Fever! Fever! Fever!
Clinical report addresses educating parents to reduce ‘fever phobia’
- Copyright © 2011 by the American Academy of Pediatrics
It is 3 a.m. and you get your third call of the night about a child with fever. A parent asks about giving antipyretics prior to routine immunizations. You are educating first-time parents about fever prior to discharge of their infant from the newborn nursery. These scenarios are common in everyday practice.
Fever accounts for one-third of all presenting conditions in children. What guidance is available to pediatricians and pediatric health care providers regarding fever treatment or prophylaxis and education for parents/caregivers?
A new AAP clinical report, Fever and Antipyretic Use in Children, summarizes recommendations and controversies related to the use of antipyretics in pediatrics (Pediatrics. 2011;127:580-587). The report, from the AAP Section on Clinical Pharmacology and Therapeutics and the Committee on Drugs, addresses the state of knowledge about antipyretic usage in pediatric patients, including common concerns, indications, treatment goals, single or combination therapy, and instructions for caregivers. Limited evidence-based information is available regarding antipyretic therapy, combination therapy and the role of fever in the natural history of an illness.
Need to educate
The report highlights the need to educate patients and families about fever and “fever phobia.”
Fever is a physiological mechanism that has beneficial effects in fighting infection. Fever, in and of itself, is not known to endanger a generally healthy child; in contrast, fever actually may be of benefit.
Although many parents administer antipyretics to a child with minimal or no fever, the report emphasizes that the primary goal of treating the febrile child should be improvement of the child’s overall comfort rather than normalization of body temperature. Parents/caregivers of an ill and/or febrile child should be counseled to focus on the general well-being of the child, his/her activity, observing the child for signs of serious illness, appropriate fluid intake and safe storage of antipyretics. Children should not be awakened to administer an antipyretic.
The degree of fever does not always correlate with the severity of illness. In addition, there is no evidence that fever worsens the course of an illness or that it causes long-term neurological complications. Possible exceptions may be children with certain underlying chronic disease (i.e., myocardial dysfunction or heart failure) or acute illness (i.e., acute myocarditis, shock, etc.) that may result in limited tolerance of the increased metabolic demands caused by a fever.
Many physicians continue to encourage the use of antipyretics, believing that most benefits result from improved comfort and the accompanying improvements in activity and feeding, less irritability, and a more reliable sense of the child’s overall clinical condition.
Administering a safe dosage of ibuprofen and acetaminophen is critical. Up to half of parents/caregivers administer an incorrect dose of antipyretics to their child, with as many as 15% exceeding the recommended dose. Parents/ caregivers need to be aware that the correct dosage is based on the child’s weight, and that an accurate measuring device always should be used for dose administration.
Acetaminophen and ibuprofen, when used in appropriate doses, generally are regarded as safe and effective agents in most clinical situations. However, as with all drugs, they should be used judiciously to minimize the risk of adverse drug effects and toxicity.
Studies provide some evidence that combination therapy may be more effective at lowering temperature. However, questions remain regarding the safety of this practice as well as the effectiveness at improving discomfort, the primary treatment endpoint. The possibility that parents will not receive or not understand dosing instructions, combined with the wide array of formulations that contain these drugs, increases the potential for inaccurate or overdosing. Finally, this practice may only promote fever phobia.
Despite the frequent use of antipyretics, whether for fever, pain or discomfort, relatively limited information is available on the long-term safety of these drugs when used at high therapeutic doses or for long periods of time. Most assessments of safety have been limited in their scope, focusing only on the presence or absence of clinical symptoms of organ failure and not actually evaluating clinical markers of organ dysfunction.
Fortunately, new methods for measuring biomarkers of toxicity are being developed into clinical tools, creating opportunities in clinical and translational research to gain a better understanding of the long-term safety of antipyretics in infants and children.
Dr. Farrar, co-author of the report, is a former member of the AAP Section on Clinical Pharmacology and Therapeutics Executive Committee. Dr. Sullivan, lead author, is the chair.