Paediatric medicine - Management of fever in children

By Dr Sara Whitburn and Dr Alastair Hay, 05 March 2009

Which medication should be used to treat fever in a child? By Dr Sara Whitburn and Dr Alastair Hay

Taking a temperature: fever in children can be distressing for parents (SPL)

Taking a temperature: fever in children can be distressing for parents (SPL)

Fever is one of the most common primary care presentations in pre-school children. It can also be one of the most challenging consultations as it raises concerns for parents and clinicians.

These concerns can be due to diagnostic uncertainty, but also due to the debate about the role of fever in illness and the best approach to treatment.

Advantages of treatment are improving the child's symptoms and decreasing discomfort. A potential disadvantage is the suppression of the immunological response to illness which may have a role in protection against future disease.

Positive effects of fever
One review discussed the evidence for positive effects of fever in children.1 The author reviewed two studies. The first looked at the presence of fever and the duration of faecal Salmonella in 102 children with Salmonella gastroenteritis.2

The investigators found that children who had a fever at any time of admission greater than 40 degsC had a shorter duration of faecal Salmonella excretion by a mean of seven weeks.

The second study reviewed assessed 835 children to see if there was a link with fever in the first year of life and subsequent positive allergy testing between six and seven years of age.3

The investigators found that children who had a fever before they were one year old were less likely to demonstrate allergic sensitivity by skin prick and serology tests or to have atopic asthma or wheeze.

Fever clearance
Other studies have found that treating fever may prolong illness. One trial investigated parasite clearance in children with malaria who were treated with paracetamol. Fever clearance decreased from 43 to 32 hours while parasite clearance took 11 hours longer in the paracetamol-treated children.4

In a trial investigating paracetamol in 72 children with chickenpox, the time to total scabbing was 6.7 days in the paracetamol group and 5.6 days in the placebo group.5

Unfortunately, the pathophysiological processes by which these effects are mediated are not clear, which makes it difficult to assess the clinical significance of these studies.

Traffic light system
Parents and clinicians may be concerned that fever is a sign of serious illness. The incidence of serious bacterial illness in a febrile child is small and decreasing, but is obviously important not to miss.

The NICE guidelines use a traffic light system to provide guidance on triaging and treating febrile illness. Its strength is that it provides systematic guidance for the assessment and management of feverish children to a range of healthcare providers with different levels of paediatric experience.

However, the guidelines have also been criticised for being over-reliant on vital signs and that several characteristics in the 'amber' section may be considered more significant in primary than in secondary care.

Antipyretic medication
Options for treating fever include physical methods and antipyretics. Examples of physical methods are undressing, fanning or tepid sponging.

A systematic review found that sponging had no significant benefit over antipyretics but adverse effects included crying and shivering. NICE guidelines recommend avoiding tepid sponging and underdressing.

The antipyretic medications paracetamol and ibuprofen have been found to be effective at lowering temperature. Ibuprofen was found to be superior to paracetamol for relief of fever.

They are often used together by practitioners and parents, either in combination or as an alternating dose. Several studies have compared ibuprofen and paracetamol in combination.

However, the studies had limitations which prevented clear conclusions from being drawn. This led to the NICE guidelines concluding that there is insufficient evidence supporting the use of combined medicines and to recommend using monotherapy only.

The Paracetamol plus Ibuprofen for the Treatment of fever in Children (PITCH) randomised, controlled trial investigated whether paracetamol and ibuprofen were superior to either medicine alone.6

The study found that in the four hours after dosing, ibuprofen reduced a child's temperature faster and for longer than paracetamol and was similar to both medicines combined. Over the first 24 hours, children given both medicines spent 4.4 and 2.5 more hours without fever compared with those given paracetamol and ibuprofen respectively.

The authors of PITCH concluded that parents and professionals wishing to treat fever should use ibuprofen first and then consider the relative benefits and risks of using both medicines over a 24-hour period.

An economic evaluation did not find any evidence to contradict the clinical findings.

Risks of using antipyretics
In most children, paracetamol and ibuprofen are unlikely to cause harm when used for short periods at the correct dose. However, paracetamol and ibuprofen can have adverse effects.

Regarding asthma, one large study found no evidence of increased hospital admissions or outpatient attendances for children with asthma in those treated with ibuprofen compared with paracetamol.7

Ibuprofen should not be used in children with dehydration as there have been reports of renal failure following NSAID use.

A more widespread issue is accidentally exceeding the maximum recommended dose of paracetamol or ibuprofen. Brand names can cause confusion about type and amount of medication being given.

We recommend that if two medicines are to be used, parents carefully record when and which medicines were given.

Recommendations
Fever is a natural part of a child's immunological response. In time we may better understand its benefits.

In order to manage the discomfort and concern associated with fever, treatment with antipyretics may be warranted.

We suggest that the following principles: first, children should be treated with the minimum number of medications and doses possible to provide symptomatic relief. If the symptoms are mild then paracetamol should be considered first as it has fewer noted adverse effects.

However, if symptoms are not settling after paracetamol or the illness is more severe then ibuprofen is more effective than paracetamol. If symptoms continue and further treatment is needed over 24 hours, then the benefits and risks of using both drugs should be considered.

If both medicines are used, then parents should be advised to keep a careful record of dosing to avoid exceeding the maximum recommended dose.

  • Dr Whitburn is an academic GP registrar and Dr Hay is a GP and consultant senior lecturer, University of Bristol.

References

1. El-Radhi A S M. Why is the evidence not affecting the practice of fever management? Arch Dis Child 2008; 93: 918-20.

2. El-Radhi A S, Rostila T, Vesikari T. Association of high fever and short bacterial excretion after salmonellosis. Arch Dis Child 1992; 67(4): 531-32.

3. Williams L K, Peterson E L, Ownby D R, Johnson C C. The relationship between early fever and allergic sensitization at age 6 to 7 years. J Allergy Clin Immunol 2004; 113(2): 291-6.

4. Brandts C H, Ndjave M, Graninger W, Kremsner P G. Effect of paracetamol on parasite clearance time in Plasmodium falciparum malaria. Lancet 1997; 350(9079): 704-9.

5. Doran T F, De A C, Baumgardner R A, Mellits E D. Acetaminophen: more harm than good for chickenpox? J Pediatr 1989; 114(6): 1045-8.

6. Hay A D, Costelloe C, Redmond N M, et al. Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial. BMJ 2008; 337: a1302.

7. Lesko S M, Louik C, Vezina R M, Mitchell A A. Asthma morbidity after the short-term use of ibuprofen in children. Pediatrics 2002; 109(2): E20.

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