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Fever: Evidence Based Practice

3.00 Contact Hours:
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    Dana Bartlett (BS, MS, MA)


The purpose of this module is to provide the professional nurse with the most recent evidence based practice about the pathogenesis of fever and the etiologies of fever, and fever in three specific clinical situations: fever in very young children, fever in the elderly, and fever in critically ill adults. Instructions for patient education about fever are included, as well. The module will focus on fever as an acute sign of illness: fever of unknown origin, by definition, is a fever of unknown cause that has lasted more than three weeks and this will not be covered in the module.


After completing this module the learner will be able to:

  1. Explain limitations and advantages of methods of measuring body temperature.
  2. Explain the process of temperature regulation.
  3. Apply evidence based practice methods of fever reduction.
  4. Explain evaluation and treatment of fever, focusing on 2 specific age groups.
  5. Discuss patient education


Fever is a common alteration of the vital signs, and a very common complication of infectious diseases. Fever can also be caused by non-infectious diseases, inflammation, injury, and by drugs. Many hospitalized patients present with a fever, many patients develop a fever at some point during their hospital stay (Dai, et al, 2012) and fever is also one of the most common signs of illness in children (Sherman, et al, 2012). The care and treatment of patients with fever occupies a considerable amount of time for many nurses.

But despite this extensive experience with fever, there are important questions about fever that are unanswered and even healthcare professionals have misconceptions about the adverse effects of a fever and about when and how a fever should treated (Demir, et al, 2012; Pangiotis, et al, 2012; Sarrell, et al, 2002; Schortgen, et al, 2012). The most recent evidence based practice should be used.

In most cases, a fever will not cause harm, it may be helpful, and fever reduction is not needed and may actually be harmful. However, in certain clinical situations fever reduction can be beneficial, and nurses need to know when and how fever reduction should be done. For very young children who are febrile and the elderly patient who has a fever, the evaluation process must take into account specific information about risks and signs and symptoms that are specific to those groups.

Learning Break: Fever and hyperthermia are not interchangeable terms: they are different and distinct processes. Hyperthermia and other clinical conditions characterized by an elevated body temperature will be briefly discussed later in the module.

Normal Body Temperature and How its Measured

The body temperature that has traditionally been considered normal is 37C. But body temperature has a range, the range varies from individual to individual, and body temperature varies depending on the time of day, as well. For adults 18-40 years the mean normal body temperature is 36.8C 0.4 (Note: This range of 36.8C 0.4 accounts for 99% of all adults).

Body temperature is lowest in the early morning and highest in the early evening: the normal range is considered to be 37.2C at 6 AM and 37.9C at 4 PM. Children normally have a body temperature that is higher than that of adults, and women who are menstruating have a greater variation in the range of body temperature than do other adults, especially in the two weeks prior to ovulation and during ovulation. Elderly people typically have a lower body temperature than adults and children. During strenuous exercise the body temperature can be as high as 40C, and strenuous exercise can increase heat production up to 20 times the normal level.

When we are measuring body temperature we are attempting to determine the core temperature. Core temperature is the temperature of the organs and structures deep within the body, and it is the temperature at which the body functions best.

Body temperature can be measured invasively or non-invasively. All of these methods of measuring body temperature are accurate and consistent if they are done correctly, and all of them - even the sophisticated invasive methods - are subject to operator error.

Oral: Measuring body temperature orally is usually an accurate and reliable method of determining body temperature and it is convenient. Oral temperature readings are lower than the core temperature and there are many variables that can affect the reliability and accuracy of this method. Oral temperatures are usually lower than rectal temperatures (Wang, 2011).

Rectal: Measuring body temperature rectally is accurate and consistently reflects core temperature. (Batra, et al, 2012; Wang, 2011).

Tympanic: Tympanic temperatures measure the heat of the tympanic membrane and the ear canal, and they are typically lower than the rectal temperature. (Wang, 2011).

Axillary: The axillary temperature is typically lower than a temperature that is measured orally or rectally (Wang, 2011).

Temperature strips: Temperature strips (TempaDot is a commonly used brand) are small plastic strips that are placed in the mouth or in the axilla and measure body temperature.

Temporal artery thermometer: Temporal artery thermometers measure heat emitted from the temporal artery. The temporal artery is highly perfused, this method of temperature method has been shown to be an accurate way of estimating core temperature, and it compares well with other methods. (Batra, 2013).

Bladder temperature sensor: Temperature-sensing indwelling urinary catheters allow continuous drainage of urine and continuous measurement of body temperature. Studies support the use of urinary bladder temperature as a reliable index of core temperature during times of thermal stability. For critically ill patients who are already under considerable stress and whose condition necessitates the use of an indwelling urinary catheter, bladder temperature monitoring is an easy and convenient method that eliminates the need to use alternative sites.

Esophageal temperature probe: An esophageal temperature probe provides a core temperature assessment; however, accurate placement is necessary.

Invasive cardiovascular catheter sensor: Most often a pulmonary artery catheter. The temperature measured by a sensor in a pulmonary artery catheter is considered to most closely reflect core temperature (Batra, et al, 2012).

