5/9/22, 11:42 PM Chapter 6: Fever | Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 20th Edition | PharmacyLibrary

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Chapter 6: Fever
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Authors: Virginia Lemay, Brett FeretVirginia Lemay, Brett Feret

Fever is a common reason for visits to pediatricians’ offices, with the National Ambulatory
Medical Care Survey estimating that 6% of all ambulatory visits to pediatricians are related
to fever.1 Fever also is the leading cause of visits to an emergency department for both
male and female patients younger than 15 years.2 In 2012, patients with the primary
complaint of fever made approximately 10.9 million medical office visits, with a slight
preponderance of men.3 Fever is more commonly reported in children than in adults: The
rate of reported fevers is 10 per 100 children younger than 5 years, versus 0.5 per 100 adults.
Nonetheless, occurrence rates do not seem to differ significantly with respect to gender,
race, or geographic area of residence in the United States.4

In most cases, fever is self-limited and nonthreatening in presentation; however, fever can
cause a great deal of discomfort and occasionally may indicate a serious underlying
pathologic condition (e.g., acute infectious process) for which prompt medical evaluation is
indicated. The principal reason for treating fever is to alleviate discomfort, but the
underlying cause should be identified and appropriate management instituted.

Fever must be distinguished from hyperthermia and hyperpyrexia. Fever is caused by a

regulated rise in body temperature, maintained by the hypothalamus, in response to a
pyrogen. Fever is defined by a body temperature higher than the normal core (oral)
temperature of 100°F (37.8°C). It thus signals an increase in the body’s thermoregulatory set
point.

Hyperthermia, by contrast, represents a malfunctioning of the normal thermoregulatory

process at the hypothalamic level caused by excessive heat exposure or production.5
Because of their different mechanisms, treatment of fever versus hyperthermia also varies.

Hyperpyrexia is defined by a body temperature greater than 106°F (41.1°C; oral) that
typically is associated with mental and physical signs and symptoms. Hyperpyrexia may
develop with either fever or hyperthermia.
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Pathophysiology of Fever
Core body temperature is controlled by the hypothalamus and regulated by a feedback
system involving information transmitted between the thermoregulatory center in the
anterior hypothalamus and the thermosensitive neurons in the skin and central nervous
system (CNS). Physiologic (e.g., sweating, vasodilation) and behavioral mechanisms
regulate body temperature within the normal range. Although skin temperature may
fluctuate greatly in response to environmental conditions, the core temperature is
maintained within a narrow range.6

Normal thermoregulation prevents wide fluctuations in body temperature, with the

average oral temperature usually maintained between 97.5°F and 98.9°F (36.4°C and 37.2°C,
respectively). Temperature maintained in this range is considered to be the “set point” at
which physiologic or behavioral mechanisms are not activated. For practical purposes, the
commonly accepted core body temperature is usually 98.6°F (37.0°C; oral).

Pyrogens, either exogenous or endogenous, are fever-producing substances that activate

the body’s host defenses, resulting in an increase in the set point. Exogenous pyrogens
(e.g., those of microbial origin or plant toxins) do not independently increase the
hypothalamic temperature set point. These substances stimulate the release of
endogenous pyrogens (e.g., immune cytokines), thereby increasing the core temperature.
Endogenous pyrogens are products released in response to or from damaged tissue, such
as interleukins, interferons, and tumor necrosis factor.6–8

Prostaglandins of the E2 series (PGE2) are produced in response to circulating pyrogens

and elevate the thermoregulatory set point in the hypothalamus. Within hours, body
temperature reaches the new set point, and fever occurs. During the period of upward
temperature readjustment, the patient experiences chills, caused by peripheral
vasoconstriction and muscle rigidity, to maintain homeostasis.6

An increase in body temperature may be idiopathic or the result of a variety of

mechanisms, including those associated with infectious and other pathologic processes,
systemic response to certain drugs, and vigorous activity.

Most febrile episodes are caused by microbial infections (i.e., due to viruses, bacteria, fungi,
yeasts, or protozoa). No basis has been found for differentiating viral from bacterial
infections according to the magnitude of the fever or temperature reduction with
antipyretic drug therapy. Fever often is less pronounced in older patients; consequently,
infection may not be recognized easily, or early, in this age group if fever is the primary
assessment criterion.9

Noninfectious pathologic causes of increases in temperature include malignancies, tissue

damage (e.g., myocardial infarction, surgery), antigen–antibody reactions, dehydration,
heat stroke, CNS inflammation, and metabolic disorders such as hyperthyroidism or gout.
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Many of these processes may cause hyperthermia, rather than fever, because they interfere
with the hypothalamic regulation of temperature.

Drug fever is simply defined as a febrile response to the administration of a medication. Its
incidence in ambulatory settings is unknown but among hospitalized patients is
approximately 10%10 (Table 6–1). With drug-induced fever, temperatures usually range from
98.9°F (37.2°C; oral) to as high as 109°F (42.8°C; oral). Drug fever should be suspected in
patients without an obvious source of fever; however, this condition often goes
unrecognized because of inconsistent signs and symptoms. Failure to discontinue the
offending drug may result in substantial morbidity and death.11,12

Table 6–1 Selected Medications That Induce Hyperthermia

Anti-infectives Antineoplastics Cardiovascular CNS Agents Other Agents

Aminoglycosides Bleomycin Epinephrine Amphetamines Allopurinol

Amphotericin B Chlorambucil Hydralazine Barbiturates Atropine

Cephalosporins Cytarabine Methyldopa Benztropine Azathioprine

Clindamycin Daunorubicin Nifedipine Carbamazepine Cimetidine

Chloramphenicol Hydroxyurea Procainamide Haloperidol Corticosteroids

Imipenem L-Asparaginase Quinidine Lithium Folate

Isoniazid 6-Mercaptopurine Streptokinase MAOIs Inhaled anesthetics

Linezolid Procarbazine Nomifensine Interferon

Macrolides Streptozocin Phenytoin Iodides

Mebendazole Phenothiazines Metoclopramide

Nitrofurantoin SNRIs Propylthiouracil

Para-aminosalicylic acid SSRIs Prostaglandin E2

Penicillins Sumatriptan Salicylates

Rifampin Thioridazine Tolmetin

Streptomycin Trifluoperazine

Sulfonamides TCAs

Tetracyclines Topiramate

Vancomycin Zonisamide

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Key: CNS = Central nervous system; MAOIs = monoamine oxidase inhibitors; SNRIs = serotonin-
norepinephrine reuptake inhibitors; SSRIs = selective serotonin reuptake inhibitors; TCAs = tricyclic
antidepressants.

Source: References 5, 10, and 12.

Drug fever may be differentiated from other potentially causative disorders by establishing
a temporal relationship between the fever and the administration of a medication, as well
as by observing a temperature elevation despite clinical improvement with respect to the
underlying disorder.

