Intermittent Unexplained Fever in 20 months old

[BriVannamommy]

Nurses!

I am writing to inquire on a patient in our office. This little girl is 20 months old and is up to date on all vaccinations. She is a lower percentile girl (tiny) as is her mother and sister, however she is healthy, meeting all milestones exceptionally and shows no cause for concern.....other than her mother's concern for a reoccurring low grade fever.

Patient Overview:

1. first 12 months: no fevers, issues, illnesses. However, a tick was discovered on her back, still alive, backed out (no penetration into skin). No rash development.

2. virus at 13 months (ran course)

3. virus at 14 months (ran course)

4. 17 months (May) - her mother noticed (at home) she began running an intermittent low grade temp (ranging rectally from 99.9 - 100.7) with no other symptoms.

5. Well visit check in May, no findings or cause for concern - dx: virus.

6. Sick visit check in July, slight blisters (healing) on throat - dx: virus.

7. 18 month vaccination: excellent.

***during each of the above visits (and many calls) her mother indicated that her low grade fevers showed up during the mid afternoon/evening, but were normal in morning and during rest periods. She indicated her daughter itched her nose often, and pulled at her ears, and held her head - she also indicated that her appetite was beginning to fluctuate and she was already a great napper, however she was sleeping on average 12 hours straight through night, then from 1.5 - 3 hour naps in the afternoon (typically from 1-3 or 3:30). Her measurements showed she was growing normally (with a spurt actually) and we saw no cause for further treatment. She displayed no signs of infection or serious illness.****

8. Her mother took her to the ER at 20 months due to a full week of continuous 100+ fevers and behavior/appetite changes - fever never reaching 101.

FINDINGS: Penny in stomach via x-ray, CBC normal, Metabolic normal, Urine Screen normal. Upper endoscopy performed at hospital to remove penny.

9. It has been two weeks since the penny was removed, her temperature remained normal for roughly 5 days following surgery - however, it has since returned, remaining at 99.9 - 100.5 (being the highest). Her systems are very sporadic, inconsistent with no clear pattern. She struggled with appetite and behavior on days with no temperature and ate/played wonderful on days where her temperature was elevated. 1/2 dose Tylenol decreased temperature immediately, as did periods of rest. Mother indicated itchy (clogged) nose, pulling/poking at ears, sporadic sneaking but no mucus or runny nose, no coughing or upper respiratory problems. Mother indicated her behavior fluctuates as well, at time clingy/cranky - other types happy and running around, no clear pattern whether health or behavior related.

My question, with her panels being normal; urine being normal; fluid intake excellent; growth great.....our office is leaning toward chronic allergies/sinusitis/rhinitis. However, her mother is very concerned due to over 4 months of intermittent/chronic low grade fevers. We have considered Lyme, however by now she would display symptoms of Bell's palsy, thus haven't moved forward with blood testing. We have considered fluid behind her ears, however she has never displayed ear infections.

I am open to all thoughts, experiences, suggestions! Thank you!

[Double-Helix, BSN, RN]

Who is taking the temperatures? The mother or the office? Has the mother used the same thermometer throughout these past months or has it been replaced (ruling out an incorrectly calibrated thermometer?

The American Academy of Pediatrics (as well as all children's hospitals I have worked at or visited), considers a child to be febrile when the temperature is above 100.4. So most of the temperatures that you listed for this child would not be considered a fever. It's normal for temperature to increase with activity and decrease with rest. It's also normal for the temperature to be higher at certain times in the day. It's also normal for some children/adults to have a stable, healthy body temperature that runs just a bit higher than average.

Some of the other symptoms you mention suggest she may have allergic rhinitis. Has she been trialed on zyrtec or another antihistamine? The (very) slightly elevated temperature- with lack of other symptoms and normal work-up- is quite likely an incidental normal finding for this child.

[~PedsRN~, BSN, RN]

I'll be honest and say my first thought is why are they taking this child's temperature rectally, at age two, every evening. Eeesh! Stop! Unnecessarily invasive.

From everything you have described, I have yet to see evidence of a fever. Children often run "warmer" in the evenings when in perfect health, from my experience. I think this may be a case of over anxious parent, quite honestly. The toddler sounds pretty much on point developmentally...

I'd love to hear other input.

[JustBeachyNurse, LPN]

What is the purpose in a night rectal temp? Referral temp is always going to be higher than other methods. No one needs a daily temp check especially if asymptomatic. Is mom looking for something to be wrong perhaps the child is just playing with their ears or face. Maybe just had an itch. A tick crawling on a back is no cause for concern any more tag finding a crumb of piece of lint. Bell's palsy is not a guaranteed sign of Lymes disease but a child MUST be bitten by an affected tick and the tick must be attached for a significant period of time. You CANNOT get Lymes or any other tick borne disease from a tick crawling on intact skin it's simply not possible.

[BriVannamommy]

The mother has an appointment on Wednesday, however our PA and DR has concluded and will advise that the warmer temps are normal and without further symptoms we advise against further charting. The child has a good family - however the mother is overly cautious due to an older child with a disability she ignored for years due to vague symptoms.... Thank you! I have passed this forum on!

[Esme12, ASN, BSN, RN]

As per the Terms of Service we cannot offer medical advice. Temps can vary from day to day and typically run higher at night. Is the Mom using the same thermometer at the same time every day? It seems like a ton of detail that you remember from the patients Mom. Kids have cranky days, clingy days, and days they refuse to eat. The child have behavior issues at times...I'll bet they do....they are almost two.

The child sounds perfectly normal to me.