What Should I do When My Child Has a Fever

Transcription

1 What Should I do When My Child Has a Fever What Is Fever? Fever is a symptom a sign that your child s body is fighting off an infection. Most fevers are caused by common things like colds, ear infections, and bronchitis. Fever is the body s way of fighting infections. If you think your child has a fever, you should take their temperature. Temperature readings are different depending on what part of the body you use (rectum, ear, mouth). Your child has a fever if their temperature is above: Rectal F (38.0 C) Oral (by mouth) 99.5 F (37.5 C) Axillary (armpit) 98.6 F (37.0 C) Tympanic (ear) F (37.8 C) Why Do We Treat a Fever? Fevers are usually not dangerous for most children and infants over the age of 3 months. Most fevers do not lead to brain damage or death. Although some children have seizures when they have a fever, medicines used to treat fever do not always prevent these seizures. The main reason we treat fevers is to keep your child comfortable so they will eat, drink, or sleep. If your child has a mild fever but is playing, drinking fluids, and generally acting well, there is no reason to treat the fever. Medicines used to treat fever do not make the fever or infection go away faster. Medicines used to treat fever may not make your child s temperature normal. However, you should call your doctor if your child has a fever and is less than 3 months old, if the fever has lasted more than 24 hours, or if your child is also vomiting. What Medicines Are Used to Treat Fever? The most commonly used medicines to treat fever are acetaminophen (Tylenol and others) and ibuprofen (Motrin, Advil, others). When used as recommended, acetaminophen and ibuprofen have few side effects and are quite safe. These medicines come in drops for infants, liquid ( elixir ) for toddlers, and chewable tablets for older children. The infant drops are more concentrated than the liquid elixir for toddlers. Do not switch back and forth between different products or you may give your child too much or too little medicine. Always closely read the directions on the label. DO NOT give your child aspirin for their fever unless your doctor tells you to. Aspirin can cause serious side effects and Reye s syndrome. Other tips for the safe use of acetaminophen or ibuprofen include: To avoid making mistakes, read the label before you open the bottle, after you measure a dose, and again before you give it. It is important to use the medicine exactly as you are told. Do not give more or less medicine and do not give it more frequently than recommended. Many allergy, cold, and flu medications contain acetaminophen or ibuprofen. Check with your pharmacist before combining medications. When giving your child a liquid medication, do not use standard tableware tablespoons and teaspoons because they usually are not accurate. Instead, use a measuring device such as a syringe, dropper, dosing spoon, or medicine cup. Other Ways to Keep Your Child Comfortable There are other ways to keep your child comfortable. These include: If shivering, keep your child warm until the shivering stops. If not shivering, you can remove your child s warm clothes and encourage them to drink plenty of fluids. Keep your child rested, quiet, and comfortable in a cool room. Place a cool washcloth on your child s forehead or sponge them with lukewarm water. If sponge bathing, make sure the water doesn t get cold, and stop if your child starts to shiver. Never use rubbing alcohol to cool your child's skin. It can be absorbed through the skin and harm your child. Prepared for the subscribers of Pharmacist s Letter / Prescriber s Letter to give to their patients. P.O. Box 8190, Stockton, CA Phone: ~ Fax:

2 (Page 2 of 5) Detail-Document # This Detail-Document accompanies the related article published in PHARMACIST S LETTER / PRESCRIBER S LETTER April 2006 ~ Volume 22 ~ Number Antipyretics and Fever in Children For more information concerning dosing of commonly-used OTC medications in children see our Detail-Document, Dosing of OTC Products in the Pediatric Population. U.S. subscribers please see document # Canadian subscribers please see document # Introduction Fever is common in infants and children. Fever is defined as an elevated core body temperature that is often, but not necessarily, part of the body s defense response to the invasion of something live or inanimate which is considered foreign to the body. 1,2 In general, fever is rarely harmful and mainly causes discomfort. Treating a fever with antipyretics assumes that fever is noxious and that using antipyretics such as acetaminophen (Tylenol, others) or ibuprofen (Motrin, Advil, others) reduces or eliminates the adverse effects associated with fever. However, neither of these assumptions has ever been proven, especially in older infants and children. 