

“I think what they’re really trying to say is ‘I’m worried about my kid — something is wrong, pay attention doc!’” he continued, his experience as a teacher showing. “Maybe that’s not the time to correct them on the numbers.”

Parents often fixate on fever. As doctors, we fixate on it only in certain situations. If our patients are immunocompromised, young infants, have complicating medical problems like cancer or immunodeficiencies, or have traveled to certain places. We worry more if fever is lasting beyond five days, prompting concern for more serious, rare, or occult illnesses. It is rare for the height, pattern, or number to be critically important. Most of the time, even a high fever in an otherwise healthy, well-appearing child is not serious or dangerous.

Perhaps we need to better explain to families when fever matters and when it doesn’t so they can better understand when to seek care or expect a work-up. We can do more to demystify fever and how it factors into our evaluation of a patient.

Because despite the concrete numerical nature of fever, in the end it is just another sign of illness, to be taken along with others (like difficulty breathing, reduced urine output, the development of a rash, altered mental status, or pain). Its presence or absence can matter, but so does its surrounding context. The whole child matters more than any number. We need to teach families and ourselves to look beyond the digits on the thermometer. We can start our communication by addressing emotions (i.e. worry, confusion, fear) before facts.

With this in mind, I took my husband’s advice on my next shift. When another parent worried about a “fever" of 99.4 degrees, I addressed the worry behind the “fever” first.

“It seems like you’re worried something is off with him. Let’s figure out what’s making him feel and look sick,” I said. Before discharge I reviewed reasons to worry, including temperatures of 100.4 degrees or greater that last for more than four days or come with other concerning symptoms. The family seemed relieved. They understood better when to worry, freed from feeling hostage to a number on a thermometer.

Julia Michie Bruckner, MD, MPH is a pediatrician, mother, survivor of recurrent cancer, writer and 2018-2019 Doximity Author. You can find her at www.juliamd.com and @JuliaMDWriter.

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