1. Fever and Antipyretic use in children Clinical report AAP 2011
Lily Ghavi
PGY1
Pedi EM conference 6/21/16

2. Fever is not the primary illness, but the physiologic mechanism that has beneficial effect in fighting infection
No evidence that fever worsens course of illness
No evidence of long term neuro complications
Goal: improve comfort rather than “normalization” of temperature

3. What to understand about the people administering antipyretics (i. e
What to understand about the people administering antipyretics (i.e. Parents!)
Parents concerned about “normal” temperature
25% of parents give antipyretic for temperature < 100 F
One half of parents consider temp <38 C (100.4 F) to be a fever.
85% of parents report waking child to give antipyretics

4. What to understand about the people administering antipyretics (i. e
What to understand about the people administering antipyretics (i.e. Parents!)
½ of parents administer incorrect doses
15% supratherapeutic doses
Those that understand dose is based on weight, not age/height less likely to give correct dose
Nurses/Physicians are primary source of information

5. Fever phobia
Caregivers concerned that high fevers, untreated, are associated with seizures/brain damage/death.
No clearly established relationship

6. Us vs. Them
As doctors
More likely to give antipyretics for child’s overall comfort
Most commonly advised for temperature > 38.3 C (101F)
80% of us agree not to wake a sleeping child for antipyretics

7. physiology Beneficial effects of fighting infection
Retards growth and reproduction of bacteria and viruses
Enhances neutrophil production and T lymphocyte proliferation
Aids in body’s acute phase reaction
Most are benign, short in duration, can protect the host

8. physiology Data shows that fever can
Have beneficial effects on immune system
Help body recover faster in viral infections

9. Benefits/risk of fever reduction
Relief of patient discomfort
Reduction of insensible water loss (decrease risk of dehydration)
Comfort can lead to increased PO intake
More activity, less irritability
“more reliable sense of child’s overall clinical condition”
Risk
Delay in dx of underlying diagnosis and initiation of appropriate therapy

10. Treatment Goals Emphasize Comfort, primary therapeutic objective
Signs of serious illness
…and not normothermia
Cold baths/cooling measures lower body temp without improving comfort
Discourage alcohol baths (and reported adverse events)

11. Reminders
No evidence that reducing fever reduces morbidity/mortality from febrile illness (exceptions exist)*
no evidence that antipyretic therapy prevent onset or recurrence of febrile seizures
Yet, still we recommend routine pretreatment
With immunizations to decrease injection
Possible decreased immune response in patients pretreated with antipyretics
Chronic kids who may not be able to tolerate increased metabolic demands of a fever

12. acetaminophen 10-15mg/kg 4-6 hrs Onset 30-60 minutes
80% show improvement/decrease in temperature
No loading dose needed
Suppository/rectal is has same efficacy
Potential effect on asthma related symptoms

13. ibuprofen Longer clinical effect of lowering body temperature 10m/kg
As effective, possibly more effective than acetaminophen
No studies to show benefit of Ibuprofen vs acetaminophen in patient comfort

14. consideration No difference in safety, but… NSAIDS Gastritis
Nephrotoxicity with renal insufficency
Children who have moderate-severe dehydration
Can worsen renal dysfunction through prostaglanding synthesis (be mindful also in kids with nephrotoxic meds)

15. Alternating/combo therapy
Survey of parents/caregivers
67% reported alternating antipyretics
81% did so at advice of pediatrician or PCP
Alternating therapy every 2, 3, 4, 6 hours
Initially no benefit, however
At 6 and 8 hours 83% and 81% afebrile vs. ibuprofen alone 58% and 35%
Still questions regarding safety of this practice and its impact on our primary therapeutic goal – comfort!
Bottom line: no evidence that this improves clinical outcomes
And increased risk for inaccurate dosing etc

16. Instructions for caregivers
Careful instructions regarding
Dosing
Dosing intervals
Acetaminophen vs ibuprofen
Careful and cautious use of cough/cold meds that contain antipyretics as to prevent simultaneous dosing or overdosing of antipyretic
Proper storage of these medications to prevent accidental ingestion

17. Summary Counsel, counsel, counsel! Help parents understand fever
Discuss its relatively benign nature
Benefits of fever
Safety and efficacy of antipyretics
Judicious use, drug effects, toxicities
Minimize fever phobia
Febrile seizures
Emphasis monitoring for signs of serious illness, maintaining hydration, safe storage, appropriate use.