The method that should be used will depend on the clinical situation. Done correctly they will all consistently provide a measurement of the body temperature that accurately reflects the core temperature - within their limits. The cardiovascular catheters, the bladder temperature sensors, and the esophageal temperature probes provide the closest approximation of core temperature (Stelfox, et al, 2010). However in almost all clinical situations in which the patients temperature must be measured, or when a patient who has a fever needs constant temperature monitoring, the non-invasive methods can be considered appropriate to use and they are accurate and consistent (Batra, et al, 2013; Jefferies, et al, 2011; Rubia-Rubia, et al, 2011; Lawson, et al, 2007).

How is Body Temperature Produced and How is it Maintained?

Body temperature is produced by the metabolic activity of organs such as the brain, heart, and liver, and by involuntary and voluntary muscular activity. These processes all produce heat as a byproduct. Body heat is lost by radiation, conduction, convection, and evaporation. Small amounts of body heat are also lost by defecation, respiration, and urination.

Learning Break: Radiation is defined as the movement of heat from one object (the body) to another (the environment). Conduction is defined as the transfer of heat between objects that are in contact with each other and are at different temperatures. Evaporation is defined as is heat loss caused by vaporization of water: in humans evaporation happens when we sweat and breathe and by insensible water loss. Convection causes heat loss by cold air moving past and over the body. The surface temperature is lowered, blood vessels dilate to bring more heat to the skin, and heat is lost from the circulating blood.

Humans have the ability to maintain body temperature at an optimal point, increasing or decreasing heat production and increasing or decreasing heat loss. This process is called thermoregulation. Thermoregulation is activated and maintained through a structure in the brain called the hypothalamus. The hypothalamus contains a group of heat-sensitive neurons collectively called the temperature regulating center. The heat sensitive neurons in the hypothalamus receive input from the temperature of the blood as it passes through the hypothalamus. The heat sensitive neurons also receive afferent messages from peripheral temperature receptors in the skin that monitor external temperature, and afferent messages about body temperature from deep tissues and the spinal cord.

If the body temperature as sensed by the hypothalamus is too high these heat sensitive neurons in the thermoregulatory center initiate cooling mechanisms: 1) vasodilation; 2) shunting blood from the core to the periphery; 3) increased heart rate and cardiac output; 4) decreasing the metabolic rate; 5) decreasing muscular activity, and; 6) increased sweating. If the body temperature is too low, heat conservation mechanisms are initiated: 1) sweating is decreased; 2) blood vessels are constricted; 3) muscular activity is increased (shivering), and; 4) the metabolic rate is increased.

The thermoregulatory center of the hypothalamus then is similar to a thermostat: it has a set point of body temperature that it tries to maintain in response to the conditions of the internal and external environment.

Table 1: Heat Loss and Heat Conservation
Increased body temperature Decreased body temperature
Increased sweating Decreased sweating
Vasodilation Vasoconstriction
Decreased metabolism Increased metabolism
Decreased muscular activity  Increased muscular activity

These mechanisms for heat loss and heat conservation are usually coordinated and balanced and despite changes in the internal and external environment, a normal body temperature is maintained.

What is the Definition of Fever

A fever is an elevated body temperature. However, a body temperature 0.1 degree above the upper limit of normal is an elevated body temperature, but this would not be considered to be a fever. Body temperature varies during the day: it is usually the lowest at approximately 6 AM and the highest at approximately 4 PM, and body temperature - low and high - also varies from individual to individual.

But fever is an elevation of body temperature at or above a specific point. The definition of fever varies from source to source: a fever may be defined as > 38.2C or > 38.4C or by some other number. But the differences in these definitions are not very large and are not significant. The definition of fever that will be used in this module is from Harrisons Principles of Internal Medicine (Dinarello, et al, 2012).

Fever is a body temperature that exceeds the normal daily variation and occurs with an increase in the hypothalamic set point. Most sources consider a body temperature of > 38C to be a fever.

So, in an adult or a child a body temperature of > 38C is commonly considered to be a fever (Miller, et al, 2012; Gould, 2011; Wang, 2011) - a body temperature that exceeds the normal daily variation, that occurs in conjunction with an increase in the hypothalamic set point, and is indicative of the presence of an infection or a disease process. Children typically have a higher body temperature than adults, so pediatricians may define fever differently.

Learning Break: In certain clinical situations a body temperature that is < 38C should be considered be a fever. This will be discussed later in the module in the Signs and Symptoms section.

The letter C indicates that the temperature was measured using the Celsius scale; the letter F indicates that the temperature was measured using the Fahrenheit scale. Either scale can be used, but the Celsius scale has become more commonly used by medical personnel than the Fahrenheit, and the Celsius scale will be used in this module when referring to body temperature.
To convert Fahrenheit to Celsius: 1) Subtract 32 from the temperature in degrees Fahrenheit; 2) multiply the result from step 1 by 5; 3) divide the result from step 2 by 9.

Example: 100F: 1) 100 32 = 68; 2) 68 x 5 = 340; 3) 340 9 = 37.7C.