1 In fact, fever is an important defense mechanism in the body and helps the body resist infection. Additionally, it has not been conclusively proven that a core temperature of up to 105.8º F (41 C) is harmful in most individuals. While some may argue that children with a history of febrile seizures derive benefit from fever suppression, this too has not been proven. 3-5 Most children who experience a febrile seizure have a body temperature of (39 C) or less and tolerate even higher body temperatures without experiencing seizures at a later time. 2 In a number of trials, antipyretics have not been shown to prevent recurrent febrile seizures. 3-5 While fever is often considered a beneficial response to foreign agents, it causes parental anxiety. Crocetti and colleagues interviewed 340 caregivers of children regarding their knowledge about fever. They found that 56% of caregivers were very worried about the potential harm of fever in their children, and felt that fever could lead to a variety of sequelae including seizures, brain damage, and death. When asked about the lowest temperature that could lead to harm, 76% of patients felt that a fever of 104 F (40 C) or less could be harmful, and 35% of caregivers felt like a temperature of 100 F (37.8 C) or less could be harmful. In this same survey, 25% of respondents said they gave antipyretics for temperatures of less than 100 F (37.8 C) and 89% gave antipyretics for temperatures of 102 F (38.9 C) or lower. Alternating acetaminophen and ibuprofen was reported by 27% of caregivers. Finally, 7% of respondents thought that fever could rise to 110 F (43.3 C) or higher if the fevers were untreated. The authors concluded that fever phobia exists and that health care providers should educate caregivers about fever and its role in illness. 6 Despite the protective role of fever, antipyretics are often recommended for treatment of fever. The primary reason to treat fever is for patient comfort. Complete normalization of body temperature is not necessary. The most commonly used antipyretics include the salicylates such as aspirin, acetaminophen, and the nonsteroidal anti-inflammatory agents such as ibuprofen. These agents block the conversion of arachadonic acid to prostaglandin E2 by inhibiting cyclooxygenase. 1,2 It is thought that prostaglandin E2 is critical in the febrile response. However, although aspirin is a very effective antipyretic, because of the association with Reye s syndrome aspirin is not recommended for use in children. Acetaminophen and Ibuprofen Antipyretics such as acetaminophen and ibuprofen are the most commonly recommended agents. Acetaminophen (Tylenol, others) is considered a safe and effective antipyretic agent. It is well absorbed orally, with a maximum temperature

3 reduction occurring at about two hours. The manufacturer s recommended dose is 10 to 15 mg/kg every four to six hours, with a maximum of five doses in a 24-hour period. However, some clinicians recommend an initial 30 mg/kg oral loading dose in order to achieve therapeutic serum concentrations and antipyretic efficacy sooner. 7 Ibuprofen is also effective in the treatment of fever. While nonsteroidals are associated with serious adverse effects such as gastrointestinal bleeding, renal failure, and allergic reactions, these reactions are rare when used short term in children less than twelve years. 8 Even in children less than two years of age, short courses of ibuprofen have been shown to be remarkably safe. 8 Because of the longer duration of action, ibuprofen can be dosed less frequently, which can be advantageous, especially at bedtime. The recommended dose is 5 to 10 mg/kg by mouth, every six to eight hours. Ibuprofen is not indicated in children less than six months of age in the U.S. and in children less than three to four months in Canada (varies by manufacturer). Studies show that higher ibuprofen doses (10 mg/kg) were more effective than lower doses (5 mg/kg), especially at higher body temperatures [greater than F (39.2 C)]. Another study found that the higher ibuprofen dose should be used at temperatures of F (38.8 C) or higher. 9 The question of differences in efficacy of multiple doses of acetaminophen and ibuprofen has been addressed in a limited number of small studies. While ibuprofen has been shown to be slightly more effective in a few studies, the trials have methodological flaws making definitive conclusions difficult. Most studies evaluate fewer than 100 children and doses of antipyretics vary widely. In addition, patient recruitment was often flawed as groups were not matched at the time of recruitment. 