The management of drug fever involves discontinuing all medications temporarily, if

feasible, in addition to the suspected medication whenever possible. If the hyperthermia is
drug-induced, the patient’s temperature generally will decrease within 24–72 hours after
the offending agent is withdrawn. After the patient’s safety has been secured and the
offending medication has been identified and discontinued, each medication may be
restarted, one at a time, with careful monitoring for fever recurrence.12

Clinical Presentation of Fever

Because clinical manifestations of fever are nonspecific and do not occur in all patients, the
specific cause of a fever may be difficult to determine. The most important indicator of
fever is an elevated body temperature; therefore, accurate temperature measurement is
paramount. Fever is symptomatic of a larger underlying process, whether an infection, an
abnormality of metabolism, or a drug-induced syndrome.

Once the presence of fever is established, investigation into the underlying cause is
essential. Signs and symptoms that typically accompany fever and cause a great deal of
discomfort include headache, diaphoresis, generalized malaise, chills, tachycardia,
arthralgia, myalgia, irritability, and anorexia. Most children will tolerate a fever well, so if
they continue to be alert, play normally, and stay hydrated, the fever is not a reason for
great concern. However, high body temperature dulls intellectual function and causes
disorientation and delirium, especially in persons with preexisting dementia, cerebral
arteriosclerosis, or alcoholism.

Detection of Fever
The most accurate method of assessing for fever is to use a thermometer properly to
measure body temperature. The patient’s age and level of physical and emotional stress,
the environmental temperature, the time of day, and the anatomic site at which the
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temperature is measured are important considerations in that each factor can affect the
temperature reading obtained.

Core temperature is estimated using various types of thermometers at the rectal, axillary,
oral, temporal, or tympanic site. Rectal temperature has long been considered the gold
standard measurement; however, its utility has been challenged.13 Many patients and
caregivers prefer other methods of temperature measurement because of comfort and
ease of use. Body temperature should be measured with the same thermometer at the
same site over the course of an illness, because the readings from different thermometers
or sites may vary (Table 6–2). Discrepancy among the various sites of temperature
measurement is normal and should not be ascribed to improper measurement technique.
On average, a rectal temperature greater than 100.4°F (38.0°C), an oral temperature greater
than 99.5°F (37.5°C), an axillary temperature greater than 99°F (37.2°C), a tympanic
temperature greater than 100.4°F (38.0°C), or a temporal measurement higher than 100.1°F
(37.8°C) is considered elevated.14,15 The observed variation in temperatures at the different
sites is in accord with a simple concept of temperature measurement familiar to the
general public: Add 1 degree to an oral temperature to get a rectal or tympanic equivalent,
and subtract 1 degree from an oral temperature for an axillary measurement. Normal body
temperature may differ by 1.8°F–2.5°F (1.0°C–1.4°C) from these general criteria. Diurnal
rhythms cause body temperature to vary during the day, with higher temperatures
typically seen in the late afternoon to early evening.

Table 6–2 Body Temperature Range Based on Anatomic Site/Method of Measurement

Site/Method of Measurement Norma Rangea Fevera

Rectal 97.9°F–100.4°F (36.6°C–38.0°C) >100.4°F (38.0°C)

Oral 95.9°F–99.5°F (35.5°C–37.5°C) >99.5°F (37.5°C)

Axillary 94.5°F–99°F (34.7°C–37.2°C) >99°F (37.2°C)

Tympanic 96.3°F–100.4°F (35.7°C–38.0°C) >100.4°F (38.0°C)

Temporal 97.9°F–100.1°F (36.6°C–37.8°C) 0–2 months of age: >100.7°F (38.1 °C)

3–47 months of age: >100.3°F (37.9°C)

>4 years of age: >100.1 °F (37.8°C)

a Conversion formulas: Celsius = 5/9(°F – 32); Fahrenheit = (9/5 × °C) + 32.

Source: References 14 and 15.

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Because the U.S. Food and Drug Administration (FDA) regulates thermometers as medical
devices, all approved types of thermometers are accurate and reliable, if used
appropriately. Today’s providers should not recommend mercury-in-glass thermometers
for use because of environmental concerns about mercury. Federal and state authorities
have lobbied for a ban on mercury thermometers, and 13 states have passed laws that
prohibit the manufacture, sale, and distribution of mercury-containing thermometers. In
addition, the National Institute of Standards and Technology in conjunction with the
Environmental Protection Agency will no longer provide any calibration services for
mercury-containing thermometers.16,17

Electronic probe thermometers are available for oral, rectal, and axillary temperature
measurements. The probes have an electronic transducer that provides a temperature
reading in approximately 10–60 seconds. The oral electronic probes are mostly available as
either a pen or a pacifier. The pacifier-shaped electronic thermometer is for oral use only
and is recommended for infants who are unable to hold a probe under the tongue. The
length of time the pacifier needs to stay in the child’s mouth varies depending on the
manufacturer but can range from 3 to 8 minutes.15,18 The pen-shaped probe may be used
in oral, rectal, and axillary sites. Because of their electronic digital temperature displays,
electronic thermometers provide quick readings, eliminate the possibility of injury from
glass breakage, and are easier to read than traditional glass thermometers. The use of
disposable probe covers with electronic thermometers also reduces the need for
disinfection between uses. Disinfection protocols are still indicated, however, if the
thermometer is being used for multiple patients. A thermometer that is used rectally
should never be used subsequently for oral measurement.

Infrared thermometers are available for tympanic artery and temporal artery temperature
measurements. These thermometers use infrared technology to detect heat from the
arterial blood supply. They must be placed directly over the course of the relevant blood
vessel, whether near the temporal artery or the tympanic membrane. Infrared
thermometers give a temperature reading in less than 5 seconds and are considered very
accurate if used properly. The major problem with infrared thermometers is that the device
may not always be placed appropriately, or it may have a dirty lens and consequently may
give inaccurate readings. Infrared thermometers are relatively expensive and require
batteries, but many families with young children prefer them because of their convenience
and noninvasive nature. Newer technology also includes no-touch infrared thermometers,
which offer the advantage of not having to wake a sleeping child to take a temperature.15,19

Color-change thermometers are easy to use, but they are not sufficiently accurate or
reliable. With these thermometers, an adhesive strip containing heat-sensitive material
changes color in response to different temperature gradients. The strip may be placed
anywhere on the skin, preferably the forehead, which shows less variation in temperature
compared with other parts of the body. Although this method may detect changes in skin
temperature, it does not reliably detect changes in core temperature.

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Patient-related factors may preclude the use of a particular type of thermometer. Although
a variety of routes for temperature measurement are practicable, rectal temperature
measurement historically has been the standard, because the site is not influenced by
ambient temperatures, and because this route is appropriate for use in patients of various
ages.14 Oral, tympanic, axillary, and temporal routes are all satisfactory for temperature
measurement if the proper procedure is followed.