The Pathogenesis of Fever

Fever is usually caused by an infection with a micro-organism. The bacteria or the virus or other pathogen stimulates monocytes, macrophages, and Kuppfer cells to produce and release cytokines. These cytokines - interferon, interleukin-1, interlukin-6, tumor necrosis factor, and others - act as endogenous pyrogens, and they stimulate the hypothalamus to produce an elevated level of prostaglandin E2 (PGE2). This elevated level of PGE2 causes the set point of the temperature regulation center in the hypothalamus to be elevated. This is the basic mechanism that causes fever.

When this set point is changed upwards, the thermoregulatory center senses - incorrectly - that body temperature is too low. Heat production and heat conservation mechanisms are activated and the patient develops a fever (Barrett, et al, 2012; Dinarello, et al, 2012; Miller, et al, 2012; Sherman, et al, 2012). Elevated levels of PGE2 are also produced in the peripheral tissues; this accounts for the arthralgias and myalgias - the aches and pains - that are often part of a febrile illness.

Learning Break: Cytokines are small proteins produced by cells of the immune system. Cytokines perform many complex activities, but they typically are involved in generating an immune response to illness or infection. A pyrogen is a substance that can produce a fever. There are endogenous pyrogens and exogenous pyrogens, such as endotoxin.

Fever: Helpful or Harmful?

Fever has long been considered by lay people to be dangerous (Bunik, et al, 2012), and some health care professionals are apprehensive and misinformed about the consequences and implications of fever (Chiappinni, et al, 2012; Sherman, et al, 2012; Carey, 2010). But fever is a self-limiting phenomenon - there are control mechanisms that prevent fever from rising to a dangerous level - and in many situations it is not harmful and is probably helpful (Dai, et al, 2012; Gardner, 2012; Sherman, et al, 2012). A fever can be directly toxic to the bacteria, viruses, and other pathogens that are the cause of fever, and fever can also inhibit their growth (Kiekkas, et al, 2012). Fever also increases the expression and activity of heat shock proteins (HSPs), proteins that protect the hosts cells and tissues against heat stress (Buccatello, et al, 2007). Fever reduces the expression and activity of certain intracellular proteins that are produced in response to heat stress and these proteins can be damaging to the host (Ryan, et al, 2003). Unless the elevated body temperature is caused by hyperthermia, neuroleptic malignant syndrome, or malignant hyperthermia (processes distinct from fever; these will be discussed later), feedback mechanisms prevent body temperature from rising to dangerous levels that cause systemic damage (Carey, 2010). Fever can also be used as a diagnostic and prognostic tool.

However, the basic enzymatic processes of the cells and organs do not function optimally if the body temperature is abnormally elevated. Increasing body temperature from 37C to 39 increases the metabolic rate by 25%, and this increases cardiac output, heart rate, and oxygen demand (Kiekkas, et al, 2012). For most people who have a fever caused by a simple, self-limiting infectious process, the body temperature will not be that high and the fever will be unpleasant but of no consequence. But fever can be a significant stressor if the febrile patient has a chronic illness such as cardiovascular disease, diabetes, or pulmonary disease. In some clinical situations, e.g., cerebral hemorrhage or septic shock, lowering a fever can decrease mortality rate.

Non-Infectious Causes of Fever

Infection is the most likely source of a fever, but auto-immune disorders, endocrine disorders, inflammatory reactions, malignancies, and vascular disorders can also cause fever (Miller, et al, 2012; Sherman, et al, 2012). Examples of these include: 1) sarcoidosis; 2) thyrotoxic storm; 3) acute respiratory distress syndrome; 4) lymphomas, and; 5) cerebral infarction.

Drugs can also cause a fever. Because of their basic pharmacologic effects, some drugs can increase body temperature when they are taken in excess amounts. These medications increase body temperature by: 1) dramatically increasing the metabolic rate; 2) by intensely increasing muscular activity; 3) by depressing heat loss mechanisms, or 4) by a combination of these mechanisms. The following are examples of commonly used drugs that can increase body temperature in these ways. (Nelson, et al, 2010; Olson, 2007)

Table 2: Drugs That Can Increase Body Temperature
Anticholinergics, e.g., antihistamines, benztropine, tricyclic anti-depressants
Hallucinogenic amphetamines, e.g., MDMA (a.k.a. ecstasy)
Monoamine oxidase inhibitors (MAOIs)
Selective serotonin re-uptake inhibitors (SSRIs), e.g., fluoxetine, paroxetine can cause the serotonin syndrome, which increases body temperature.
Sympathomimetics, e.g., amphetamine, cocaine, phencyclidine (PCP)
Thyroid medications, e.g., levothyroxine

Learning Break: Non-steroidal anti-inflammatory drugs such as ibuprofen and corticosteroids such as prednisone can decrease the fever response to an infection.

Drug Fever

Another non-infectious source of fever is drug fever. Drug fever is a febrile response that is caused by administration of a therapeutic dose of a medication. The elevated temperature coincides with drug administration, and the body temperature returns to normal when the drug is discontinued (Patel, 2010). Antimicrobials, anticonvulsants, and anti-arrhythmics are the drugs that are the most likely to cause drug fever, but the list of medications implicated as a cause of this phenomenon is extensive (Mackowiak, 1987). Drug fever can happen at any time, but 7-10 days after starting medication therapy is the median time of onset (Patel, 2010). There are at least five mechanisms that can cause drug fever: a hypersensitivity reaction is the most common (Hanson, 1991; Johnson, et al, 1996).

