Alternating antipyretics for fever reduction in children: an unfounded practice passed down to parents from pediatricians

A convenience sample of parents/caregivers completed a 10-question survey on their patterns of antipyretic therapy administration to determine if antipyretics were alternated, how often, who advised them to do this, and how they learned to dose the antipyretic. Of the 256 caregivers (93%) who completed the survey, 67% responded that they alternated acetaminophen and/or ibuprofen. The frequency varied: every 2 hours (9%), every 3 hours (16%), every 4 hours (43%), every 6 hours (23%) and other (8%). Of these, 81% stated that their health care provider/pediatrician advised them to alternate acetaminophen and/or ibuprofen; 8% stated that nobody advised them. Only 61% received written instructions on how to dose antipyretics from their health care provider. Most caregivers of young children reported alternating acetaminophen and ibuprofen for fever reduction in their children. There was a wide variability of the dosing interval. Most learned this practice from their pediatrician/health care provider.     

Acetaminophen and ibuprofen dosing by parents

BACKGROUND: Acetaminophen and ibuprofen are two of the most commonly used medications in children. It is our experience that parents often misdose these medications. Misdosing may lead to unintended toxicity or inadequate symptomatic improvement. There are limited data on the extent of misdosing of these antipyretics. We sought to determine the prevalence of and risk factors for inaccurate dosing by parents seeking care for their children in the emergency department (ED). METHODS: A cross-sectional observational study was performed in an urban academic pediatric ED. Two hundred patients 10 years of age and younger who were given a known dose of acetaminophen or ibuprofen in the 24 hours prior to the ED visit were enrolled. The treating physician completed a questionnaire for each patient. Caregivers were asked about quantity and frequency of antipyretic use prior to the ED visit, the source of information used to determine dosage, and which factor (eg, age, sex, height, weight, height of fever, severity of illness) they considered most important in determining the correct dosage of medication. Doses of 10 to 15 mg/kg for acetaminophen and 5 to 10 mg/kg for ibuprofen were considered accurate. RESULTS: Overall, 51% of patients received an inaccurate dose of medication, including 62% of patients given acetaminophen and 26% of patients given ibuprofen. Infants < 1 year old were more likely to receive an inaccurate dose (RR 1.40, P < 0.04, 95% CI = 1.06-1.86). Caregivers who stated that medication dosage was based on weight were less likely to give an inaccurate dose of medication (RR 0.71, P < 0.03, 95% CI = 0.52-0.97). CONCLUSIONS: Over half of the caregivers surveyed gave an inaccurate dose of acetaminophen or ibuprofen, particularly to infants. Caregivers who reported that antipyretic dosage was based on weight were less likely to misdose medication, suggesting a valuable role for patient education.     

Relationship of bacteremia to antipyretic therapy in febrile children

We undertook a prospective study of children from three to 24 months of age with rectal temperatures of greater than or equal to 40.0 degrees C (104.0 degrees F) to determine if children whose fevers fail to respond to antipyretic therapy are more likely to be bacteremic than children whose fevers are lowered by antipyretic measures. Children from two clinical settings were studied: primarily black lower-class children at an inner-city hospital (n = 188) and primarily white middle-class children at a suburban hospital (n = 45). We found an overall prevalence of bacteremia of 7.3%, which was not statistically different between two hospitals. A response to antipyretic therapy, defined as a decrease in temperature of at least 1 degrees C, was seen in 83.7% of children. Children who did not respond to antipyretics had no more increased prevalence of bacteremia than did responders. We conclude that lack of fever response to antipyretics is not a clinical marker for bacteremia in children.     

Familial use of ibuprofen in febrile children: a prospective study in the emergency room of an hospital in Lille]