Table 6–3 describes the proper methods of taking rectal temperatures in children and
adults. Although the rectal route gives the closest estimate of stable core temperature, its
intrusive nature can be very frightening and possibly psychologically harmful to older
children. In children younger than 3 months, however, rectal temperature measurement is
the preferred method for assessing fever and should be recommended if caregivers are
confident they can safely use this technique.15 Risks associated with taking a rectal
temperature include retention of the thermometer, rectal or intestinal perforation, and
peritonitis. Rectal temperature measurement is also very time-consuming, and the patient
should never be left unattended while the rectal thermometer remains in place; a
positional change may cause the thermometer to be expelled or broken. Rectal
temperature measurement is relatively contraindicated in patients who are neutropenic,
have had recent rectal surgery or injury, or have a pathologic process involving the rectum
(e.g., obstructive hemorrhoids, diarrhea). In addition, rectal temperature measurement is
slow to detect rapid changes in body temperature because of the large muscle mass and
poor blood flow in the surrounding anatomic area.14,15,20

Table 6–3 Guidelines for Rectal Temperature Measurement Using Electronic Thermometers

1. Cover the tip of thermometer with a probe cover.

2. Turn on the thermometer and wait until the device signals that it is ready for use.
3. Apply a water-soluble lubricant or petroleum jelly to tip of thermometer to allow for easy passage through the
anal sphincter and to reduce risk of trauma.
4. For infants or young children, place child face down over your lap or face up with legs bent to the chest, separate
the buttocks with the thumb and forefinger of one hand, and insert the thermometer gently in the direction of
the child’s umbilicus with the other hand. For infants, insert the thermometer to the length of the tip only. For
young children, insert it no more than 1 inch into the rectum.
5. For adults, have the patient lie on one side with the legs flexed to an approximately 45-degree angle from the
abdomen. Insert the tip 0.5–2 inches into the rectum by holding the thermometer 0.5–2 inches away from the
tip and inserting it until the finger touches the anus. Have the patient take a deep breath during this process to
facilitate proper positioning of the thermometer.
6. Hold the thermometer in place until it beeps and a temperature is displayed.
7. Remove the thermometer and record the displayed temperature.
8. Dispose of probe cover and clean thermometer with an antiseptic such as alcohol or a povidone/iodine solution
by wiping away from the stem toward tip. Rinse with cool water.
9. Wipe away any remaining lubricant from the anus.

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Table 6–4 summarizes the proper methods of oral temperature measurement with
electronic thermometers.15 Of note, use of oral measurement techniques is not acceptable
in patients who are mouth-breathing or hyperventilating; have recently had oral surgery;
are not fully alert; or are uncooperative, lethargic, or confused. Oral digital probe
thermometers may not be appropriate for use in most children younger than 3 years of age
owing to the difficulty of maintaining a tight seal around the thermometer and keeping
the thermometer under the tongue. Accordingly, in these younger children, use of a
pacifier thermometer may be recommended. Pacifier thermometers provide reliable
temperature readings compared with rectal measurements; however, in children younger
than 3 months, pacifier thermometers are less accurate.21,22

Table 6–4 Guidelines for Oral Temperature Measurement Using Electronic Thermometers

Digital Probe

1. Wait 20–30 minutes after drinking or eating.

2. Place a clean disposable probe cover over tip of thermometer.
3. Turn on the thermometer and wait until it is ready for use.
4. Place tip of thermometer under tongue.
5. Close mouth and breathe through nose.
6. Hold thermometer in place until it beeps and temperature has been recorded (usually after 5–30 seconds).
7. Remove the thermometer from mouth and record the displayed temperature.
8. Remove and dispose of probe cover.

Digital Pacifier Thermometer

1. Wait 20–30 minutes after drinking or eating.

2. Inspect the pacifier for any tears or cracks. Do not use if worn.
3. Press the button to turn on thermometer.
4. Place the pacifier in the child’s mouth.
5. Have the child hold pacifier in mouth without moving, if possible, for time specified on packaging of
thermometer (2–6 minutes).
6. Remove thermometer after the beep and record displayed temperature.

Source: References 15 and 18.

Table 6–5 describes the proper method of using tympanic thermometers, which varies
slightly with the age of the patient.15 Tympanic thermometers have digital readouts, and
many can be set to provide either a rectal or an oral temperature equivalent. The tympanic
membrane is close to the hypothalamus, and the blood supply to both anatomic areas is at
the same temperature, providing an accurate reading of the core body temperature. The
thermometer must be positioned in the ear canal properly to ensure that the measured
infrared radiation is from the tympanic membrane and not from the ear canal or adjacent
areas. In clinical trials, accuracy of tympanic thermometers is lower, with more variable

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readings, than that for thermometers using rectal and oral routes.23,24 Variations in
measured tympanic temperatures have been attributed to cerumen impaction,
inflammation in the ear canal (e.g., otitis media), age of the patient (and corresponding size
of the ear canal), and inappropriate technique.15 Use of tympanic thermometers is not
recommended in infants younger than 6 months, in whom the ear canal is not fully
developed, leading to inappropriate technique and inaccurate readings. Although not as
reliable as the rectal method in children, if used correctly, tympanic thermometry has been
found to be more accurate than axillary or oral thermometry in estimating core
temperature.20

Table 6–5 Guidelines for Tympanic Temperature Measurement

1. Place a clean disposable lens cover over ear probe or clean probe per manufacturer directions.
2. Turn on thermometer and wait until it is ready for use.
3. For children 6 months to 1 year, pull ear straight backward to straighten ear canal. Place ear probe into canal,
aiming the tip of the probe toward the patient’s eye on that side.
4. For patients older than 1 year, pull ear backward and then upward to straighten ear canal. Place the ear probe
into canal, aiming the tip of probe toward the patient’s eye.
5. Press the button for temperature measurement (which usually appears after only 1–5 seconds).
6. Read and record temperature.
7. Discard lens cover.

Source: Reference 15.

Temporal touch thermometers are placed on the side of the forehead directly over the
temporal artery and moved across the forehead (Table 6–6). The temporal artery is directly
supplied by the hypothalamus and is near the surface of the skin at the side of the head,
permitting surface measurement using infrared technology. The temporal thermometer is
capable of providing a reading in a few seconds. The rapid, noninvasive nature of this
method makes temporal touch a preferred route of temperature measurement for most
patients, and the temporal thermometer is significantly more sensitive than the tympanic
thermometer for detecting fever in infants.25 Of note, however, temporal temperature
measurement still has not shown superiority or greater reliability over the rectal method.21
Temporal temperatures may differ from rectal temperatures by ±2.3°F (1.3°C).22,23 The
presence of hair near the temporal area may confound the temperature reading, so hair
must be pushed away before a reading is obtained.

Table 6–6 Guidelines for Temporal Artery Temperature Measurement

1. Allow thermometer to acclimatize to the environment for about 30 minutes if the thermometer was moved
from a hot room to a cold room or vice versa.
2. Remove protective cap and clean probe per manufacturer directions.

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3. Place probe on one side of forehead midway between hairline and eyebrows.
4. Depress button and hold while scanning for the temporal artery temperature.
5. Lightly sweep thermometer across forehead to the hairline on the opposite side of the head. Ensure that probe
remains in contact with skin at all times, and hold button down until scanning is completed.
6. If sweat is visible on the forehead, sweep the thermometer as normal, but nestle the thermometer on the neck
directly behind the ear lobe before releasing the button.
7. Lift thermometer, release the button, and document the recorded temperature.