Metal Fume Fever

Metal fume fever is a febrile illness that is caused by the inhalation of fumes that contain metal particles. Metal fume fever happens when galvanized metal is being burned or welded, and the person or persons doing the work is not wearing a respirator. Persons with metal fume fever typically have a fever and they complain of headache, malaise, and muscle aches. Metal fume fever is self-limiting; there should be no sequelae and the illness resolves with time and supportive care (Wong, et al, 2012). The pathogenesis of metal fume fever is not completely understood, but the disorder is probably caused by an inflammatory reaction and the release of cytokines (Wong, et al, 2012).

Signs and Symptoms of Fever

The typical signs of a fever are chills, diaphoresis, flushing, shivering, and tachycardia. Arthralgias, malaise, and myalgias are also common. Most people who have a simple febrile illness such as influenza will be uncomfortable and they may not feel well enough to work, but they will be able to perform basic activities of daily living.

Special Populations: The Elderly and the Very Young

Someone who has a fever will have obvious signs and symptoms. She/he looks sick and feels sick, that person can tell you about the symptoms, and there is objective data - the body temperature is > 38C - that is proof that this person is ill. However, the presentation of a febrile illness can be very different and less obvious in two populations: the elderly and the very young. There is also a complication of febrile illnesses, febrile seizures, which happens only to children; this will be discussed separately.

In the elderly, the first consideration is the possibility that the fever may not be due to an infection. It is more likely with an elderly person than it would be for a younger adult or a child that the cause of a fever is a non-infectious medical condition or drug related: these possibilities are more likely simply because of advanced age. The second consideration is that the elderly who have a febrile illness may present differently and the presence of a fever is more likely to indicate a serious illness (Cassel, et al, 2003; Norman, et al, 2007; Norman, 2000; Norman, 2007; Norman, 1996). The febrile response in elderly persons can be absent: approximately 20-30% of elderly patients who have a serious infection such as bacteremia or meningitis may not have a fever (Cassel, et al, 2003). The fever response of an elderly person can also be blunted - the temperature may not reach 38C - or the fever response may be essentially normal, but the patients baseline core temperature is lower than average so the temperature elevation does not meet the standard definition of fever (Cassel, et al, 2003).

Finally, the elderly patient with a febrile illness may not have the typical signs of a fever such as chills, diaphoresis, flushing, etc.: he/she may be confused, have shortness of breath, or the patient's activity level or mobility may be noticeably decreased. The safest and most sensible approach is to keep in mind the possibility of an infectious process if an elderly patient has a sudden change in his/her mental or physical functioning.

Learning Break: The febrile response is absent or attenuated in some elderly people. Obviously some part - or parts - of the febrile response is not normal; perhaps the sensitivity of the hypothalamus may be decreased, the quantity and activity of the endogenous pyrogens may be diminished, or the level of prostaglandin E2 produced is not sufficient (Norman, 1996). But although this phenomenon of an altered febrile response in the elderly is well known and well described, it is still not clear why it happens.

Very young children (90 days old or younger) who have a fever should also be considered separately. Most children who develop a fever have a self-limiting, non-serious illness. The fever does not last and it may actually be protective and help fight the infection (Demir, et al, 2012; Sherman, et al, 2012; Stephan, et al, 2011). But children who have a fever and who are 90 days old or younger deserve special concern, and children who have a fever and are 28 days old or younger should be evaluated very carefully and conservatively (Bunik, et al, 2012; Gould, 2011; Wang, 2011). A fever in these age groups is more likely to indicate the presence of a serious bacterial infection (SBI), and an infection in the first week of life is likely to be from vertical transmission from the mother (Bunik, et al, 2012; Gould, 2011). In addition, because of their age these children are more difficult to evaluate than older children; the physical exam is a somewhat limited tool and there are fewer behavioral clues that can be used to determine the severity of the illness or what illness the child has.

Febrile Seizures

Febrile seizures are a complication of common febrile illnesses occurring in children between the ages of one month and seven years. The definition of a febrile seizure is an epileptic seizure occurring in childhood after the age of 1 month, associated with a febrile illness not caused by an infection of the central nervous system, without previous neonatal seizures or a previous unprovoked seizure, and not meeting criteria for other acute symptomatic seizures (Anonymous 1993).

Febrile seizures are the most common cause of seizures in children (Teran, et al, 2012); the exact incidence is not known, but it is approximately 3-7% (Cross, 2012). Febrile seizures are most often associated with common infectious illnesses such as otitis media and upper respiratory infections. There are risk factors such as developmental delays, a family history of febrile seizures, day care attendance and others that pre-dispose children to febrile seizures (Graves, et al, 2012), but it is not known why these febrile illnesses cause seizures. Most febrile seizures are what are called simple febrile seizures: the seizure is generalized; the duration of the seizure is < 15 minutes; there is only one seizure; there are no post-seizure complications or sequelae, and; the child has no history of neurological disease (Graves, et al, 2012). The higher the body temperature, the greater the risk for a febrile seizure to occur. However, there is no evidence that a rapid rise in body temperature increases the risk for a febrile seizure to occur (Tejani, 2011).