10,11 While an apparent advantage of acetaminophen is the availability of rectal suppositories (especially in a child who is unable to tolerate oral medications), problems exist. Rectal administration of acetaminophen often leads to erratic absorption with peak levels varying by as much as nine-fold and often does not reach therapeutic concentrations. In addition, the time to peak is substantially longer when (Detail-Document #220409: Page 3 of 5) compared to the time to peak of orally administered acetaminophen. Consequently, the American Academy of Pediatrics discourages its use. 12 Alternating Acetaminophen and Ibuprofen When fever reduction is inadequate with maximal doses of either acetaminophen or ibuprofen monotherapy, some clinicians recommend alternating acetaminophen and ibuprofen. While this is commonly recommended, there is surprisingly little published information to support this practice. Clinical trials evaluating this practice suffer from many flaws Trials evaluating the efficacy of combination therapy for resistant high temperatures are needed before this practice can be routinely recommended. Alternating antipyretics can be considered when children experience breakthrough fever before another dose of the same antipyretic can be given. For example, ibuprofen can be given every six to eight hours. However, fever sometimes reoccurs after three to four hours, before ibuprofen can be safely given again. In this scenario, acetaminophen can be given three to four hours after the ibuprofen dose. There are a variety of regimens which can be used, but care must be given to avoid giving the medications on the same schedule (i.e., every four hours). In a survey of pediatricians, 50% of the 161 respondents recommended alternating antipyretics. The most commonly cited regimen was a regimen of acetaminophen every four hours with ibuprofen every six hours. This would entail giving a dose of acetaminophen at times 0 and 4 hours, ibuprofen at time 6 hours, acetaminophen at time 8 hours and potentially both at time 12 hours. 13 This regimen could cause confusion in some caregivers and potentially lead to overdose. Alternatively, regimens utilizing these medications at a fixed dosing interval (i.e., a regimen where these medications are given every six hours, so either acetaminophen or ibuprofen is given every three hours or every eight hours, so either acetaminophen or ibuprofen is given every four hours) have been used. Care should be given to avoid exceeding five doses of acetaminophen or four doses of ibuprofen in a 24-hour period. Caution should be used in alternating antipyretics in infants and children at risk for renal failure, such as those with mild to moderate

4 dehydration. 12 There is a case report of acute renal failure associated with alternating antipyretics in a dehydrated child. The authors hypothesize that the synergistic and additive mechanisms of action and toxicities of acetaminophen and ibuprofen can predispose these individuals to adverse effects. 14 Nonpharmacologic Treatment of Fever In the majority of cases, antipyretics are the most convenient method of reducing fever. However, sponging is a useful alternative to antipyretics in children who are allergic to an antipyretic or if they cannot tolerate it. Additionally, sponging can be used in combination with antipyretics. Common situations when sponging can be considered include: 17 Fever is making the child uncomfortable Temperature is over 104 F (40 C) The child is unable to tolerate oral medications When sponging is used, the child should be put into a tub of one to two inches of tepid water [85 to 90 F (29.4 to 32.2 C)]. Colder water is uncomfortable and can lead to shivering which can further elevate body temperature. The water should be spread over the trunk, arms, and legs, using a sponge or washcloth. Water evaporates from the skin surface and cools the body, usually within thirty to forty-five minutes. The room should be kept warm, about 75 F (23.9 C). Alcohol should not be added to the water since it can be inhaled or absorbed through the skin leading to adverse effects such as coma. 17 Other nonpharmacologic methods which can be utilized in a child with a fever include keeping the child lightly dressed, encouraging extra fluid intake, and avoiding overexertion. 