Source: References 15 and 19.

No-touch infrared thermometers do not require contact of the device with the body for
measurement. Temperature is measured by aiming the thermometer at the center of the
patient’s forehead. Certain models may also allow use of alternative sites such as the navel
and neck, although readings at these sites are less accurate.15 Although no-touch infrared
thermometers are convenient and less invasive, a study of children 1 month to 4 years of
age treated in the emergency department found no-touch infrared thermometers to be
less accurate and reliable than rectal measurement.26

Axillary temperature measurement is frequently used by caregivers and in ambulatory

settings, because it is relatively noninvasive. However, axillary measurement performed
with digital thermometers (Table 6–7) is not as reliable for detecting fever compared with
the oral and rectal methods.27,28 Reported large variations in temperatures taken by the
axillary method are attributable to inappropriate placement of the thermometer,
movement of the arm during measurement leading to a poor seal around the
thermometer, and insufficient duration of the measurement period. Axillary temperature
should not be taken directly after vigorous activity or bathing because both can affect
body temperature temporarily without altering the thermoregulatory set point at the
hypothalamus. If a fever is detected with the axillary method, a confirmation reading using
another method is recommended.

Table 6–7 Guidelines for Axillary Temperature Measurement Using Electronic Thermometer

1. Place a clean disposable probe cover over tip of thermometer or clean probe per manufacturer directions.
2. Turn on thermometer and wait until it is ready for use.
3. Place tip of thermometer in armpit. Ensure that armpit is clean and dry. Thermometer must be touching skin,
not clothing.
4. If taking a child’s temperature, hold the child close, if necessary, to secure the thermometer within the armpit.
5. Read and record temperature when thermometer beeps.

Source: Reference 15.

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Complications of Fever
The presence of fever is of great concern among caregivers, although in most cases fever
typically is self-limiting and serious complications are rare. In one study, 73% of caregivers
were “very concerned” about the potential complications of fever, and 88% were “very
concerned” when a child’s fever was not reduced by antipyretics. There is less concern
about complications of fever now than 20 years ago; however, interviewed caregivers still
perceived seizures (32%), brain damage (15%), and death (16%) as the main complications of
fever.29 Overall, the major risks associated with fever are rare but may include acute
complications such as seizures, dehydration, and change in mental status.

Febrile seizure is defined as a seizure accompanied by fever in infants or children who do

not have an intracranial infection, a metabolic disturbance, or an otherwise defined
cause.30 Febrile seizures occur in 2%–5% of all children from the ages of 6 months to 5
years, with peak occurrence in the age range of 18–24 months. Risk factors for a first febrile
seizure include daycare attendance, developmental delay, a family history of febrile seizure,
and a neonatal hospital stay longer than 30 days. The severity of the fever and the rate of
temperature increase also appear to be critical determinants in the precipitation of a first
febrile seizure.31 The most common seizures associated with fever are simple febrile
seizures, which are characterized by nonfocal movements, generally less than 15 minutes in
duration, with only one episode in a 24-hour period. Significant neurologic sequelae (e.g.,
impaired intellectual development, epilepsy) are unlikely after a single pediatric febrile
seizure. The risk of recurrence is increased in children who have had multiple febrile
seizures, are younger than 1 year at the time of their first seizure, and have a family history
of epilepsy. Antipyretics generally are recommended to make the child more comfortable,
although they do not reduce the risk of recurrent febrile seizures.30,32,33 Prophylaxis against
simple febrile seizures with antiepileptic or antipyretic drugs is not recommended by the
American Academy of Pediatrics.30

Serious detrimental effects (e.g., dehydration, delirium, seizures, coma, irreversible

neurologic or muscle damage) occur more often in patients with hyperpyrexia
(temperatures >106.0°F [41.1°C]; oral), which is usually associated with hyperthermia and not
fever. Because of the homeostatic mechanisms of the hypothalamus, a core temperature
exceeding 106.0°F (41.1°C; oral) in a febrile person is rare. Even body temperature elevations
of lesser magnitude, however, may be life-threatening in patients with heart disease or
pulmonary dysfunction. Increased risk of complications is recognized in infants and
patients with brain tumors or hemorrhage, CNS infections, preexisting neurologic damage,
and a decreased ability to dissipate heat in concert with lower tolerance of elevated body
temperature. Older patients are at a higher risk for fever-related complications because of
their decreased thirst perception and ability to perspire.6,34

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Treatment of Fever
Overall treatment of fever should focus on the primary cause, rather than on the
temperature reading itself. No correlation exists between the magnitude and pattern of
temperature elevation (i.e., persistent, intermittent, recurrent, prolonged) and the principal
etiologic disorder or severity of the disease. Consequently, determining the cause of the
fever on the sole basis of the temperature reading is difficult.

The decision to treat fever is based on a patient-specific risk-benefit ratio and the desire to
improve comfort.35 Fever is not associated with many harmful effects unless the
temperature exceeds 106.0°F (41.1°C; oral); most fevers are of short duration and may
actually have beneficial effects on host defense mechanisms (e.g., antigen recognition, T-
helper lymphocyte function, leukocyte motility). Certain microbes are thermolabile, and
their growth may be impaired by higher-than-normal temperatures. Accordingly,
overtreatment of fever for viral and bacterial infections may be detrimental.35 Other
arguments against treatment include the generally benign and self-limited course of fever,
the delayed identification of the diagnosis, and the untoward effects of antipyretic
medications.36

Treatment Goals
The major goal of self-treatment is to alleviate the discomfort of fever, rather than treating
to achieve a specific temperature.35,37

General Treatment Approach

Treatment of fever using antipyretics (see Chapter 5, Tables 5–2 and 5–3) is most often
indicated for patients with elevated temperatures who have an underlying medical
problem such as heart or lung disease or have discomfort.38 Fever may be treated with
antipyretic agents as well as nonpharmacologic measures.

Self-care measures, including antipyretics, are appropriate initial therapy, unless the
patient has exclusions for self-treatment (Figure 6–1). 35,37,39 In all cases, self-care measures
should be started while medical evaluation is being sought.

