1. Are Antipyretics Beneficial in Febrile Children? Dennis Scolnik MSc, MB, ChB, DCH, FRCP(C) Divisions of Emergency Services & Clinical Pharmacology & Toxicology Project Director, Research Institute Hospital for Sick Children Associate Professor of Paediatrics University of Toronto, Canada

2. I am arguing against this proposition!!

3. Fever Physiological response (Adam 1996) Body does not allow lethal temperature if: –no dehydration –open environment –no neurological abnormalities (Kluger 1992, Adam 1996) Purposeful & protective (Kluger 1991,1992, Roberts 1991)

4. Fever Good … rarely harmful (malignant hyperthermia)

5. Fever Phobia ‘New’ phenomenon Association with: –seizures febrile seizures Rx does not → ↓ –CNS infections rare that no other signs & clinician not able to identify

6. Fever Phobia Association versus Cause

7. Are Antipyretics Beneficial in Febrile Children? Symptomatic (at best)!! –makes child feel better NOT necessary for the medical condition Empowers parents

8. Primum Non Nocere Harmless symptom … Is it harmless to treat fever?

9. Downsides of Treating Fever 1. Perpetuates fever phobia 2.‘Medicalisation’ (Hay 2006) 3.Increased use of medical facilities

10. Downsides of Treating Fever 4. ↑ nosocomial infection 5.Side-tracks parents (& some physicians!) from more important signs of illness 6.POISONING!!

11. Poisoning Physician error Parent error

12. Physician Error Acetaminophen/Paracetamol (Kozer, Scolnik et al 2002) Emergency Department 1678 drug orders/prescriptions

13. Physician Error Acetaminophen/Paracetamol (Kozer, Scolnik et al 2002) 10% in ED c.f. 6.6 - 11.7% in paediatric intensive care units

14. Physician Error Acetaminophen/Paracetamol (Kozer, Scolnik et al 2002)

15. Insignificant/minimal –minimal likelihood harm –e.g. 5 mg dexamethasone instead of 3 mg Significant –non-life-threatening consequences/less effective treatment –e.g. 10x lower dose of amoxicillin for otitis media Severe –could cause death/decrease chance successful treatment of life-threatening condition –e.g. 10x error insulin dosage

16. Parent Error Acetaminophen/Paracetamol (Heubi 1998) Published, FDA, own hospital with therapeutic intent 47 patients 5 wks - 10 yrs 60 - 420 mg/kg/day for 1 - 42 days 24/43 patients (55%) died 3 survived after transplant

17. Parent Error (Acetaminophen/Paracetamol Rivera-Penera 1998) Over 10 yrs ≤ 19 yrs age Parts of California Overdose with previous normal LFT’s

18. Parent Error (Acetaminophen/Paracetamol Rivera-Penera 1998) 28/73 (38%) abnormal LFT’s All 28 severe hepatotoxicity –6 (21%) liver transplantation

19. Parent Error (Acetaminophen/Paracetamol Rivera-Penera 1998) 14/73 ≤ 10 yrs age –71% (10/14) of these had abnormal LFT’s (versus 31% in older) These 10 had all been overdosed by parents in error

20. Drug Error: Ibuprofen (Ulinski 2004, Paediatric Nephrology, Hôpital Trousseau, Paris) 20 months in 1 centre 7 children with diarrhoea &/or vomiting & fever therapeutic doses (11.5 – 32 mg/kg/day) 1 - 3 days → ACUTE RENAL FAILURE 1 dialyzed

21. What Should We Do? Education >>> treatment

22. Education 1. Fever is a symptom not a disease

23. Education 1.Fever is a symptom not a disease 2.A child can have meningitis with a low fever or a viral URTI with a high fever

24. Education 1.Fever is a symptom not a disease 2.A child can have meningitis with a low fever or a viral upper respiratory tract infection with a high fever 3.The difference is in how sick the child is!!

25. Education 1.Fever is a symptom not a disease 2.A child can have meningitis with a low fever or a viral upper respiratory tract infection with a high fever 3.The difference is in how sick the child is!! 4.MINIMAL CLOTHES & COOL ENVIRONMENT 5.FLUIDS

26. Are Antipyretics Beneficial in Febrile Children? NO May make child feel better Cause more harm than good

27. Therefore antipyretics are NOT beneficial in febrile children

28. Thank you!

29. J Pediatrics 1997:130(2);300-304

30. J Pediatrics 1998: 132(1);22-27