No matter how meticulous you may be about hand washing and keeping your child away from germs, all toddlers will experience fevers from time to time. This is the most common reason that doctors see young children for urgent care. The good news is that fevers generally occur during mild illnesses, usually viral infections which clear up on their own. Still, most parents worry at some point that a serious disease is causing the fever or that a fever will harm their child. Many misconceptions exist about the causes and effects of fever.
What is a fever? Even this simple question is not as straightforward as it appears. A fever is a body temperature significantly above ‘normal.’ However, normal body temperature varies according to where and when it is measured. The surrounding environment and your child’s clothing can also affect body temperature.
The type of thermometer and the method used to measure a child’s temperature depend on his age, the circumstances, and the equipment available.
Mercury: An old-style mercury thermometer is not recommended because of the potential for mercury exposure if the thermometer breaks. It also takes a few minutes to record the temperature, which can be a long time when you are trying to keep the tip under the arm or under the tongue of a crying, uncooperative, squirmy child.
Digital: Digital thermometers are safe, easy to use, inexpensive, versatile and suitable for use orally and rectally. In addition, they’re ready to read in less than a minute.
Tympanic: Tympanic thermometers are convenient but less reliable in children under two years of age because the device must fit easily inside the ear canal. They do give a reading in a few seconds but are more expensive than a simple plastic digital thermometer. Generally, they are not necessary for use at home.
Axillary (under the arm): Axilllary temperature measurement may be convenient, but it is also the least reliable. You can use a digital oral or rectal thermometer, with the tip placed in the armpit and the arm held snugly against the chest. A temperature of 99°F (37.2°C) or above indicates fever.
Oral (under the tongue): This route is generally not practical for younger toddlers. By the age of four or five years, children generally cooperate for oral temperature measurement, which requires keeping the thermometer under the tongue. If the temperature reaches 99.5°F (37.5°C) or above, your child has a fever.
Tympanic: A disposable tip is first placed on the end of the thermometer. Next, it is placed in the outer part of the ear. After a few seconds, the machine beeps, indicating the temperature has been recorded. While these thermometers are often used in hospitals and doctors’ offices, they are generally a bit expensive for home use. If the temperature reaches 99.5°F (37.5°C) or above, there is a fever.
Rectal: Nobody likes having things placed in their bottom, and toddlers are no exception! This is not a practical way to take a temperature in this age group. Fever is present if the temperature reaches 100.4°F (38°C) or above. Since this is the most accurate method, it is sometimes used in doctor’s offices in rare cases where a precise measurement is required.
If your child shows any of the following signs and symptoms in addition to fever, see a health-care provider immediately:
Most fevers in young children are caused by viral infections such as a common cold or stomach flu (gastroenteritis) that will run their course. In fact, fever is a normal and important part of the body’s natural immune response to infection.
It tells you that your toddler is fighting off infection appropriately. Think of it as a sign that your child’s immune system is battling germs.
The height of a fever does not indicate the severity of illness. In fact, some serious infections may be accompanied by only a slightly elevated or even a lower than normal body temperature. Much more important than the degree of the fever is how your child looks. Most toddlers with a fever will be a bit cranky, less energetic and uninterested in food. However, the child who doesn’t show any interest in her surroundings, is listless or seems inconsolable should trigger concern.
Many parents are concerned about the potentially harmful effects of an elevated body temperature. Rest assured that fever caused by uncomplicated infections will not cause brain damage, hearing loss, blindness or any other serious problems. Between the ages of six months and six years, a fever can occasionally trigger a seizure (febrile convulsion). This generally consists of ‘funny’ movements of the eyes and limbs with the child losing consciousness for a brief period, usually a minute or two. While this is incredibly frightening for the parent, it doesn’t cause any damage to the child!
