Pediatric Fever – Myth 3/10: Can fevers cause brain damage?

Myth #3: Fevers can cause brain damage, and are dangerous

Throughout most of history, fever was feared by ordinary people as a manifestation of punishment, induced by evil spirits or a marker of death. But what does modern day research have to say on the topic? This is part 3 of a 10-part series where I will busting what I consider to be the top 10 myths involving pediatric fever.

William Osler, one of the 4 founding professors of Johns Hopkins and name to about 15 different eponyms even described the fear of fever at the turn of the 20^thcentury 

“Humanity has three enemies, fever, famine and war, but fever is by far the greatest.” – William Osler (1849-1919)

Let’s take a step back to define 2 very different causes of elevated body temperature. Fever, which is due to a change in hypothalamic set point and Hyperthermia, which is caused by some failure in thermoregulation as is seen in Malignant Hyperthermia or a true hypothalamic dysfunction where heat gain is greater than the body capacity to cool. Picture a child left in a hot car…

Many studies have been done assessing parents’ misconceptions about fevers. 2 of the most cited US studies were done 21 years apart. 

Schmitt BD, 1980¹

• The initial study in 1980 published in the American Journal of Diseases of Children
• 52% of parents thought fever of 40° C or less could cause serious neurological outcome 
• This apparent fear of fevers coined the phrase “Fever Phobia”

Public education about the inappropriate fear of fever was brought to the forefront and then this study was reproduced in 2001 to see how these misconceptions of fever changed after 2 decades. 

Crocetti M, 2001²

• Surprisingly, what they found is that the public fear of fever only worsened with 91% of parents now thinking that an untreated fever has harmful neurological effects. 
• Compared with 20 years ago, more caregivers listed seizure as a potential harm of fever, woke their children and checked temperatures more often during febrile illnesses, and gave antipyretics or initiated sponging more frequently for possible normal temperatures.
• 44% considered a temperature of 38.9° C(102°F) to be a “high” fever,
• 7% thought that a temperature could rise to >110° F) if left untreated. 
• 52% said that they would check their child’s temperature < 1 hour when their child had a fever
• 25% gave antipyretics for temperatures <37.8° C(<100° F)
• 85% would awaken their child to give antipyretics. 
• 14% percent of caregivers gave acetaminophen at too frequent intervals.
• 44% gave ibuprofen at too frequent dosing intervals. 
• 73% said that they sponged their child to treat a fever, 
• 18% used alcohol. 

And you know what. Healthcare providers aren’t much different…

Poirier MP, 1998³

• Here is a survey of 88 Pediatric Emergency Department nurses taken in 1998
• 40.6° C was the median temp thought to be considered “dangerous”
• Seizure were the most common concern 
• 28% said brain damage or death can occur
• 18% said it was dangerous for a child to leave Emergency Room still with a fever 

And physicians aren’t much better…

Al-Eissa YA, 2001⁴

• A survey of 419 physicians
• 35% of physicians think fever causes brain damage
• 8% said fever can cause death
• 70% think fever should be treated to prevent seizure 
• 84% advised waking a sleeping child up just to give scheduled doses of Tylenol or Motrin  

Demir F, 2012⁵

• Here we go. Another survey. This time 80 Italian primary care physicians were surveyed.
• 52% fever dangerous 
• 60% treat to prevent seizures 
• 68% brain damage
• 72% think brain damage occurs from seizure
• 98% would wake a sleeping child 
• 61% think height of fever indicates bacterial
• 27% think it’s ok to use aspirin

So, how do we know that high fevers don’t cause brain damage? This isn’t new stuff…

Cool history lesson…

In 1886, an Austrian psychiatrist by the name of Julius Wagner noticed that sometimes, psychotic patients would develop a fever and their psychosis would resolve. So, he started to experiment the effects of febrile diseases with things like typhus and Tuberculosis; but the fevers wouldn’t get high enough with these diseases.⁶ Then, in 1917, during WWI, a soldier with malaria was accidentally admitted to the psychiatric hospital. So, Wagner took his blood and smeared it into cuts on the bodies of nine patients with the diagnosis of “dementia paralytica.” We now know dementia paralytica as neurosyphilis. Inoculation with malaria would consistently cause cycles of fevers of up to 105.8° F. Six of the nine patients studied were cured of their syphilis. He would then give quinine to treat the malaria.