Nonpharmacologic Therapy
Nonpharmacologic therapy consists mainly of adequate fluid intake to prevent
dehydration. Sponging or baths have limited utility in the management of fever. Body
sponging with tepid water may facilitate heat dissipation, in that only a small temperature
gradient between the body and the sponging medium is necessary to achieve an effective
antipyretic response. However, sponging is not routinely recommended for patients with a
temperature less than 104.0°F (40°C; oral); sponging is usually uncomfortable and often
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induces shivering, which could raise body temperature further. Bathing with ice water or
sponging with hydroalcoholic solutions (e.g., isopropyl or ethyl alcohol) is uncomfortable,
dangerous, and not recommended owing to risk of cutaneous absorption. Unlike with
acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), sponging does not
reduce the hypothalamic set point; therefore, implementation of this measure, if utilized,
should be delayed until 1 hour after an oral antipyretic dose, to permit appropriate
reduction of the hypothalamic set point and promote a more sustained temperature-
lowering response.40

Other nonpharmacologic interventions, regardless of the temperature reading, include

wearing lightweight clothing, removing blankets, maintaining a comfortable room
temperature of approximately 68.0°F (20.0°C), and drinking sufficient fluid to replenish
insensible losses. Because a fever will cause a child to lose fluids more rapidly, sufficient
fluid intake is recommended to avoid dehydration. Fluid intake in fever should be increased
by at least 30–60 mL (1–2 ounces) of fluids per hour in children and by at least 60–120 mL (3–
4 ounces) of fluids per hour in adults, unless fluids are contraindicated. Sports drinks, fruit
juice, water, balanced electrolyte replacement products, or ice pops may be offered. Milk
should also be offered to children who are still on formula or breastfeeding. Caution should
be exercised in recommending fruit juice and sports drinks to patients with diarrhea;
drinks with high sugar loads may worsen concurrent diarrhea.38

Pharmacologic Therapy
Antipyretics inhibit PGE2 synthesis, which decreases the feedback between the
thermoregulatory neurons and the hypothalamus, thereby reducing the hypothalamic set
point during fever. All antipyretics decrease the production of PGE2 by inhibiting the
cyclooxygenase (COX) enzyme. NSAIDs including aspirin inhibit the COX enzyme in both
the peripheral nervous system and CNS, whereas acetaminophen mainly inhibits the COX
enzyme in the CNS.41Chapter 5 provides an in-depth discussion of the pharmacokinetics,
dosing, adverse effect profile, interactions, contraindications, and precautions for
nonprescription antipyretic agents.

Acetaminophen typically effects a maximum temperature reduction at 2 hours at usual

recommended dosing of 10–15 mg/kg every 4–6 hours, with a maximum of 5 doses daily
(see Chapter 5, Tables 5–2 and 5–3). Approximately 80% of children will experience a
reduction in their fever with this regimen.35 Adult dosing ranges from 325 mg to 1000 mg
every 4–6 hours, up to a maximum of 4000 mg daily. Some providers have recommended
loading doses of acetaminophen for the reduction of fever at 30 mg/kg per dose, after a
small study found a faster (one-half hour) and more significant (0.9°F [0.5°C]) decrease than
that achieved with a traditional dose.42 This practice is not recommended, however,
because of the lack of any follow-up evidence of benefit, as well as the small size and
limitations of the study.

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Acetaminophen also is available in rectal suppository form. Although a suppository may be

an advantage for parents and caregivers who have problems giving their children oral
medications, or for children who are vomiting or are having a febrile seizure, absorption
with this dosage form is erratic, and studies on its antipyretic activity have yielded
conflicting findings.43

Ibuprofen is the most common NSAID used as an antipyretic; maximum temperature

reduction typically is achieved at 2 hours at the recommended dosing of 5–10 mg/kg per
dose every 6–8 hours, with a maximum of 4 doses per day (see Chapter 5, Tables 5–2 and 5–
3). Of note, ibuprofen is approved for the reduction of fever only in patients older than 6
months, and patients and caregivers should recognize the two different pediatric
concentrations of ibuprofen available (100 mg/5 mL and 50 mg/1.25 mL). Adult dosing
ranges from 200 to 400 mg every 4–6 hours, up to a maximum of 1200 mg daily.

Although NSAIDs and acetaminophen are safe and effective when taken at low doses for
short-duration therapy, they should not be used for more than 3 days to treat fever without
medical referral for further evaluation to determine the underlying cause. Common
medication errors associated with use of nonprescription antipyretics include overdosing
or duplicating therapy, attributed to using multiple products with similar ingredients, and
inappropriate dosing for pediatric patients, attributed to mathematical errors in calculating
a weight-based dose. A study of dosing by parents demonstrated that 51% of pediatric
patients received an inaccurate dose of medication (62% for acetaminophen and 26% for
ibuprofen).44 Because of these alarming statistics, an important function for pharmacist
health care providers is to demonstrate to patients and caregivers proper dosing and
measurement of the medications with the measuring device provided. In addition, patients
should be educated on the appropriate dosing interval and the avoidance of combining
antipyretics with cold and cough products containing either acetaminophen or ibuprofen.
Furthermore, owing to safety concerns, FDA issued a guidance statement to companies
that manufacture, market, or distribute nonprescription liquid medications regarding the
dispensing devices that accompany the drug products. Specifically, FDA recommends that
dosage delivery devices such as cups and syringes be included with all nonprescription
liquid medications, marked with clear and appropriate calibrated units, and used only with
the accompanying medication.45

Pharmacotherapeutic Comparison
Both ibuprofen and acetaminophen are more effective than placebo in reducing fever,
with both showing reductions of approximately 1 or 2 degrees within 30 minutes to 1 hour.
Clinical trials comparing the antipyretic effects of ibuprofen and acetaminophen in
recommended dosages have produced variable results, making conclusions on superiority
of one or the other agent difficult. A review of the findings in 14 clinical trials comparing
ibuprofen and acetaminophen in febrile children found that ibuprofen was slightly more
effective than acetaminophen in reducing fever after a single dose; furthermore, ibuprofen
was found to be more effective after 6 hours, thus showing a longer duration of action.46

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The same review found that multiple-dose studies failed to show any statistically
significant clinical difference. The risk of serious adverse effects did not differ between the
medications. The investigators concluded that the efficacy and safety of acetaminophen
and of ibuprofen are similar at recommended dosages, with slightly more benefit for
ibuprofen in time to onset of effect and duration of action and fever reduction; however,
more conclusive findings are needed. A meta-analysis of data for both children and adults
also concluded that ibuprofen was more efficacious than acetaminophen in the reduction
of fever in both adults and children and that both were equally safe.47 Although ibuprofen
has been studied most frequently, other NSAIDs (e.g., naproxen, aspirin) may also be
appropriate as antipyretics in adults.

Alternating different antipyretics in the same regimen has become a widespread practice.
A survey of 256 caregivers showed that 67% alternated acetaminophen and ibuprofen, and
81% stated that their primary care provider or pediatrician advised them to do so. Although
alternating the antipyretics was recommended, only 61% of caregivers received any type of
written instructions on how to dose the medications, and the dosing intervals varied,
ranging from 2 to 6 hours.48 Despite those practices and clinical trials showing lower
temperatures at 4 or more hours with combination therapy, the American Academy of
Pediatrics does not recommend alternating antipyretics because of the risk of overdose,
medication errors resulting from the complexity of the regimens, and an increased rate of
adverse effects.35,44 In addition, only one study actually showed less stress and time missed
from day care with alternating therapy.49 HCPs should be prepared to provide counseling
on the practical application of alternating antipyretics if the patient or caregiver has been
instructed to use this regimen by a primary care provider. For example, caregivers should
be encouraged to write down the generic name, dose, and time of administration for each
medication, to minimize the likelihood of duplicate dosing and adverse effects.