AIM OF THE STUDY: To assess the place of ibuprofen in the treatment of fever in children. PATIENTS AND METHODS: An anonymous self-questionnaire was submitted to the parents of 156 children aged less than 15 years and 3 months consulting for a fever in a pediatric emergency care unit. Questions related antipyretic drugs availability at home and their administration modality to the febrile child. RESULTS: Acetaminophen (liquid or rectal) was the first drug owned by families (N = 149, 96%). Ibuprofen was owned by 79 families (51%). The antipyretic drug administered as a first intention treatment was acetaminophen in 131 children (77%), ibuprofen in 27 (17%) and aspirin in 6 children (4%). An antipyretic bi-therapy was received by 58 children (35%), nearly always acetaminophen and ibuprofen (N = 48, 87%). The use of a bi-therapy was more frequent when ibuprofen was the first drug used. Children who received an antipyretic bi-therapy as compared to those who received a monotherapy exhibited significantly a higher fever level and long lasting fever period. Antipyretic drugs given to the sick children were prescribed by a physician in more than 90% of cases. CONCLUSION: Ibuprofen was largely used in febrile children. This drug has almost always been prescribed by a physician. However, due to its side effects, ibuprofen should be used only in high and badly tolerated fever that is not altered by a well conducted acetaminophen monotherapy.     

Fever management: Evidence vs current practice

Fever is a very common complaint in children and is the single most common non-trauma-related reason for a visit to the emergency department. Parents are concerned about fever and it’s potential complications. The biological value of fever (i.e., whether it is beneficial or harmful) is disputed and it is being vigorously treated with the belief of preventing complications such as brain injury and febrile seizures. The practice of alternating antipyretics has become widespread at home and on paediatric wards without supporting scientific evidence. There is still a significant contrast between the current concept and practice, and the scientific evidence. Why is that the case in such a common complaint like fever The article will discuss the significant contrast between the current concepts and practice of fever management on one hand, and the scientific evidence against such concepts and practice.     

Antipyretics and delirious behavior during febrile illness

BACKGROUND: The purpose of the present paper was to study the use of antipyretics in children with delirium associated with fever in order to clarify their possible adverse effects. METHODS: The use of antipyretics was investigated in 26 children with delirious behavior associated with fever. Temporal relation between delirious behavior and the use of antipyretics was recognized in six children. RESULTS: In four children, delirious behavior was observed soon after administration of antipyretics. The antipyretics used were acetaminophen in two children, mephenamate in one, and diclofenac in one. In the other two children, delirious behavior was observed when body temperature began to fall 1-2 h after administration of antipyretics. The antipyretics used were acetaminophen in one child and mephenamate in one. CONCLUSION: A temporal relationship between antipyretics and delirious behavior was observed in some patients with febrile delirium. This suggests that antipyretics can be a trigger of delirium.     

Antipyretic treatment in young children with fever: acetaminophen, ibuprofen, or both alternating in a randomized, double-blind study

OBJECTIVE: To compare the antipyretic benefit of acetaminophen or ibuprofen monotherapy with an alternating regimen of both drugs in young children aged 6 to 36 months. DESIGN: Randomized, double-blind, parallel-group trial. SETTING: Three primary pediatric community ambulatory centers in central Israel. PARTICIPANTS: A total of 464 children aged 6 to 36 months with fever. INTERVENTION: Infants were assigned to receive either acetaminophen (12.5 mg/kg per dose every 6 hours) (n = 154) or ibuprofen (5 mg/kg per dose every 8 hours) (n = 155) or to receive alternating acetaminophen and ibuprofen (every 4 hours) (n = 155) for 3 days after a loading dose. MAIN OUTCOME MEASURES: Temperature, stress score, amount of antipyretic received, total days that the infant or caregiver was absent from day care or work, respectively, at the 3-day time point, recurrence of fever, and number of emergency department visits. RESULTS: The group given the alternating regimen was characterized by a lower mean temperature, more rapid reduction of fever, receiving less antipyretic medication, less stress, and less absenteeism from day care as compared with the other groups; all of the differences were statistically significant (P< .001). None of the regimens were associated with a significantly higher number of emergency department visits (P = .65) or serious long-term complications (P = .66). The drug used for initial loading had no effect on outcome in any of the groups. CONCLUSIONS: An alternating treatment regimen of acetaminophen (12.5 mg/kg per dose) and ibuprofen (5 mg/kg per dose) every 4 hours for 3 days, regardless of the initial loading medication, is more effective than monotherapy in lowering fever in infants and children.     

Fever education: does it reduce parent fever anxiety?