Try getting that past the IRB. Anyways, he won a Nobel prize for this. He was the only psychiatrist ever to do so. Although, he wasn’t exactly someone to look up to. Besides his questionable ethics conducting research studies, he was also a Nazi sympathizer who advocated for racial eugenics and forced sterilization or the mentally ill.⁷

Pyrotherapy

Malariatherapy continued until about 1940, when it was aborted for safety concerns.⁷ It also sparked a form of medical treatment termed “Pyrotherapy,” where patients were placed in hot boxes or wrapped in electrical blankets for its hyperthermic effects. Temperatures were kept at around 107° F and a nurse would cool the patients head with water and a fan to help regulate this temperature range. After 40 years of Pyrotherapy, clinicians gained knowledge that if the core body temperature surpassed 108° F, neurological damage and death could occur. Keep in mind, this is hyperthermia…NOT FEVER! Even with the malariatherapy from Julius Wagner, fevers maxed out around 105.8 F.⁶ Pyrotherapy was done until the 1950’s when antibiotics became a better option. 

Benefits of fever have been expressed by prominent physicians throughout history. 

Hippocrates, the founder of Western medicine for more than two thousand years observed the benefits of fevers and detailed accounts of the periodic fevers of malaria nearly 2200 years before Julius Wagner’s super shady study.

“Give me the power to create a fever, and I shall cure any disease.”– Hippocrates (300 BC)

“Fever was beneficial in Ophthalmia.”– Hippocrates (300 BC)

“Fever is a mighty engine which nature brings into the world to remove her enemies”– Thomas Sydenham (17 AD)

“Fever is a good remedy for an individual seized with convulsion, and if there were a physician skilful enough to produce a fever it would be useless to seek any other remedy against disease.”– Rufus of Ephesus (2 AD)

Let’s summarize the evidence… 

• Fevers from infections DO NOTget high enough to cause brain damage. 
• Fever is a controlled response to help the body fight an infection. 
• Only body temperatures above 108° Fhave been shown cause brain damage…
• The body temperature climbs this high from extreme environmental temperatures of in conditions that cause hypothalamic dysfunction….not from fever related to infection. 

So, for our third myth questioning if fevers can cause brain damage….I would consider this BUSTED.

References

1. Schmitt BD. (1980). Fever phobia: misconceptions of parents about fevers. Am J Dis Child, 134(2):176-81. PMID: 7352443
2. Crocetti M, et al. (2001). Fever phobia revisited: have parental misconceptions about fever changed in 20 years?. Pediatrics, 107(6):1241-6. PMID: 11389237
3. Poirier MP, et al. (1998). Pediatric Emergency Department nurse’s perspectives on fever in children, Pediatric Emergency Care, 14(4):316 
4. Al-Eissa YA, et al. (2001). Physician’s perceptions of fever in children. Facts and myths. Saudi Med J. 22(2):124-8. 
5. Demir F, Sekreter O,. (2012). Knowledge, attitudes and misconceptions of primary care physicians regarding fever in children: a cross sectional study. Ital J Pediatr, 38:40. doi: 10.1186/1824-7288-38-40
6. Karamanou M, et al. (2013). Julius Wagner-Jauregg (1857-1940): Introducing fever therapy in the treatment of neurosyphilis. Psychiatriki, 24(3):208-12. 
7. Raju T (2006). “Hot brains: manipulating body heat to save the brain”. Pediatrics. 117 (2): e320–1. doi:10.1542/peds.2005-1934. PMID 16452338.
8. “The complete idiot’s guide to understanding the brain”, Arthur Bard, Mitchell Geoffrey Bard. Alpha Books, 2002. p. 49.