Hyperthermia and Other Clinical Conditions Causing Extremely High Body Temperature

There are three clinical conditions that are distinct from the infectious processes and non-infectious medical conditions that were previously discussed that can cause a very elevated body temperature: hyperthermia, malignant hyperthermia, and neuroleptic malignant syndrome.

These conditions differ from the typical febrile illness in three ways: 1) they are not mediated by the effects of cytokines on the hypothalamus; 2) the body temperature is often much higher and; 3) they are associated with much higher rates of morbidity and mortality. Also, anti-pyretics would have essentially no value in treating these conditions.


Hyperthermia is defined as a body temperature > 40.1C (Olson, 2007). Hyperthermia is caused by: 1) high environmental heat; 2) greatly increased metabolic activity and/or muscular activity; 3) a decreased functioning of the body's heat loss mechanisms, or; 4) a combination of these mechanisms. The etiologies of hyperthermia are heatstroke and drugs. Hyperthermia is very dangerous. Body temperatures this high can denature proteins in the central nervous system and can cause irreversible brain damage, and hyperthermia can also cause acid-base-disturbances, coagulation disorders, liver damage, rhabdomyolysis, seizures, and other systemic effects. A fever caused by an excess amount of certain drugs (see Table 2) is relatively common, but hyperthermia caused by other drugs would be uncommon. Anti-pyretics are not useful for treating hyperthermia because the elevated body temperature is not caused by an alteration of the hypothalamic set point.

Malignant Hyperthermia

Malignant hyperthermia is a life-threatening condition caused by volatile inhalational anesthetics such as halothane and by the non-depolarizing muscle relaxer succinylcholine. It is an inherited metabolic disorder, and when people who have the disorder receive a volatile inhalational anesthetic or succinylcholine, massive amounts of calcium are released from the sarcoplasmic reticulum. This causes a very complex systemic hypermetabolic state, and the patient's body temperature can rise as high as 45C (Chapin, 2011).

Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome (NMS) is a rare, idiosyncratic, and potentially dangerous reaction to typical or atypical anti-psychotics such as haloperidol and risperidone. These drugs are (in part) dopamine receptor antagonists, and NMS is thought to be initiated by a drastic decrease in dopamine activity in the central nervous system (Benzer, 2012; Juurlink, 2010). The decrease in dopamine activity causes intense muscular contraction, it affects the thermoregulatory center of the hypothalamus, and hyperthermia is possible.

Which Patients Benefit From Fever Reduction

When and how should a fever be treated? The only reasonable answer is: it depends. Fever reduction should not be routinely done, and fever reduction should be subject to the same considerations as any therapy. There should be an indication for fever reduction, the patient should be considered individually to determine if she/he will benefit - or suffer - from fever reduction, and the advantages and potential adverse effects of fever reduction should be factored into the decision to us or not use cooling techniques.

Most patients who have a fever, either adults or children, have an infectious illness that is quickly diagnosed and treated or they have a non-serious, self-limiting illness such as influenza. In the first case, specific therapies are more important than fever reduction and in the second case the illness and the fever lasts at most a few days and neither the illness nor the fever require specific therapies. There is no evidence that treating a fever in either of these situations will decrease the length of the illness, and there is some evidence that suggests that anti-pyretics and cooling techniques may prolong the course of an illness (Carey, 2010). So for these patients, treating a fever would be a comfort measure and not a vital part of therapy.

But in some clinical situations lowering body temperature can be an important part of treatment. Treating a fever can increase patient comfort and that can be very helpful. If the patient has a fever and has chronic cardiac or pulmonary disease, fever reduction should be considered. These patients have limited physical reserves and the increased metabolic demand and oxygen consumption caused by a fever could be harmful. If the patient has suffered a neurological injury, fever reduction is considered beneficial (Egi, M, et al, 2012). If the patient is in septic shock, the beneficial effects of fever (decreased growth of microorganisms) do not seem to be operative and cooling the patient may decrease mortality and decrease the need for vasopressors (Kiekkas, et al, 2012; Schortgen 2012; Schortgen, et al, 2012; Launey, et al, 2011).

Learning break: Reducing fever in critically ill patients who have a neurological injury has many positive effects. It can decrease cerebral edema, decrease the metabolic rate and oxygen demand of the brain, enhance cellular function, decrease the risk of seizures, and reduce intracranial pressure (Polderman, 2008).

Fever Reduction

Fever reduction can be done using anti-pyretics drugs to reset the temperature regulating center of the hypothalamus, by using physical cooling techniques that encourage heat loss, or by using both. Both methods are effective: the physical cooling techniques work faster, but they are more complex and time consuming to initiate and monitor.


The drugs that are used as antipyretics are non-steroidal anti-inflammatories (NSAIDs) such as aspirin and ibuprofen, or acetaminophen. Aspirin is very seldom used, and the reason for this will be discussed later.