OBJECTIVE: The aims of the study were to determine the following: 1) if a fever education program (interactive or written) reduces parent fever anxiety; 2) if an interactive fever program was more effective as a teaching style than standard written material alone; and 3) if a fever program increases parent fever home management and reduces return emergency department (ED) visits. METHOD: A quasiexperimental, pretest and post-test pilot study examining parental fever anxiety was conducted at The Children's Hospital of Philadelphia. Eligible participants consisted of 87 parents and their children, aged 3 months to 5 years presenting with fever >38.4 degrees C, and without coexisting serious illness. RESULTS: Both the interactive fever education program and the standard written fever pamphlet were equally effective as teaching methods. Data revealed a 30% reduction in fever anxiety rated as moderate-severe on arrival to none-low post-fever education, increased parent fever home management skills with correct use of thermometer and antipyretics, and reduced unnecessary return ED visits. CONCLUSION: Parents in the acute and nonacute care setting may benefit from an interactive fever education program that includes the definition and benefit of fever, the correct use of a thermometer, fever home management skills, and appropriate fever telephone follow-up.     

Double blind comparison of ibuprofen and paracetamol for adjunctive treatment of uncomplicated typhoid fever

BACKGROUND: Antipyretics reduce the prolonged, high fever characteristic of typhoid fever. The benefits of nonsteroidal drugs in this role have not been quantified. There have been concerns about the safety of antipyretics in typhoid. METHODS: In a double blind randomized study, 80 Vietnamese children with uncomplicated typhoid fever were randomized to receive identical syrup preparations of ibuprofen (10 mg/kg) or paracetamol (12 mg/kg) every 6 h until 36 h after defervescence. Children with a nalidixic acid-susceptible (Na) isolate of Salmonella typhi were treated with ofloxacin (15 mg/kg/day) for 3 days and those with a nalidixic acid-resistant (Na) isolate were treated for 7 days. RESULTS: S. typhi was isolated from 36 of 40 children randomized to ibuprofen (11 isolates Na) and 37 of 40 randomized to paracetamol (13 isolates Na). The median (range) fever clearance time (hours) was shorter in the ibuprofen group than the paracetamol group (68, 4 to 260 vs. 104, 12 to 404; P = 0.055) as was the area under the temperature time curve above 37 degree C (74, 0 to 237 vs. 127, 0 to 573; P = 0.013). The differences occurred predominantly in the children infected with a NaS. typhi whose infections responded more slowly to antibiotic treatment. There were no major side effects associated with the use of either drug. There were no differences between the two treatment arms in the concentrations of circulating interleukin-6 and tumor necrosis factor alpha during the course of treatment. CONCLUSION: The antipyretic effect of ibuprofen is superior to that of paracetamol in children with typhoid fever, particularly those with prolonged fever. Both antipyretics appeared to be safe.     

Ability of mothers to subjectively assess the presence of fever in their children

We assessed the ability of mothers to subjectively determine the presence or absence of fever in their children when compared with simultaneous temperature determination obtained by thermometer. Mothers who said their children were febrile were correct 52.3% of the time; those who said their children were afebrile were correct 93.9% of the time. The sensitivity was 73.9% of the specificity was 85.6%. Ninety percent of children aged 2 years or younger with temperatures of 38.9 degrees C or higher were correctly identified as febrile. Administration of antipyretics to both febrile and afebrile children was greater among those whose temperature was determined at home by thermometer than among those whose temperature was determined by subjective criteria. We conclude that maternal subjective fever assessment criteria are useful as a screening method to rule out the presence of fever at all ages and that mothers can identify high fevers in most young children without the use of a thermometer.     

Effect of recent antipyretic use on measured fever in the pediatric emergency department

