Clinical Report—Fever and Antipyretic Use in Children Abstract

Guidance for the Clinician in Rendering Pediatric Care Clinical Report—Fever and Antipyretic Use in Children Janice E. Sullivan, MD, Henry C. Farrar, MD, and the abstract SECTION ON CLINICAL PHARMACOLOGY AND THERAPEUTICS, and COMMITTEE ON DRUGS Fever in a child is one of the most common clinical symptoms managed by pediatricians and other health care providers and a frequent cause KEY WORDS fever, antipyretics, children of parental concern. Many parents administer antipyretics even when ABBREVIATIONS there is minimal or no fever, because they are concerned that the child NSAID—nonsteroidal anti-inflammatory drug must maintain a “normal” temperature. Fever, however, is not the The guidance in this report does not indicate an exclusive primary illness but is a physiologic mechanism that has beneficial course of treatment or serve as a standard of medical care. effects in fighting infection. There is no evidence that fever itself wors- Variations, taking into account individual circumstances, may be ens the course of an illness or that it causes long-term neurologic appropriate. complications. Thus, the primary goal of treating the febrile child This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors should be to improve the child’s overall comfort rather than focus on have filed conflict of interest statements with the American the normalization of body temperature. When counseling the parents Academy of Pediatrics. Any conflicts have been resolved through or caregivers of a febrile child, the general well-being of the child, the a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any importance of monitoring activity, observing for signs of serious ill- commercial involvement in the development of the content of ness, encouraging appropriate fluid intake, and the safe storage of this publication. antipyretics should be emphasized. Current evidence suggests that there is no substantial difference in the safety and effectiveness of acetaminophen and ibuprofen in the care of a generally healthy child with fever. There is evidence that combining these 2 products is more effective than the use of a single agent alone; however, there are con- cerns that combined treatment may be more complicated and contrib- ute to the unsafe use of these drugs. Pediatricians should also promote patient safety by advocating for simplified formulations, dosing in- structions, and dosing devices. Pediatrics 2011;127:580–587 www.pediatrics.org/cgi/doi/10.1542/peds.2010-3852 INTRODUCTION doi:10.1542/peds.2010-3852 Fever is one of the most common clinical symptoms managed by pedi- All clinical reports from the American Academy of Pediatrics atricians and other health care providers and accounts, by some esti- automatically expire 5 years after publication unless reaffirmed, mates, for one-third of all presenting conditions in children.1 Fever in a revised, or retired at or before that time. child commonly leads to unscheduled physician visits, telephone calls PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). by parents to their child’s physician for advice on fever control, and the Copyright © 2011 by the American Academy of Pediatrics wide use of over-the-counter antipyretics. Parents are frequently concerned with the need to maintain a “normal” temperature in their ill child. Many parents administer antipyretics even though there is either minimal or no fever.2 Approximately one- half of parents consider a temperature of less than 38°C (100.4°F) to be a fever, and 25% of caregivers would give antipyretics for temperatures of less than 37.8°C (100°F).1,3 Furthermore, 85% of parents (n ϭ 340) reported awakening their child from sleep to give antipyretics.1 Unfortunately, as many as one-half of parents administer incorrect doses of antipyretics; approximately 15% of parents give suprathera- peutic doses of acetaminophen or ibuprofen.4 Caregivers who under- 580 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 28, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS stand that dosing should be based on more quickly from viral infections, al- tributable to heat stroke. Thus, extrap- weight rather than age or height of fe- though the fever may result in discom- olating similar outcomes from these ver are much less likely to give an in- fort in children.11,16–18 Evidence is in- different illnesses is problematic. correct dose.4 conclusive as to whether treating with Physicians and nurses are the primary antipyretics, particularly ibuprofen TREATMENT GOALS source of information on fever man- alone or in combination with acet- A discussion of the use of antipyretics agement for parents and caregivers, aminophen, increases the risks of in febrile children must begin with although there are some disparities complications with certain types of in- consideration of the therapeutic end between the views of parents and phy- fections.19,20 