Most fevers due to viral infections can be managed at home. If the fever is low grade and does not seem to bother your toddler, no treatment is necessary. With fever accompanied by chills, crankiness, and discomfort, most parents resort to medications. There are dozens of different fever reducers, generally all equally effective. Acetaminophen (Tylenol™, Tempra™) and ibuprofen (Advil™, Motrin™) are available without a doctor’s prescription. Find a product (drops, syrup or chewable tablets) that your child will be willing to take, in an acceptable flavor. Carefully read the dosing instructions for age/weight as stated on the box. There are no real significant side effects unless you give too much. If you give too little it will not work adequately.
Some parents alternate acetaminophen and ibuprofen for difficult to control fevers. The evidence behind this is still lacking. Although it seems like it may be more effective in keeping temperature down longer, the risks of side effects are a bit higher as trying to remember the time of the next dose is more complicated.
Beware of home remedies. Cold water baths and alcohol sponging are potentially dangerous and should not be used. Aspirin (ASA) should not be given to children because of the risk of Reye’s syndrome, a serious condition that can cause liver and brain injury.
Toddlers always seem to have a cold, particularly in winter. In fact, the average toddler can be expected to have as many as eight to 10 colds a year, particularly if she attends daycare or has older siblings at home. The numerous viruses that cause colds are around throughout the year but are much more common during fall and winter months. Nasal congestion and discharge, cough, low-grade fever, and mild sore throat are common. These symptoms tend to last for days, but it is not unusual for a nagging cough to remain for several weeks. If your child contracts several infections back to back, it may seem like she always has a cough or cold!
It would seem logical that the cure for the common cold is preventing cold viruses from spreading, but preventing all colds is practically impossible. Careful washing of hands can help reduce infections. Still, the viruses that cause colds are hardy. They can live on tabletops, toys, and other objects for days before finding their way to your child’s hands. It’s only a short trip from there to the nose, mouth, and eyes – and the inevitable infection occurs.
Despite claims to the contrary by manufacturers, no medication, vitamin, or nutritional supplement has been shown to prevent colds in toddlers. Many people are discouraged when they catch colds despite getting an influenza vaccination. Such vaccines target only a specific influenza virus – which generally causes much more severe symptoms than a common cold – not the many other viruses that cause colds. There is no truth to the myth that going outside with wet hair or not bundling up appropriately on a cool day will lead to colds. In fact, colds spread easily in the winter partly because we spend more time cooped up sharing germs, instead of being active outdoors in the fresh air!
Signs that indicate that more than a cold might be present include the following. If you note any of these red flags, see your doctor:
Ear infections are often seen in toddlers. They are one common reason for children in this age group to wake up in the middle of the night screaming in pain. Ear infections are most common between six months and two years of age. By the time children are two to four years old, the majority will have had at least one ear infection.
Most ear infections follow a common cold. Signs of an ear infection include fever, pain, and ear rubbing or pulling. Children with ear infections often have difficulty sleeping and will wake from sleep because the pain is more prominent at night.
Your doctor can diagnose an ear infection only by using an otoscope to look in the ear and examine the eardrum, looking for redness, swelling, or perforation. Ear infections cannot be accurately diagnosed without a good look in the ear. Even then, it can be difficult if the toddler is uncooperative and has a narrow ear canal or if the canal is blocked with a lot of earwax.
Ear infections are extremely painful. An important part of treatment focuses on pain relief, using analgesics such as acetaminophen or ibuprofen. We know that viruses cause most ear infections. They may resolve without antibiotics, which only work against ear infections caused by bacterial germs. Many doctors still prescribe antibiotics for children under the age of two with a definite ear infection. However, they often suggest using pain relief and waiting 48 hours with older children, to see if they can get better by themselves.
Some children get very frequent ear infections, which may start to interfere with hearing. In this case, your doctor may suggest having an ear, nose and throat specialist place ventilation (tympanostomy) tubes in the eardrum.
For some reason, we parents are often preoccupied with the bowel habits of our toddlers. Too few stools (constipation) or too constant (diarrhea), as well as tummy aches, are a common complaint during the toddler years.
