Fever phobia Lanessa D. Bass, MD, MEd Pediatric Hospital Medicine Director PHM West Campus

Special Thanks Dr. Hank Farrar Emergency Physician and Toxicologist, UAMS AAP Section on Clinical Pharmacology and Therapeutics

Objectives At the end of the presentation, you will be able to Explain the physiologic reasons and effects of fever Effectively reassure parents in the evaluation and treatment of fever Recognize red flags for fever that would require prompt physician/provider evaluation

Beliefs About Fever High Fevers are Dangerous Must Treat Fever High fevers cause brain damage (93% of parents) Any fever is dangerous (74% of parents) Concern that T ≥40oC (104oF) are harmful Believe T <40oC is a high fever (40-50%) Must Treat Fever Untreated Fevers Continue to Rise ≥42oC (107oF) 15% - 45% of parents agree Schmitt BD, Am J Dis Child 1998 Crocetti M, et.al. Pediatrics, 2001

Beliefs About Fever If Parents Believe … Then Parents are Likely to … Fever is dangerous, especially high fever If untreated, fever will continue to rise Then Parents are Likely to … Worry a lot Check temperature frequently Treat early and often Focus on lowering temperature

Fever Phobia Reaction of Parents to Fever Frequent Concern of Parents 10-50% take temperature hourly 20% will treat a temperature <38oC (100.4oF) 50-85% awaken their child to treat Frequent Concern of Parents Fever accounts for one-third of acute visits 89% would schedule a visit if their child has a fever 50-90% have taken child to clinic/ED

Pediatricians Percent who Agreed The primary goal of treatment is to improve the comfort of the child 71% A sleeping child with fever should be left undisturbed 88% An elevated temperature … can become dangerous to a child* 65% Dangerous - Most pediatricians can recall a patient who had medical problems with fever – e.g., a child with a poorly controlled seizure disorder who developed status epilepticus with fever. I think this contributes to this high number. I would be surprised if they thought that a fever with a simple illness in a normal child is dangerous. *Seizures (58%), Dehydration (23%), Brain Damage (10%) May A, Bauchner H. Pediatrics, 1992

Two Big Questions Will a child’s temperature continue to rise to a dangerous level if left untreated? Does fever cause brain damage? Fever with infection vs. Heat-Related Illness

Hypothalamic Set Point Temperature Control Increase Temperature Hot Hypothalamic Set Point T=37oC Shivering Vasoconstriction Get a Blanket Sweating Vasodilation Find a Fan Heat Dissipation Cold

Heat-Related Illnesses Exercise & Dehydration in a Hot Environment Increase Temperature Hot Hypothalamic Set Point T=37oC Sweating & Vasodilation become inadequate Temperature continues to Rise Shivering Vasoconstriction This is why hyperthermia and heatstroke have temperatures that continue to rise. They are overwhelming the set point. The body is trying to stop the increase in temperature but cannot. Heat-Related Illness Cold

Hypothalamic Set Point Febrile Illnesses Infection Fever T=39oC Hot Pyrogens Hypothalamic Set Point T=39oC Shivering (having a chill) Vasoconstriction (mottled skin) Sweating Vasodilation There are 2 reasons why fever with a simple infection does not continue to rise. It will not go above the set point. It goes to the set point and then stops. Endogenous cryogens (with or without antipyretics) try to reset the Set Point to 37C Heat Dissipation “Cold” T=37oC Cryogens and Antipyretics reset the Set Point to 37oC

Fever is Not Dangerous Fever is a normal response to infection There is no evidence that fever … With simple infections will continue to rise Will result in heatstroke Brain Damage Fever alone will not cause brain damage Brain damage caused by another insult Febrile Seizures do not cause permanent damage

Fever Can Be Disruptive Caregiver Reports Changes in activity, sleep and feeding Mean duration of changes – 3.5 days Disruption of family routine – 4 days Concerns of Health Care Providers Affects overall clinical picture More difficult to assess overall well-being Greater risk of dehydration Mistry RD et.al., Pediatr Emerg Care 2007

Effects of Antipyretics Normalized Temperature Fever increases discomfort Reducing fever improves comfort Better Sense of the child’s well-being Reduced Pain Many illness include pain Pharyngitis, Acute Otitis Media, Myalgia Reducing pain will improve comfort

Effects of Fever Positive Effects of Fever May improve the outcome of infections May improve the antibody response to vaccines Some Patients do not Tolerate Fever Do not tolerate increased metabolic demands Cardiomyopathy Multiple complex medical problems Debate over critically ill patients

The Goal of Treatment “A primary goal of treating the febrile child should be to improve the child’s overall comfort.” American Academy of Pediatrics Section on Clinical Pharmacology & Therapeutics and the Committee on Drugs; Pediatrics 2011

Treating with antipyretics Ibuprofen Typically use over 6 months Antiplatelet effect Can cause/worsen gastritis May contribute to acute kidney injury or worsen chronic kidney disease (especially if dehydrated) Acetaminophen Can use younger Doesn’t affect platelets Liver toxicity possible high dose or if underlying liver injury

A Treatment Question The Problem: Management of children with simple febrile illnesses The Question: Is there a benefit to alternating ibuprofen and acetaminophen when compared to treating children with either drug alone Outcomes: Does it improve comfort Does it increase fever phobia

Antipyretics and Comfort Mild to Moderate Discomfort APAP 12.5 mg/kg Q6 hours / IBU 5 mg/kg Q8 hours / Alternating Q4 hours Uses the Non-Communicating Children’s Pain Checklist (NCCPC) – max score =90; mild/mod = 6-10; normal <4 Fewer total doses of antipyretics given each day using combined therapy – also fewer daycare days missed. Authors state that the curve is steeper for combined therapy but did not provide statistical analysis or data. Sarrell ME et.al., Arch Pediatr Adol Med 2006

Point, Counter-Point To Alternate Not To Alternate May lower fever more effectively than one drug May allow return to usual activities sooner Doing more may reduce the parents’ anxiety No toxicity has been reported Not To Alternate May not improve the overall comfort of the child May interfere with the body’s usual defenses May worsen fever phobia This could get confusing and result in errors Is toxicity under-reported

Assessing fever No correlation with height of fever and severity of illness. When patient has fever, please assess: Patient’s general appearance, level of awareness, etc. Perfusion (skin warmth, cap refill) Other vitals-heart rate, respiratory rate, blood pressure

Quiz Which patient with fever is most concerning: A 6 month old with vomiting and fever and found to have UTI. A 2 y/o seen in EC with cellulitis/abscess on buttock and with fever. An 18 m/o with history of febrile seizure with fever for 3 days. A 2 week old admitted with RSV who now has a fever. A 5 y/o with pneumonia admitted for oxygen and has fever during hospital day 1.

Red flag conditions Fever in young infant Fever in immunocomprised patient (cancer patient, patient on chronic immunosuppresants including steroids, sickle cell patients). Fever in short gut patient Fever in patient with central line Fever with other vital sign changes, concerns for SIRS/shock

My Message to Parents Fever is a normal reaction Fever is not bad It is part of your body’s defense It may help fight infection Sign of something. If we know from what, then more reassuring. Fever is not bad Does not cause brain damage It does not continue to rise and cause heatstroke

My Message to Parents Focus on Comfort Improving appetite, sleep and activity If the fever is not bothering them then leave it alone Don’t wake them up for treatment Keep things simple When to call your doctor or return Altered activity when not febrile Signs of dehydration

? Questions ?