OBJECTIVES: To determine the prevalence of recent antipyretic use among febrile infants at a pediatric emergency department (ED) and to test the hypothesis that recent antipyretic use is associated with lower measured temperatures in the ED. METHODS: We prospectively enrolled infants younger than 366 days at a pediatric ED. Eligible subjects had a history of fever prior to arrival at the ED or had a measured temperature of 38 degrees C or higher at the ED. Research assistants collected detailed information about recent use of antipyretic drugs. Peak measured temperature prior to arrival at the ED (temperature maximum [Tmax]), measured temperature at the ED, defervescence from Tmax to measured ED temperature, and rates of diagnostic testing were compared between subjects who had or had not been treated with antipyretic medication within the past 6 hours. RESULTS: We enrolled 474 infants. Infants treated with an antipyretic medication (n = 187) had a significantly higher Tmax and a significantly higher measured ED temperature than untreated subjects (n = 287) (P<.001). Treated and untreated subjects did not differ in the amount of defervescence from Tmax to measured ED temperature (P = .41) unless treated subjects included only those who reportedly received therapeutic doses of antipyretic medication within 1 to 5 hours prior to arrival at the ED (P = .02). CONCLUSIONS: Although many febrile infants seen in the pediatric ED have recently received antipyretics, only a few have received a therapeutic dose between 1 and 5 hours prior to arrival. Among febrile infants seen in the ED, recent antipyretic use is associated both with a higher reported Tmax and with higher measured temperatures at the ED. Patients treated with a therapeutic antipyretic dose 1 to 5 hours prior to arrival experience more defervescence from their Tmax than untreated subjects.     

Burden of influenza in healthy children and their households

Objective: A prospective, multicentre study was conducted to evaluate the burden of laboratory confirmed influenza in healthy children and their household contacts. Methods: The patients were enrolled in four emergency departments (EDs) and by five primary care paediatricians (PCPs) in different Italian municipalities 2 days a week between November 1, 2001 and April 30, 2002. The study involved 3771 children less than 14 years of age with no chronic medical conditions who presented with a respiratory tract infection in EDs or PCP outpatient clinics during the study period. Nasopharyngeal swabs were collected for the isolation of influenza viruses and RNA detection. Information was also collected concerning respiratory illnesses and related morbidities among the study children and their household contacts. Results: Influenza virus was demonstrated in 352 cases (9.3%). In comparison with the influenza negative children, those who were influenza positive had an older mean age, were more often attending day care centres or schools, more frequently experienced fever and croup, received more antipyretics, and had a longer duration of fever and school absence. Furthermore, their parents and siblings had more respiratory illnesses, received more antipyretics and antibiotics, needed more medical visits, missed more work or school days, and needed help at home to care for the ill children for a longer period of time. Conclusions: Influenza has a significant clinical and socioeconomic impact on healthy children and their families. Prevention strategies should also focus on healthy children regardless of their age because of their role in disease transmission.     

Burden of influenza in healthy children and their households.

OBJECTIVE: A prospective, multicentre study was conducted to evaluate the burden of laboratory confirmed influenza in healthy children and their household contacts. METHODS: The patients were enrolled in four emergency departments (EDs) and by five primary care paediatricians (PCPs) in different Italian municipalities 2 days a week between November 1, 2001 and April 30, 2002. The study involved 3771 children less than 14 years of age with no chronic medical conditions who presented with a respiratory tract infection in EDs or PCP outpatient clinics during the study period. Nasopharyngeal swabs were collected for the isolation of influenza viruses and RNA detection. Information was also collected concerning respiratory illnesses and related morbidities among the study children and their household contacts. RESULTS: Influenza virus was demonstrated in 352 cases (9.3%). In comparison with the influenza negative children, those who were influenza positive had an older mean age, were more often attending day care centres or schools, more frequently experienced fever and croup, received more antipyretics, and had a longer duration of fever and school absence. Furthermore, their parents and siblings had more respiratory illnesses, received more antipyretics and antibiotics, needed more medical visits, missed more work or school days, and needed help at home to care for the ill children for a longer period of time. CONCLUSIONS: Influenza has a significant clinical and socioeconomic impact on healthy children and their families. Prevention strategies should also focus on healthy children regardless of their age because of their role in disease transmission.     

Efficacy and safety of acetaminophen vs ibuprofen for treating children's pain or fever: a meta-analysis