The NSAIDs inhibit the activity of cyclooxygenase-1 and cyclooxygenase-2 enzymes. Decreased activity of these enzymes decreases the amount of prostaglandin that is formed and the set point of the temperature regulating center is re-adjusted to the normal level. The anti-pyretic mechanism of acetaminophen is not completely understood, but it is probably works through the temperature regulating center of the hypothalamus.

Acetaminophen and the NSAIDS appear to have essentially the same degree of anti-pyretic effectiveness (Sherman, et al, 2012; Mullins, et al, 2011; Pierce, et al, 2010). Regardless of which drug is used, anti-pyretics should be administered before physical cooling methods are applied (Carey, 2010). Fever is caused by a change in the temperature regulating center, but physical cooling methods do not reset the temperature regulating center; they decrease body temperature by increasing heat loss through conduction, convection, evaporation, or radiation. Also, when the physical cooling methods are applied, the peripheral temperature receptors sense cold, and heat conservation and heat production mechanisms such as vasoconstriction and shivering are activated.

Alternating acetaminophen and ibuprofen has often been recommended as a useful technique for lowering fever in children. The pros and cons of this will be discussed later in the module.

Physical cooling

Physical cooling can be done using core methods, surface methods, or by using both (Polderman, et al, 2009).

Core methods include cold peritoneal lavage, infusion of cold IV fluids, and extracorporeal access and infusion of cold fluids. These cooling methods can decrease body temperature much more quickly than the surface cooling techniques, but they are complex, invasive, and time consuming. Surface cooling methods can be divided into two categories:

  • Surface cooling by air: Disrobing/exposing the patient, fans, sponge bathing with alcohol or water, and cooling beds.
  • Surface cooling by fluids: Cold water immersion, ice packs, and various types of cold water-circulating devices placed on and around the patient.

All of the surface cooling methods can be effective, each has advantages and disadvantages, and they can be combined. (Polderman, et al, 2009) Example: Disrobing the patient and using a fan is simple, inexpensive, and does not require a lot of nursing time but the rate of temperature reduction is relatively slow. Cold water immersion is highly effective but the practical considerations are obvious.

Cooling Techniques: Side Effects

Polderman (et al, 2009) provides a comprehensive review that discusses the advantages, disadvantages, and the effectiveness (i.e., degrees C per hour that temperature can be lowered) of the physical cooling techniques. Multiple methods of cooling and/or invasive cooling techniques that dramatically and rapidly lower body temperature might be used for a patient would had hyperthermia or malignant hyperthermia (Eyer, 2007), but would seldom be needed for a patient with a fever. However, nurses should know about side effects associated with cooling techniques. (Polderman, et al, 2009).

  • Arrhythmias, bradycardia
  • Coagulation pathway impairment
  • Electrolyte disorders from intracellular shifts and renal excretion. Calcium, magnesium, phosphate, and potassium levels can be affected.
  • Insulin resistance with hyperglycemia
  • Patient discomfort, e.g., shivering, skin breakdown.

Evaluation and Treatment of Fever in the Very Young: Children 90 Days Old and Younger

A child who has a fever and is three months old or younger is more likely to have an serious bacterial infection (SBI) than an older child (Gould, 2011; Claudius, et al, 2010): the incidence of SBI in young febrile children has been reported to be as high as 12.3% (Huppler, et al, 2010) An SBI is an infection that associated with high rates of morbidity and mortality if not treated: the most common SBIs in this age group are bacteremia and sepsis, pneumonia and sinusitis, meningitis, and urinary tray infection (Wang, 2011).

Determining if the very young child with a fever has an SBI is imperative. These illnesses are very serious and especially so in this age group because children who are three months old or younger have a relatively weak immune response to infection and fewer barriers against pathogens. It is also important to discriminate between a very young child with an SBI and one who has a simple, self-limiting illness in order to avoid potentially harmful over treatment. But evaluation of a febrile child 90 days old or younger is difficult. There few behavioral clues (e.g., activity level) that may indicate how sick the child is, communication with the child is not an option, and the physical exam is a limited tool because of the child's age.

Criteria have been developed that can be used to distinguish febrile children 90 days old and younger who have an SBI from those who simply have a self-limiting viral illness - low-risk patients. Low-risk patients will not need antibiotics and will not need to be admitted if the parents are reliable and close follow up is possible. At least four different evaluation protocols have been developed: the Boston Criteria, the Philadelphia protocol, the Pittsburgh guidelines, and the Rochester criteria (Nield, et al, 2011).

Example: The Philadelphia protocol states that children between 29-60 days old who have a fever = 38.2 should be evaluated with a blood culture, a complete blood count (CBC), a urinalysis and a urine culture, with gram stain, and examination of the cerebrospinal fluid (CSF) A chest x-ray and stool cultures are optional. If certain parameters are met, e.g., the white blood cell count (WBC) is < 15, 000 /L, the CSF WBC is < 8 /L, the child can be considered low-risk.

Each of the evaluation protocols is reliable, but they do differ slightly and there is no consensus as to which of these is the most sensitive and specific (Sherman, et al, 2012). However, all of these evaluation protocols do specify that these low-risk criteria should not be used in two circumstances: if the febrile child appears ill or toxic and/or if the febrile child is 28 days old or younger (Neild, et al, 2011; Sherman, et al, 2012; Wald, 2011).