Constipation is extremely common in children, especially toddlers. There is a wide variation in the frequency of passing stools. Some children have three a day, others three a week. Both patterns may be normal.
Long-standing constipation can make toilet training more difficult. The fear of pain leads to holding stool, setting up a cycle of worsening constipation and sometimes accidents.
In toddlers, constipation is often due to a diet low in fiber and fluids. It often begins when the change is made from breast milk and formula to cow’s milk and when switching from baby food to solid food.
If constipation persists despite adding fiber and water to the diet, many products can help. Lactulose, a non-absorbable liquid sugar, and mineral oil, available as a liquid or jelly spread, are widely available, effective, and don’t result in long-term dependence. Mineral oil should not be used for children less than two years old or those with swallowing difficulties, because it can cause pneumonia if it goes down the wrong way.
If constipation is an ongoing problem, speak with your health-care provider about other options.
‘Mommy, my tummy is sore’ is a common refrain during the toddler years. How do you know when to be worried, and how to handle this? Well, there are two types of tummy pain: one that is fairly sudden and short-lived (acute), and another that tends to last for days and recur quite often (chronic).
With acute tummy pains, certain signs prompt you to get immediate advice from your health care provider:
Acute tummy aches
Acute tummy pains are usually related to eating too much, too quickly, or simply eating something that disagrees with your child.
Constipation can certainly cause abdominal cramps. Stomach flu, or viral gastroenteritis, is another common cause. Vomiting and diarrhea usually accompany cramps. In this scenario, other family members or friends at daycare may have an upset stomach. Your toddler may also have a low-grade fever, and feel generally under the weather with little energy and appetite. If you think the cramps are part of stomach flu, watch your toddler for signs of dehydration and rehydrate as necessary. Otherwise try reassurance and distraction. Food poisoning is much less common, and usually appears within hours of eating the offending food. Most others who ate the same meal will likely also be complaining!
The most serious cause of an acute tummy pain would be appendicitis or another problem requiring surgery.
Appendicitis usually affects school-aged children, but occasionally affects preschoolers as well. The pain usually starts around the belly-button, is sharp and steady, and moves down to the right groin area over a matter of hours. Movements such as coughing or jumping usually make pain more intense. Other serious surgical causes include intussusception and volvulus. Intussusception occurs when a piece of the intestine telescopes into the next past of the intestine and gets stuck. The pain comes and goes and stools may look like red currant jelly! Volvulus occurs when the intestine twists on itself, causing severe pain and dark green vomiting.
Recurrent or chronic tummy pains are more common in school-aged children but can occur at a younger age as well. Constipation can cause cramps at any age. ‘Reflux’ (heartburn) can also occur at any age. It usually involves a burning sensation in the pit of the stomach, moving up behind the breast bone, after eating certain foods. Inflammatory bowel disease usually first appears in teenagers but occasionally affects preschoolers.
In young children, it may be associated with bloody diarrhea, poor growth and weight gain, mouth ulcers and skin rashes. A few children cannot digest lactose sugars, and feel bloated and gassy after eating dairy products. Often, no clear reason exists for the tummy ache. Such cases tend to settle down with time and reassurance.
With recurring tummy pain, a number of red flags should alert you to the need for an expert opinion. This can rule out inflammatory bowel disease, infectious colitis or other disorders needing specific treatment. If your toddler is constipated, you can try a number of approaches. If you suspect reflux, avoiding certain foods or using a simple antacid may help. With lactose intolerance, it may be worth stopping all dairy products for a few days to see if symptoms settle. If this is the case, your health care provider can arrange testing. Once lactose intolerance is confirmed, appropriate enzyme treatment can begin. Perhaps your doctor cannot find a cause, your toddler is growing well and has none of the red flags. If so, reassure and encourage him to continue with regular activities as much as possible.
Recognizing the signs and symptoms of common illnesses your child may experience is the first step to knowing when to consult your health-care provider.
It can also help ease the anxiety and fear that comes with caring for a child who is ill.