OBJECTIVE: To summarize studies testing the efficacy and safety of single-dose acetaminophen and ibuprofen for treating children's pain or fever. DATA SOURCES: Reports were gathered by searching computerized databases (from their inception through May 2002) and registries, relevant journals, and bibliographies of key articles. STUDY SELECTION: Seventeen blinded, randomized controlled trials with children (<18 years) receiving either drug to treat fever or moderate to severe pain. DATA EXTRACTION: Under a fixed-effects model, outcome measures for an initial single dose of ibuprofen vs acetaminophen were the risk ratio for achieving more than 50% of maximum pain relief, effect size for febrile temperature reduction, and risk ratio for minor and major harm. DATA SYNTHESIS: Ibuprofen (4-10 mg/kg) and acetaminophen (7-15 mg/kg) showed comparable efficacy (3 pain relief trials; 186 children). The risk ratio point estimates was 1.14 (95%confidence interval [CI], 0.82-1.58) at 2 hours after receiving the dose, and 1.11 (95% CI, 0.89-1.38) at 4 hours. Ibuprofen (5-10 mg/kg) reduced temperature more than acetaminophen (10-15 mg/kg) at 2, 4, and 6 hours after treatment (respective weighted-effect sizes: 0.19 [95% CI, 0.05-0.33], 0.31 [95% CI, 0.19-0.44], and 0.33 [95% CI, 0.19-0.47]) (9 fever trials; 1078 children). For ibuprofen 10 mg/kg (acetaminophen, 10-15 mg/kg), corresponding effect sizes were 0.34 (95% CI, 0.12-0.56), 0.81 (95% CI, 0.56-1.03), and 0.66 (95% CI, 0.44-0.87). There was no evidence the drugs differed from each other (or placebo) in incidence of minor or major harm (17 safety trials; 1820 children). CONCLUSIONS: In children, single doses of ibuprofen (4-10 mg/kg) and acetaminophen (7-15 mg/kg) have similar efficacy for relieving moderate to severe pain, and similar safety as analgesics or antipyretics. Ibuprofen (5-10 mg/kg) was a more effective antipyretic than acetaminophen (10-15 mg/kg) at 2, 4, and 6 hours posttreatment.     

Mothers' perceptions of fever in children

The fever is one of the commonest symptoms of disease in childhood. A mother's knowledge and conception of fever may determine the degree of her anxiety and fear, and reflect on the way the fever is managed at home. Our understanding of mothers' attitudes may help to improve the home management of fever by correcting unrealistic beliefs. Mothers of 100 children were randomly selected and interviewed to answer a questionnaire about fever. Sixty mothers thought that fever could lead to death, others thought that it might lead to paralysis, mental retardation or brain damage. This may explain their undue anxiety and fear when having a child with fever. Cold exposure, teething, exposure to sunlight and having a warm drink were considered as causes. A minority reduced the child's clothes during fever. Tap water sprinkling and occasionally alcohol were used. Ninety-four mothers used antipyretics, all used paracetamol and 23 per cent used aspirin. Sixty two used antibiotics indiscriminately. Improved health education is required to allay mothers fear and anxiety and promote a more appropriate fever management at home.     

The association of overweight and ankle injuries in children.

OBJECTIVES: Overweight children are at increased risk for many medical problems. Trauma is the leading etiology of childhood morbidity and mortality. No previous study has evaluated the association between overweight and acute ankle injuries in children. We hypothesized that being overweight is associated with an increased risk of ankle injury in children. METHODS: We conducted a case-control study in an urban pediatric emergency department. Subjects aged 5 to 19 years were recruited from June 2005 through July 2006. Children with acute ankle trauma were enrolled as cases. A convenience sample of children with a chief complaint of fever, headache, or sore throat was enrolled as controls. Demographic information and anthropometric measurements were obtained. Age- and gender-specific body mass index percentiles (BMI-Ps) were calculated using pediatric norms. Multivariate unconditional logistic regression was used to assess the relationship between overweight and ankle injury, adjusting for demographic variables. Through medical records, we obtained demographic information and weight, but not height, of all cases that were not enrolled. This allowed us to conduct a sensitivity analysis in which we combined the enrolled and nonenrolled cases into a single case group and made increasingly more unlikely assumptions about the height percentiles of the nonenrolled cases. RESULTS: One hundred eighty cases and 180 controls were enrolled in the study. We observed a significant association between overweight and ankle injury (multivariate-adjusted odds ratio 3.26, 95% confidence interval, 1.86-5.72; P value for trend <.0001). Although this result may be an overestimate of the magnitude of the association due to a possible bias in the selection of cases, sensitivity analysis demonstrated the robustness of the statistical significance of the finding. CONCLUSIONS: Overweight children may be at increased risk of ankle injury.