If a child is 28 days old or younger and has a fever of = 38C, the following laboratory studies should be done: CBC, blood cultures, urinalysis and urine culture, and cell count, culture and gram stain of the CSF. A chest x-ray can be done and stool cultures can be obtained if needed (Gould, 2011; Wang, 2011; Claudius, et al, 2010). The child should be admitted and empiric IV antibiotic therapy should be started. Recommendations differ slightly, but a combination of IV ampicillin, cefotaxime, or gentamicin should be used. (Gould, 2011; Nield, et al, 2011; Wang, 2011) If the child is between 28 and 90 days old, evaluation and treatment should be guided by using one of aforementioned protocols.

Evaluation of any febrile child 90 days old or younger should begin with assessment of the vital signs. The child should then be completely undressed and a physical exam performed. Take special note of skin color and temperature, activity level, responsiveness or lack of responsiveness to touch or handling, and examine the child carefully for signs of a local infection. After the vital signs and physical exam have been done, ask about the child's health and activity during the febrile illness. Has the child been especially agitated or lethargic? Has oral intake been significantly decreased, or does the child not tolerate feedings? Has the child been coughing or having difficulty breathing? If a cough has been present, ask about the duration and quality of the cough. Have the child's bladder and/or bowel habits been abnormal?

The prenatal and birth history of history of the child should be reviewed, and the history of the child's health prior to the febrile illness should be reviewed. Ask the mother if she has had, or has hepatitis B or C, an infection with HIV, or a sexually transmitted disease. Ask the parent/parents if the child has had exposure to any adults with an illness, exposure to animals, or exposure to anyone who has recently arrived from another country.

Case Study 1

A 56-year-old male comes to the emergency room, and he reports that he has had abdominal pain, anorexia, diaphoresis, fever, and vomiting for five days prior to arrival. He has a past medical history of alcohol abuse and hypertension. The patients temperature is 39.8C (measured rectally), his pulse is 116, his blood pressure is 78/40 mm Hg, and his respiratory rate is 28. He is pale, diaphoretic, and his extremities are cool to the touch. The results of the laboratory tests are normal except for a white blood cell count of 19, 000/L. Because of the fever, hypotension, tachypnea, and the leukocytosis, a diagnosis of septic shock is made.

Blood and urine cultures are obtained, an IV infusion of Ringers lactate is started, therapy with several broad-spectrum antibiotics is started, and the patient is assigned a bed in the intensive care unit (ICU). At this point (three hours after arrival at the hospital) the source of the infection is not known; the physician suspects necrotizing pancreatitis, but more diagnostic tests need to be done.

The physician asks the nurse to give the patient an acetaminophen suppository, 650 mg. She also orders a cooling blanket to be applied and the patient's temperature to be monitored by a rectal probe; the physician makes a point of telling the nurse that the acetaminophen should be given before external cooling is started. The physician also informs the nurse that the current research does not provide strong evidence of a beneficial or a detrimental effect of fever control in all critically patients. However, she says that there is a lot of strong evidence that suggests that lowering body temperature in cases of septic shock may decrease mortality rate, decrease the need for vasopressors, and improve outcome. She advises the nurse to watch the patient closely for signs that cooling is proceeding too fast. Cooling techniques, she says, can lower body temperature very quickly, but temperature probes lag behind in the reading.

Case Study 2

A three-year-old boy is brought to the emergency room by his parents. The parents report that for the past two days the child has had a fever - the temperature has been as high as 102F - and he has been listless and his oral intake has been well below normal. The child has no prior medical history and does not take any prescription medications. The parents have been giving the child acetaminophen whenever his temperature was above 99F. The parents are basing this decision on what they read on the internet: 1) that a high fever can cause permanent brain damage and seizures; 2) that the normal temperature should not be higher than 98.6F. Neither parent can remember how much acetaminophen they give the child with each dose or how often they have given it and the mother says you can buy acetaminophen at any drug store, and they would not sell it over-the-counter if it was not safe. They have also been giving the child ibuprofen every once in a while because again, they had read on the internet that using acetaminophen and ibuprofen was a better way to lower a fever than using either one alone.

After reviewing the history of the current illness and examining the child, the physician makes the diagnosis of otitis media and prescribes an antibiotic. The physician informs the parents that a temperature of 102F is not unusual in cases of otitis media, higher fevers are not uncommon, and except for cases of hyperthermia, the seriousness of the illness does not correlate with the degree of fever. She also tells the parents: 1) a high fever in a child who has a simple infectious process will not cause brain damage; 2) treating a fever will not prevent febrile seizures; 3) lowering a fever that is caused by a simple, easily treated infectious process will not decrease the time it takes for the illness to resolve, and; 4) a fever is considered to be a defense mechanism and a fever may decrease the length of an infectious illness. A fever can be treated, she notes, if it is > 100.4, but this is an arbitrary number and lowering the fever is not the goal; the goal is to lower the fever to make the child comfortable and help increase oral intake. Finally, she advises the parents that there is no evidence that alternating anti-pyretics is more effective than using one alone and that overusing over-the-counter antipyretics, especially acetaminophen and especially in the context of giving this drug to a child who has a fever, can be dangerous and cause liver damage.