The use of antipyretics immediately after vaccine administration is a widespread practice

meant to reduce anticipated discomfort and fever. Two open-label randomized trials found
that the administration of acetaminophen was effective in reducing febrile episodes, but it
also significantly reduced the antibody response to several vaccines, although all levels
achieved were still considered protective.50 The clinical significance of these antibody
reductions is still unknown; nevertheless, the Advisory Committee on Immunization
Practices (ACIP) discourages the use of antipyretics before or at the time of vaccination.51
Symptomatic postvaccination reactions may still be treated with antipyretics until
additional data indicate otherwise.

Product Selection Guidelines

Age is an important consideration in the utilization and/or selection of an antipyretic,
particularly for neonates. Parents and caregivers of children younger than 3 months of age
should immediately seek medical evaluation for rectal temperatures or their equivalent of
100.4°F (38.0°C) or higher. Children older than 3 months with a rectal temperature or
equivalent of 104.0°F (40.0°C) or higher should also be referred. Ibuprofen should be used

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only in children older than 6 months; because of the risk of Reye’s syndrome, children and
teenagers who have or are recovering from chicken-pox or influenza-like symptoms should
not use aspirin or aspirin-containing products.52 (See Chapter 5 for a complete discussion
of these products.) Special populations of patients, such as pregnant women and older
adults, may require additional consideration in assessing fever and referring their care.
Specifically, as previously stated, fever may be blunted in older patients, thereby
predisposing them to a greater risk of complications if a more serious underlying disorder
goes unrecognized. In addition, pregnant women or patients with uncontrolled high blood
pressure, heart failure, renal failure, or an allergy to aspirin should avoid use of NSAIDs,
including aspirin-containing products. A detailed description of additional criteria for the
appropriate use of antipyretic agents in special populations is available in Chapter 5.

The choice of an antipyretic depends on the patient, since both are safe and effective. Both
acetaminophen and ibuprofen are available in a variety of dosage forms and flavors for
both children and adults, including tablets, chewable tablets, suspensions, and even
suppositories. Selection of a dosage form can be left to patient preference. Consideration of
palatability and the taste of the different ibuprofen and acetaminophen suspensions may
improve outcomes and adherence to antipyretic regimens in children. (See Chapter 11
under “Special Populations,” for FDA requirements for dispensing devices included in liquid
nonprescription products.) The more favorable dosing frequency for ibuprofen of once
every 6–8 hours, versus that for acetaminophen of once every 4–6 hours, may also improve
adherence and can be considered in product selection, especially in children who have
difficulty taking medicine.

Complementary Therapies
Currently, insufficient evidence exists to recommend any dietary supplement or other
complementary therapy to treat fever.

Algorithm: Fever

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Figure 6–1 Self-care for fever. Key: CNS = Central nervous system; CV = cardiovascular;
D/C = discontinue; HIV = human immunodeficiency virus.

Assessment of Fever: A Case-Based Approach

The first step in assessing a patient with fever-related symptoms is to obtain an objective
temperature measurement to confirm the presence of fever and rule out any subjective
sense of increased body temperature or an inaccurate thermometer reading. If fever is
present, assessment of its severity, the seriousness of the underlying cause, and other
associated symptoms is indicated. Children who are capable of providing and
understanding information should be included in any dialogue concerning their care.

Cases 6–1 and 6–2 are examples of the assessment of two different patients presenting with
fever.

Case 6–1

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Relevant Evaluation Criteria Scenario/Model Outcome

Collect

1. Gather essential information

about the patient’s symptoms
and medical history, including

a. Description of symptom(s) (i.e., A worried mother reports that her son Colin came home today after school
nature, onset, duration, severity, complaining of not feeling well. She noticed Colin seemed more tired than
associated symptoms) usual and did not have much of an appetite. She states that before today,
Colin was feeling healthy and well. Colin’s mother also noticed that his
forehead felt warm. When she took Colin’s temperature with a tympanic
thermometer, it was 102.4°F.

b. Description of any factors that Colin’s mom cannot identify anything that makes his symptoms worse or
seem to precipitate, exacerbate, provides relief.
and/or relieve the patient’s
symptom(s)

c. Description of the Neither Colin nor his mother had tried anything to treat his fever up to this
patient’s/caregiver’s efforts to point.
relieve the symptoms

d. Patient’s identity Colin Betts

e. Patient’s age, gender, height, 12 years, male, 5 ft 1 in., 95 lb

and weight

f. Patient’s occupation Colin attends sixth grade.

g. Patient’s dietary habits Normal diet, but he has decreased appetite today.

h. Patient’s sleep habits Normal sleep patterns, but he is more tired today.

i. Concurrent medical conditions, Seasonal allergies Loratadine 10 mg by mouth once every morning
prescription and nonprescription
medications, and dietary
supplements

j. Allergies NKDA

k. History of other adverse None

reactions to medications

l. Other (describe) _______ Colin also complains of a dull headache that just started this morning. You
retake his temperature in the pharmacy using an oral thermometer, which
reads 102.1°F.

Assess

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Relevant Evaluation Criteria Scenario/Model Outcome

2. Differentiate the patient’s Colin is experiencing symptoms associated with a fever. When asked, he
signs/symptoms, and correctly denies noticing any additional signs or symptoms, suggestive of a more
identify the patient’s primary serious illness, that would warrant immediate medical attention.
problem(s).

3. Identify exclusions for self- None

treatment (Figure 6–1).

4. Formulate a comprehensive list Options include

of therapeutic alternatives for the (1) Refer Colin for immediate medical attention.
primary problem to determine
whether referral to a primary care
(2) Monitor his symptoms and fever, and recommend nondrug
provider is required, and share measures only.
this information with the
patient/caregiver
(3) Recommend a medication alone or in combination with
nondrug measures.

(4) Take no action.

Plan

5. Select an optimal therapeutic Colin has a fever and is experiencing some discomfort. He has no
alternative to address the exclusions for self-care at this time (Figure 6–1), so treatment with either
patient’s problem, taking into acetaminophen or ibuprofen is appropriate. Drug therapy should be used
account patient/caregiver in conjunction with nondrug measures. He should not receive any aspirin-
preferences. containing medications.

6. Describe the recommended See Table 5–2 in Chapter 5 for recommended doses of acetaminophen or
therapeutic approach to the ibuprofen. “If fever persists for longer than 72 hours with or without
patient/caregiver. treatment, Colin should be seen by a primary care provider”

7. Explain to patient/caregiver the “Colin has a fever that is causing some discomfort, so minimizing the fever
rationale for selecting the with an antipyretic medication, either acetaminophen or ibuprofen,
recommended therapeutic should help. His pediatrician should be contacted if his fever gets worse or
approach from the considered persists for longer than 72 hours or if he complains of other symptoms,
therapeutic alternatives. such as a stiff neck, severe headache or sore throat, or severe ear pain, or if
an unexplained rash or repeated vomiting or diarrhea develops.”