Potential benefits of fever points. When counseling families, physicians regarding antipyretic treat- reduction include relief of patient dis- sicians should emphasize the child’s ment.1 The most common indications comfort and reduction of insensible comfort and signs of serious illness for initiating antipyretic therapy by pe- water loss, which may decrease the rather than emphasizing normother- diatricians are a temperature higher occurrence of dehydration. Risks of mia. A primary goal of treating the fe- than 38.3°C (101°F) and improving lowering fever include delayed identifi- brile child should be to improve the the child’s overall comfort.5 Although cation of the underlying diagnosis and child’s overall comfort. Most pediatri- only 13% of pediatricians specifically initiation of appropriate treatment cians observe, with some supporting cite discomfort as the primary indi- and drug toxicity. data from research, that febrile chil- cation for antipyretic use,6 this in- There is no evidence that children with dren have altered activity, sleep, and tent is generally implied in their rec- fever, as opposed to hyperthermia, are behavior in addition to decreased oral ommendations. Most pediatricians at increased risk of adverse outcomes intake.28 Unfortunately, there is a pau- (80%) believe that a sleeping ill child such as brain damage.7,9,21–23 Fever is a city of clinical research addressing the should not be awakened solely to be common and normal physiologic re- extent to which antipyretics improve given antipyretics.5 sponse that results in an increase in discomfort associated with fever or ill- Antipyretic therapy will remain a com- the hypothalamic “set point” in re- ness. It is not clear whether comfort mon practice by parents and is gener- sponse to endogenous and exogenous improves with a normalized tempera- ally encouraged and supported by pe- pyrogens.9,23 In contrast, hyperthermia ture, because external cooling mea- diatricians. Thus, pediatricians and is a rare and pathophysiologic re- sures, such as tepid sponge baths, can health care providers are responsible sponse with failure of normal ho- lower the body temperature without for the appropriate counseling of par- meostasis (no change in the hypotha- improving comfort.7,29 The use of alco- ents and other caregivers about fever lamic set point) that results in heat hol baths is not an appropriate cooling and the use of antipyretics.7 production that exceeds the capability method, because there have been re- to dissipate heat.9,23 Characteristics ported adverse events associated with PHYSIOLOGY OF FEVER of hyperthermia include hot, dry skin systemic absorption of alcohol.30 Fur- It should be emphasized that fever is and central nervous system dysfunc- thermore, antipyretics have other clin- not an illness but is, in fact, a physio- tion that results in delirium, convul- ical outcomes, including analgesia, logic mechanism that has beneficial ef- sions, or coma.23 Hyperthermia which may enhance their overall clini- fects in fighting infection.8–10 Fever re- should be addressed promptly, be- cal effect. Regardless of the exact tards the growth and reproduction of cause at temperatures above 41°C to mechanism of action, many physicians bacteria and viruses, enhances neu- 42°C, adverse physiologic effects be- continue to encourage the use of anti- trophil production and T-lymphocyte gin to occur.7,9,24 Studies of health pyretics with the belief that most of the proliferation, and aids in the body’s care workers, including physicians, benefits are the result of improved acute-phase reaction.11–14 The degree have revealed that most believe that comfort and the accompanying im- of fever does not always correlate with the risk of heat-related adverse out- provements in activity and feeding, the severity of illness. Most fevers are comes is increased with tempera- less irritability, and a more reliable of short duration, are benign, and may tures above 40°C (104°F), although sense of the child’s overall clinical con- actually protect the host.15 Data show this belief is not justified.5,23,25–27 A dition. Because these are the most im- beneficial effects on certain compo- child with a temperature of 40°C portant benefits of antipyretic therapy, nents of the immune system in fever, (104°F) attributable to a simple febrile it is of paramount importance that pa- and limited data have revealed that fe- illness is quite different from a child rental counseling focus on monitoring ver actually helps the body recover with a temperature of 40°C (104°F) at- of activity, observing for signs of seri- PEDIATRICS Volume 127, Number 3, March 2011 581 Downloaded from www.aappublications.org/news by guest on September 28, 2021 ous illness, and appropriate fluid in- ited on the actual risks of fever and the leading to hepatotoxicity; therefore, take to maintain hydration.

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