Fever and Antipyretic use in children Clinical report

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

• 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

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

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

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

Us vs. Them • As doctors – More likely to give antipyretics for child’s overall comfort – Most commonly advised for temperature > 38. 3 C (101 F) – 80% of us agree not to wake a sleeping child for antipyretics

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

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

Benefits/risk of fever reduction • Benefit – 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

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)

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

acetaminophen • • 10 -15 mg/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

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

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)

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

Instructions for caregivers • Careful instructions regarding – 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

Summary • 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.