Implement

8. When recommending self-care

with nonprescription medications
and/or nondrug therapy, convey
accurate information to the
patient/caregiver.

a. Appropriate dose and “You can give Colin regular strength acetaminophen tablets (325 mg per
frequency of administration tablet). Give 2 tablets every 4–6 hours while symptoms last. Do not exceed
5 doses per 24 hours.”

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Relevant Evaluation Criteria Scenario/Model Outcome

b. Maximum number of days the “Do not give Colin the medication for more than 3 days.”
therapy should be employed

c. Product administration “If Colin cannot swallow tablets, chewable tablets and liquid are available
procedures options. Colin should swallow the tablet completely, followed by drinking a
full glass of water.”

d. Expected time to onset of relief “A reduction in temperature with some relief of discomfort usually occurs
within 1/2 to 1 hour. Maximum reduction is usually seen within 2 hours.”

e. Degree of relief that can be “A 1- or 2-degree reduction in temperature is expected, but complete
reasonably expected resolution of symptoms may or may not be achieved, depending on the
underlying cause of the fever.”

f. Most common adverse effects “Adverse effects are rare, but gastrointestinal effects such as upset
stomach or rash are possible. Colin can take the medication with food if an
upset stomach occurs.”

g. Adverse effects that warrant “Contact your primary care provider if signs of an allergic reaction, such as
medical intervention, should they a rash or trouble breathing, occur after a dose is given.”
occur

h. Patient’s options in the event “Contact your primary care provider if the fever persists or symptoms
that condition worsens or persists worsen beyond 72 hours.”

i. Product storage requirements “Keep medication in a tightly secured container away from any extreme
temperatures and out of reach of children.”

j. Specific nondrug measures “Maintain room temperature at 68°F. Encourage adequate fluid intake and
have him dress in lightweight clothing.”

Solicit follow-up questions from “I read on my favorite ‘Mommy Blog’ that I can check Colin for fever by
patient/caregiver. feeling his forehead with my palm, which is a lot easier than using that ear
thermometer! Is that ok?”

Answer patient’s/caregiver’s “You should not use your hand to measure his temperature. This practice is
questions. called tactile temperature measurement, and it will not give an accurate
representation of his temperature, since your sense of the warmth of his
skin may be affected by your own body temperature. If he does not like the
ear thermometer, we have many other options, which I am happy to show
you how to use.”

Follow-up: Monitor and Evaluate

9. Assess patient outcome. Contact Colin’s mother in 1–2 days to see if Colin’s fever is responding.

Key: NKDA = No known drug allergies.

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Case 6–2

Relevant Evaluation Criteria Scenario/Model Outcome

Collect

1. Gather essential information

about the patient’s symptoms
and medical history, including

a. Description of symptom(s) Mrs. Martinez approaches the pharmacy counter looking for a medication to
(i.e., nature, onset, duration, treat her child’s fever. She says her daughter, Ryann, woke up this morning
severity, associated symptoms) with a red rash on her tummy, arms, and legs and has not been eating.
When taking Ryann’s temperature orally for the past 5 days, she had
temperature readings of 101.4°F, 101.6°F, 102.1°F, 101.7°F, and 101.5°F. Mrs.
Martinez does not want to “bother” Ryann’s pediatrician since the medical
office is “always so busy.”

b. Description of any factors that Ryann’s mother states lukewarm baths seem to temporarily soothe Ryann;
seem to precipitate, exacerbate, however, this has not helped to bring down Ryann’s temperature.
and/or relieve the patient’s
symptom(s)

c. Description of the Mrs. Martinez has given Ryann 10 mL (2 teaspoonsful) of Children’s Advil
patient’s/caregiver’s efforts to liquid (100 mg/5 mL) every 6 hours.
relieve the symptoms

d. Patient’s identity Ryann Martinez

e. Patient’s age, gender, height, 5 years, female, 42 in., 40 lb

and weight

f. Patient’s occupation n/a

g. Patient’s dietary habits Ryann eats 3 meals a day with 2 or 3 snacks in between.

h. Patient’s sleep habits Usually sleeps at least 8–9 hours every night, but during the last few nights,
she has been getting only 4–5 hours of sleep and takes 30-minute naps
during the day.

i. Concurrent medical Advair Diskus 100/50 mcg 1 inhalation twice a day and ProAir HFA 2 puffs
conditions, prescription and every 4 to 6 hours as needed for mild persistent asthma
nonprescription medications,
and dietary supplements

j. Allergies NKDA

k. History of other adverse None reported

reactions to medications

l. Other (describe) n/a

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Relevant Evaluation Criteria Scenario/Model Outcome

Assess

2. Differentiate the patient’s Ryann has a fever that is concerning because of its duration despite
signs and symptoms, and treatment; the recent appearance of a skin rash also is concerning.
correctly identify the patient’s
primary problem(s).

3. Identify exclusions for self- Fever lasting for more than 72 hours and skin rash
treatment (Figure 6–1).

4. Formulate a comprehensive Options include

list of therapeutic alternatives (1) Refer Ryann to her pediatrician.
for the primary problem to
determine whether referral to a
(2) Refer Ryann to a hospital emergency department for
primary care provider is
immediate medical attention.
required, and share this
information with the
(3) Monitor her symptoms and fever, and recommend nondrug
patient/caregiver.
measures only.

(4) Recommend a medication alone or in combination with

nondrug measures.

(5) Take no action.

Plan

5. Select an optimal therapeutic Ryann has exclusions for self-care: (1) persistent fever lasting more than 72
alternative to address the hours and (2) appearance of a skin rash. Ryann’s mother should contact her
patient’s problem, taking into pediatrician immediately to rule out any serious conditions.
account patient/caregiver
preferences.

6. Describe the recommended “No medication is recommended at this time. Immediate medical referral is
therapeutic approach to the indicated.”
patient/caregiver.

7. Explain to the “Ryann has a fever that has persisted longer than 72 hours even after
patient/caregiver the rationale treatment with appropriate medication, and a skin rash that appeared
for selecting the recommended today.”
therapeutic approach from the
considered therapeutic
alternatives.

Implement

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Relevant Evaluation Criteria Scenario/Model Outcome

8. When recommending self-

care with nonprescription
medications and/or nondrug
therapy, convey accurate
information to the
patient/caregiver.

a. Appropriate dose and None recommended

frequency of administration

b. Patient’s options in the event “If fever worsens or continues without improvement, you should take Ryann
that condition worsens or to a hospital emergency department after speaking with the pediatrician.”
persists

c. Specific nondrug measures “Maintain a room temperature of 68.0°F, and dress her in lightweight
clothing.”

Solicit follow-up questions from “Can I try giving Ryann ibuprofen (Advil) liquid and acetaminophen (Tylenol)
patient/caregiver. liquid at alternating times until I can get her to her pediatrician?”

Answer patient’s/caregiver’s “Alternating between acetaminophen and ibuprofen has not been proven to
questions. help children feel better faster, and it may increase risk of adverse effects. I
am concerned Ryann may require additional treatment that is not available
over the counter. Please call your pediatrician immediately.”

