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9 October 2014

The baby only had chickenpox. But then she suddenly stopped breathing

Dr Phil Whitaker’s Health Matters column. 

By Phil Whitaker

It seemed a straightforward visit – a feverish 13-month-old in an outlying village whose mum couldn’t bring her to surgery. I drove out on the lunchtime round and it didn’t take long to ascertain the reason for her daughter’s temperature: the first spots of chickenpox were apparent when I removed her Babygro. I continued my examination, making sure everything else was all right, and was in the middle of listening to her chest when suddenly the child arched her back grotesquely, her body incredibly stiff. Her eyes rolled, leaving just the whites visible, and she stopped breathing.

For a few seconds, my shocked brain refused to think of anything medically useful. Then, two things happened. The little girl’s body began to jerk violently, accompanied by her strangulated efforts to draw breath. And her mother began to scream.

I was inexperienced – this was during my first months in general practice – and I felt a huge surge of adrenalin. In the hospital, where I’d worked up until then, the press of a button would bring colleagues running in seconds and every conceivable drug was to hand. Out here in the middle of nowhere, aside from a stethoscope, a torch and a prescription pad, I had nothing.

The mother was hysterical – it did look for all the world as though an infanticidal poltergeist was choking the life out of her child. I managed to maintain enough presence of mind to put the girl in the recovery position and note the time (seizures that last longer than five minutes may need treatment to terminate them). By insistently and loudly repeating the mother’s name, I eventually broke through her terror and got her to dial 999.

This was almost certainly a febrile convulsion – a seizure associated with a high temperature. Despite the alarming appearances, they are in essence benign. They usually stop spontaneously within a few minutes, as this one did. For a first episode, admission is advised to rule out serious causes of fits such as meningitis, but subsequently, once a child is known to be prone to them, convulsions can be managed at home.

It used to be thought that taking steps to reduce fever must be helpful in preventing their occurrence. For years, doctors told parents to strip their febrile child off, put a fan to blow over them, even sponge them with tepid water. However, measures that cool the outside of the body often result in a reduction in skin blood flow. The skin is the body’s radiator: shut down its circulation and the heat simply remains inside, elevating the core temperature further.

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More recently, advice has shifted to paracetamol and ibuprofen (antipyretics) – drugs that can but don’t always reduce fever. Many doctors and nurses exhort parents to monitor their children’s temperature, dose them up frequently and seek help if the fever isn’t “controlled”. A mythology has developed in which the fever is viewed as a dangerous phenomenon, one requiring treatment, and a cause for grave concern if it doesn’t respond.

Fevers, though, are part of our body’s natural fightback against infection. High temperatures, though unnerving if they cause a convulsion or delirium, are in reality helpful. Interestingly, recent research suggests that febrile convulsions are provoked not by the fever per se but by rapid changes in temperature. There is no evidence that antipyretics
are of any use in preventing seizures; indeed, they may make matters worse. It is possible that using them routinely to blunt this important part of the body’s immune response may ultimately prolong the course of infectious illnesses.

Children outgrow febrile convulsions. They’re most common in the first year, becoming progressively less frequent thereafter and virtually unheard of beyond the age of five. This coincides with the maturation of the “electrical insulation” – called myelin sheaths – that surrounds nerve cells in the brain. Once myelin has been fully laid down, the “short circuits” between nerve cells that kick-start seizures seem no longer to occur. It will take far longer to dismantle the mythology that surrounds fever, overturning beliefs that have become as ingrained in the health-care professions as they are in the wider culture.

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