Patient Education

Many lay people have misconceptions about fever. They believe a fever is dangerous is dangerous, that fever can cause brain damage, and that a fever will almost always cause febrile seizures. These beliefs can be very upsetting at the least and at the worst can cause behaviors that are non-productive and harmful. Emergency rooms see many, many patients who have a simple viral syndrome and the patient sought help because of a high fever. Patients and parents may overuse anti-pyretics and over-the-counter cough and cold preparations. Therapeutic overuse of acetaminophen can cause liver damage, and the excessive dosing of cough and cold preparations can, and has caused serious harm (Vasslev, et al, 2010; Ryan, et al, 2008; Dart, et al, 2006). Patient education about fever can do much to avoid this emotional distress and encourage sensible treatment of a fever.

Educating Parents

The following points should be discussed with parents (Sullivan, et al, 2011). 

  • Fever is a normal defense mechanism against illness, and fever may actually decrease the length of time a child is sick.
  • The degree of fever does not correlate with the severity of the illness.
  • Lowering a fever does not prevent febrile seizures.
  • A high fever in itself will not cause serious harm to a child.
  • The only reason to treat a fever is to make the child more comfortable. Lowering a fever will not decrease the amount of time the child is sick.

The summary of educating parents about fever should essentially be:

If your child has a fever, you should always notify the pediatrician and discuss the situation, but most fevers are caused by simple, self-limiting illnesses such as influenza or a cold, and the fever will not harm your child.

Parents of course are concerned about their child and want to intervene. Stress to them that for a febrile child, rest and fluids are much more helpful than medications. Over-the counter cough and cold preparations should not be given to children under the age of six: the Food and Drug Administration, the American Academy of Pediatrics, and several other medical associations have all advised against the use of these products in children.

These preparations typically have some combination of an antihistamine, a decongestant, and an anti-tussive, so it would seem reasonable to use them to treat the signs and symptoms of a febrile illness. However, there is no evidence that they work, they have never been tested in children, and over use of these products can cause serious harm (Blake, 2008; Dolanksy, et al, 2008). Anti-pyretics can be used, but parents should be instructed to carefully read labels and to never exceed recommended doses, either a single dose or the 24 hour total dose.

Acetaminophen or ibuprofen can be used; both are equally effective at lowering a fever. Alternating the two has been recommended in the past, but there is no evidence that doing so is more effective than using either drug alone (Pereira, et al, 2012; Sherman, et al, 2012).

Learning Break: Aspirin should not be given to a child who has a fever or to anyone 19 years of age or younger who has a fever. Aspirin is an effective anti-pyretic, but its use in febrile children has been associated with a disease called Reyes syndrome. Reyes syndrome is quite rare, and the link between aspirin and Reyes syndrome is still somewhat controversial: some authorities do not believe aspirin can cause Reyes. But Reyes syndrome is a very serious disease, and acetaminophen and ibuprofen are as effective as aspirin and if they are used correctly are much safer, as well.

Other medications - antibiotics, vitamin supplements, mineral supplements, antihistamines, etc - will not be effective treatments for children who have a fever from a simple illness (Fashner, et al, 2012), and parents should never treat a febrile child with a medication unless the pediatrician has been consulted and approved its use.

Some children who have a fever do have a serious illness, and some children are susceptible to SBIs. If a child has a fever, parents should be instructed to bring the child to the pediatrician as soon as possible if:

  • The child is 90 days old or younger.
  • The child is immuncompromised.
  • The child has a chronic medical condition such as cancer, diabetes, heart disease, sickle cell disease, etc.
  • The childs oral intake is significantly decreased or if the child is losing a lot of fluid because of persistent diarrhea and/or vomiting.
  • The child is lethargic.
  • The child is exceptionally irritable and cant be consoled.
  • The child is wheezing or seems or be having difficulty breathing, or if the child has a barking type of cough.
  • The child has a seizure.

Educating Adults

Much of the same information for parents applies to adults. Adults who have a fever should be instructed to rest and stay well hydrated. Over-the-counter cough and cold medications offer minimal benefit and some of the ingredients they have can cause harmful interactions with many commonly used prescription medications. For example, dextromethorphan is an anti-tussive, and it can cause serotonin syndrome if it is used in combination with anti-depressants such as fluoxetine or paroxetine. Phenylephrine is a decongestant that is a sympathomimetic, and it should not be used, or only used cautiously by people who have cardiovascular disease. Acetaminophen or ibuprofen can be used for fever control. But adults, especially older adults, should check with a physician before using these medications. Acetaminophen may not be safe for someone who has liver disease, and ibuprofen should be used cautiously by people who have gastric ulcers. Aspirin is an effective ant-pyretic, but even for adults it is not the drug of choice. Acetaminophen and ibuprofen are safer alternatives, especially for elderly adults.


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This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Registered Nurse (RN)


CPD: Practice Effectively, Medical Surgical

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