Follow-up: Monitor and

Evaluate

9. Assess patient outcome. Contact Mrs. Martinez in 1–2 days to ensure that she sought medical care for
Ryann.

Key: n/a = Not applicable; NKDA = no known drug allergies.

Patient Counseling for Fever

Although fever is a common presenting symptom, it often is misunderstood and poorly
treated. Studies suggest that fever may be incorrectly considered a disease associated with
detrimental consequences, is frequently treated inappropriately, and is evaluated
improperly.53 Many parents and caregivers have “fever phobia,” characterized by
heightened anxiety regarding effects of fever and in consequent inappropriate
treatment.29

Pharmacists as health care providers are well poised to improve clinical outcomes by
educating patients and caregivers about fever and by teaching self-assessment skills (e.g.,
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the proper methods for measuring body temperature using the variety of thermometers
available, as well as interpretation of the results). If patients and caregivers are still using
mercury-in-glass thermometers, they should be urged to dispose of these devices
according to local environmental standards. Patient counseling also should include an
explanation of the appropriate nonpharmacologic and pharmacologic treatments for fever
and should identify indications for seeking further medical care. Discussions of
pharmacologic treatments should highlight methods for safe use of antipyretics and
nonpharmacologic therapy. The box “Patient

Education for Fever” provides specific information to include in patient counseling.

Evaluation of Patient Outcomes for Fever

The primary monitoring parameters for febrile patients are temperature and discomfort. In
one study, 32% of caregivers stated that they would check a febrile patient’s temperature at
least every hour.29 Overaggressive monitoring may result from “fever phobia.” Because
fever may actually be of physiologic benefit, the ultimate goal of antipyretic therapy is not
to normalize temperature but rather to improve overall comfort and well-being.35 The
presence of any associated signs and symptoms (e.g., headache, diaphoresis, generalized
malaise, chills, tachycardia, arthralgia, myalgia, irritability, anorexia) should also be
monitored daily. Although most patients demonstrate a reduction in temperature after
each individual dose of an antipyretic, pharmacologic therapy for fever may take up to 1
day to result in core temperature decrease. If clinical improvement is not obtained or if
symptoms worsen over the course of 3 days of self-treatment, regardless of a drop in
temperature, a primary care provider should be consulted by either phone or appointment
for further evaluation.39 Timeliness of patient follow-up assessment with appropriate
medical care is important in identifying a non–self-limiting underlying cause.

Patient Education for Fever

The primary objectives of treating fever are (1) to relieve the discomfort of fever and (2)
to prevent complications associated with fever. For most patients, carefully following
product instructions and the self-care measures listed here will help to ensure optimal
therapeutic outcomes.

Temperature Measurement

Do not rely on skin contact to detect fever. Take a temperature reading with an
appropriate thermometer.

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For children up to 3 months of age, the rectal method of temperature

measurement is preferred (Table 6–3). Use of a tympanic thermometer is not
recommended in children younger than 6 months because of the specific size
and shape of the infant’s ear canal.
For children ages 6 months to 3 years, the rectal, oral, tympanic, or temporal
method may be used if proper technique is followed (Tables 6–3 through 6–6).
For patients older than 3 years, the oral, tympanic, or temporal method is
appropriate (Tables 6–4 through 6–6).

Nondrug Measures

Do not use isopropyl or ethyl alcohol for body sponging. Alcohol poisoning can
result from skin absorption or inhalation of aerosols from topically applied alcohol
solutions.
For all levels of fever, wear lightweight clothing, remove blankets, and maintain
room temperature at 68°F.
Unless advised otherwise, drink or provide sufficient fluids to replenish body fluid
losses. For children, increase fluid intake by at least 1–2 ounces per hour; for adults,
increase intake by at least 2–4 ounces per hour. Sports drinks, fruit juice, a
balanced electrolyte formulation, and water all are acceptable.

Nonprescription Medications

Nonprescription analgesics and antipyretics, specifically acetaminophen and

ibuprofen (see Chapter 5, Tables 5–2 and 5–3, for dosages), help in alleviating
discomfort associated with fever and reducing the temperature, respectively.
Nonprescription analgesics and antipyretics typically take 30 minutes to 1 hour to
begin to decrease discomfort and lower body temperature.
Monitor level of discomfort and body temperature using the same thermometer
at the same body site 2 or 3 times per day during a febrile illness.
Use single-entity nonprescription analgesics and antipyretics at low doses for up
to 3 days for treatment of fever (see Chapter 5, Tables 5–2 and 5–3 for dosages), in
the absence of any exclusions for self-care (Figure 6–1).
Avoid alternating antipyretics because of the complexity of the dosing regimens,
increased risk of medication errors, and adverse effects.
Dosing of either ibuprofen or acetaminophen in children should be based on
body weight, not age.
To avoid incorrect dosing, use the measuring device that was provided with the
product, such as a syringe, dosing spoon, or medicine cup, for administering
liquid medication.
Patients who are pregnant or have uncontrolled high blood pressure, congestive
heart failure, renal failure, or an allergy to aspirin should avoid use of nonsteroidal
anti-inflammatory drugs (ibuprofen and naproxen sodium) or aspirin-containing
products.

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To avoid the possible risk of Reye’s syndrome, do not use aspirin or aspirin-
containing products for fever in children and teenagers who have or are
recovering from chickenpox or an influenza-like illness.

When to Seek Medical Attention

Seek medical attention if fever or discomfort persists or worsens after 3 days of

drug treatment.

Key Points for Fever

➤ Fever is self-limiting and rarely poses severe consequences unless the core
temperature is greater than 106.0°F (41.1°C; oral).

➤ The main treatment goals for fever are to alleviate the associated discomfort
and to eliminate the underlying cause.

➤ Fever should be confirmed only by means of a thermometer, which is an

FDA-regulated medical device.

➤ Patients should be educated on the proper measurement techniques for the

selected thermometry method.

➤ Patients should be referred for further evaluation if the rectal temperature or

its equivalent is greater than 104.0°F (40.0°C), they have a history of febrile
seizures, they have comorbid conditions compromising their health, or they
are younger than 3 months of age with a rectal temperature exceeding
100.4°F (38.0°C) or its equivalent.

➤ Sponge baths using topical isopropyl or ethyl alcohol to reduce fever should
be discouraged.

➤ Acetaminophen and ibuprofen are both safe and efficacious nonprescription

medications that may be used as antipyretics in both adults and children.

➤ Referral for further medical evaluation is appropriate to detect an underlying

cause if self-treatment for 3 days does not successfully reduce fever in a
patient older than 2 years and for at least 24 hours in a child younger than 2
years of age.

➤ Health care providers should counsel patients on the proper use of

nonprescription antipyretic agents (including appropriate use of measuring
devices), to limit medication errors and adverse effects. For patients for

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5/9/22, 11:42 PM Chapter 6: Fever | Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 20th Edition | PharmacyLibrary

whom concomitant use of alternate antipyretic therapies has been

recommended, counseling should emphasize the importance of recording
the generic name of each drug given, the dose, and the time of
administration, to avoid any adverse effects.

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