17 Preventing Overdoses of Antipyretics Overdoses of antipyretics can occur for a variety of reasons. Some overdoses occur in children whose caregivers feel that if some is good, more is better. Some caregivers administer extra doses or higher doses than recommended if the fever is not reduced as expected. Parents should understand that temperature normalization is not the goal, but rather patient comfort. Another reason for unintentional overdose is giving the wrong formulation. For example, concentrated infant drops (80 mg/0.8 ml) are (Detail-Document #220409: Page 4 of 5) used instead of children s suspension (160 mg/5 ml), or an adult strength tablet (325 mg) is used instead of children s chewable (80 mg) or junior strength tablet (160 mg). Caregivers should understand the differences between the products and the importance of using a calibrated measuring device to administer liquid medications. Finally, many combination products contain an antipyretic. If a child is getting multiple medications for a variety of symptoms, caregivers may unknowingly give more doses of an antipyretic than recommended. Caregivers should be warned that many preparations contain an antipyretic and that simultaneous use can be dangerous. They should be instructed to read the entire label of any over-the-counter product, especially those recommended for cough, fever, or headaches or other painful conditions. If their child is receiving an antipyretic and they are concerned about duplication of therapy, they should ask the pharmacist before purchasing or administering any over-the-counter product. Users of this document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and Internet links in this article were current as of the date of publication. Project Leader in preparation of this Detail- Document: Neeta Bahal O Mara, Pharm.D., BCPS References 1. Plaisance KI, Mackowiak PA. Antipyretic therapy: physiologic rationale, diagnostic implications, and clinical consequences. Arch Intern Med 2000;160: Mackowiak PA. Concepts of fever. Arch Intern Med 1998;158: Offringa M, Moyer VA. Evidence based management of seizures associated with fever. BMJ 2001;323: American Academy of Pediatrics. Committee on Quality Improvement, Subcommittee on Febrile Seizures. Practice parameter: long-term treatment of the child with simple febrile seizures. Pediatrics 1999;103: El-Radhi AS, Barry W. Do antipyretics prevent febrile convulsions? Arch Dis Child 2003;88:

5 (Detail-Document #220409: Page 5 of 5) 6. Crocetti M, Moghbeli N, Serwint J. Fever phobia revisited: have parental misconceptions about fever changed in 20 years? Pediatrics 2001;107: Treluyer JM, Tonnelier S, d Athis P, et al. Antipyretic efficacy of an initial 30-mg/kg loading dose of acetaminophen versus a 15-mg/kg maintenance dose. Pediatrics 2001; /4/e73. (Accessed March 8, 2006). 8. Lesko SM, Mitchell AA. The safety of acetaminophen and ibuprofen among children younger than two years old. Pediatrics 1999;104,e39. (Accessed March 8, 2006). 9. Bell EA. Pediatric Ambulatory Care. In: Schumock G, Brundage D, Chapman M, et al. eds. Pharmacotherapy Self-Assessment Program, 5th ed. Pediatrics. Kansas City, MO: American College of Clinical Pharmacy, 2006: Perrott DA, Piira T, Goodenough B, Champion GD. Efficacy and safety of acetaminophen vs ibuprofen for treating children s pain or fever. Arch Pediatr Adolesc Med 2004;158: Goldman RD, Ko K, Linett LJ, Scolnik D. Antipyretic efficacy and safety of ibuprofen and acetaminophen in children. Ann Pharmacother 2004;38: American Academy of Pediatrics. Committee on Drugs. Acetaminophen toxicity in children. Pediatrics 2001;108: Mayoral CE, Marino RV, Rosenfeld W, Greensher J. Alternating antipyretics: is this an alternative? Pediatrics 2000;105: DelVecchio MT, Sundel ER. Alternating antipyretics: is this an alternative? Pediatrics 2001;108: (letter to the editor) 15. Sarrell EM, Wielunsky E, Cohen HA. Antipyretic treatment on young children with fever: acetaminophen, ibuprofen, or both alternating in a randomized, double-blind study. Arch Pediatr Adolesc Med 2006;160: Nabulsi M, Tamim H, Mahfoud Z, et al. Alternating ibuprofen and acetaminophen in the treatment of febrile children: a pilot study [ISRCTN ]. BMC Med 2006;4:4. [Epub ahead of print] doi: / (Accessed March 9, 2006). 17. American Academy of Pediatrics. Fever Making your child comfortable. ub_cat=1. (Accessed March 8, 2006). Cite this Detail-Document as follows: Antipyretics and fever in children. Pharmacist s Letter/Prescriber s Letter 2006;22(4): Evidence and Advice You Can Trust 3120 West March Lane, P.O. Box 8190, Stockton, CA ~ TEL (209) ~ FAX (209) Subscribers to Pharmacist s Letter and Prescriber s Letter can get Detail-Documents, like this one, on any topic covered in any issue by going to or