Monday, March 14, 2011

AAP Issues Statement on Treating Fever in Pediatric Patients

From Medscape Education Clinical Briefs

News Author: Emma Hitt, PhD
CME Author: Laurie Barclay, MD

March 3, 2011 — Treatment of febrile children should focus on improving the child's comfort rather than bringing the temperature down to normal levels or preventing the onset of fever, according to a new clinical report issued by the American Academy of Pediatrics (AAP).

Janice E. Sullivan, MD, and Henry C. Farrar, MD, and the AAP's Section on Clinical Pharmacology and Therapeutics, and Committee on Drugs authored the report, published in the March issue of Pediatrics.

"Many parents administer antipyretics even when there is minimal or no fever, because they are concerned that the child must maintain a 'normal' temperature," the study authors note. "Fever, however, is not the primary illness but is a physiologic mechanism that has beneficial effects in fighting infection," they write. "There is no evidence that fever itself worsens the course of an illness or that it causes long-term neurologic complications."

According to the study authors, there is "no evidence that reducing fever reduces morbidity or mortality from a febrile illness" or that it decreases the recurrence of febrile seizures.

The article outlines strategies to counsel caregivers about treating febrile illness, stating that acetaminophen and ibuprofen, "when used in appropriate doses, are generally regarded as safe and effective agents in most clinical situations."

The appropriate dosing for acetaminophen is 10 to 15 mg/kg per dose given every 4 to 6 hours orally, which produces an antipyretic effect within 30 to 60 minutes in approximately 80% of children.
The appropriate dosing for ibuprofen is 10 mg/kg per dose.

The study also emphasizes the importance of clear labeling, dosing, and proper storage of medications used to treat fever.
It also warns that use of combination therapy with acetaminophen and ibuprofen may place infants and children at increased risk for dosing errors and adverse outcomes.

"To promote child safety, pediatricians should advocate for a limited number of formulations of acetaminophen and ibuprofen and for clear labeling of dosing instructions and an included dosing device for antipyretic products," they suggest.

Pediatrics. 2011;127:580-587. Full text

Clinical Context

Fever in a child is one of the most common symptoms for which parents and caregivers seek medical attention from pediatricians, family practitioners, and other healthcare providers. Because of their concern that the child should maintain a "normal" temperature, many parents administer antipyretics to their child even when fever is minimal or absent.

However, fever is a physiologic response that helps the body to fight infection; therefore, it is not the primary illness. Evidence is lacking that fever, in and of itself, worsens the course of an illness or causes long-term neurologic complications.

Study Highlights

* The AAP issued a clinical report, "Fever and Antipyretic Use in Children," to assist pediatricians in educating parents and families about fever and "fever phobia."
* Appropriate counseling on fever management should help parents understand that fever, in and of itself, is not harmful and may actually be of benefit in helping a generally healthy child to ward off infection.
* Clinicians should also emphasize that antipyretic use does not prevent febrile seizures.
* The main objective in treating a child with fever should therefore be to improve the child's overall comfort level, rather than to lower body temperature to the normal range.
* Clinicians should emphasize the child's overall well-being, the need to monitor the child's activity and recognize signs of serious illness, and encouragement of appropriate fluid intake when they advise the parents or caregivers of a febrile child.
* To avoid accidental ingestion by children, clinicians should counsel parents regarding safe storage of antipyretics, in addition to educating them regarding appropriate use and dosing.
* Parents or caregivers should not wake up a sleeping child to administer antipyretic medication.
* When used in appropriate doses, acetaminophen and ibuprofen are generally considered to be safe and effective in most clinical situations, and both have analgesic as well as antipyretic effects.
* Appropriate dosing for acetaminophen is 10 to 15 mg/kg per dose given every 4 to 6 hours orally, which produces an antipyretic effect within 30 to 60 minutes in approximately 80% of children.
* Appropriate dosing for ibuprofen is 10 mg/kg per dose.
* As with all drugs, however, acetaminophen and ibuprofen should be used judiciously to minimize the risk for adverse drug effects and toxicity.
* For a generally healthy child with fever, acetaminophen and ibuprofen do not differ markedly in safety and effectiveness, based on current evidence.
* Current evidence suggests that combining acetaminophen and ibuprofen is more effective than using either medication alone.
* However, using both drugs in combination may be more complicated, may increase the risk for inaccurate dosing and adverse outcomes, and may promote unsafe use. These potential risks should be carefully considered before combination therapy is prescribed.
* Parents should be informed that they should always use an accurate measuring device for antipyretic medications and that the correct dosage is based on the child's weight.
* To improve patient safety, pediatricians should advocate for a limited number of acetaminophen and ibuprofen formulations, clear labeling of dosing instructions, and a dosing device to be included with antipyretic products.
* The use of alcohol baths is not an appropriate method to reduce fever because of reported adverse events associated with systemic absorption of alcohol.

Clinical Implications

* Appropriate counseling on fever management should help parents understand that fever, in and of itself, is not harmful in a generally healthy child. Therefore, the main goal in treating a child with fever should be to improve the child's overall comfort level, rather than to lower body temperature to the normal range.
* When used in appropriate doses, acetaminophen and ibuprofen are generally considered to be safe and effective in most clinical situations, and both have analgesic as well as antipyretic effects. As with all drugs, however, acetaminophen and ibuprofen should be used judiciously to minimize the risk for adverse drug effects and toxicity.

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