Treatment of fever in childhood

[Septic shock secondary to non-congenital chikungunya fever in a young infant: A clinical case]

INTRODUCTION

A chikungunya outbreak took place in the State of Yucatan starting in the second half of 2015 OBJECTIVE: To analyse the clinical course of a case of chikungunya in a previously healthy infant, providing practical evidence to guide future diagnoses and treatment during outbreak seasons in endemic areas

CASE REPORT

Clinical manifestation started with a sudden onset of fever and a diffuse macular-papillary erythema, originally treated in the community with non-steroidal anti-inflammatory drugs. Two days later, the fever relapsed with hypoactivity, severe thrombocytopenia and neutropenia (without lymphopenia), respiratory distress, liver dysfunction, sepsis, followed by septic shock with a fatal outcome. IgM test was positive to chikungunya, while her mother tested negative. Pseudomonas aeruginosa was isolated from the blood culture possible due to contamination, without ruling out the possibility of a mixed origin sepsis.

CONCLUSIONS

Chikungunya is a disease in which the manifestations in neonates and young infants can be severe, and even fatal. It is important to suspect it in this age group at risk of vector contact, in the presence of fever without apparent source of infection and cutaneous manifestations. It is important to use the antipyretics cautiously, considering the possibility of aggravating the underlying infection, and the potential hepatic and haematological damage.

Beliefs and practices regarding childhood fever among parents: a cross-sectional study from Palestine

BACKGROUND

Fever is an extremely common occurrence in paediatric patients and the most common cause for a child to be taken to the doctor. The literature indicates that parents have too many misconceptions and conflicting information about fever management. The aim of this study was to identify parents' beliefs and practices regarding childhood fever management.

METHODS

We conducted a cross-sectional survey among parents whose children were enrolled and presented for health care at primary health care clinics in the Nablus region of Palestine. Data were collected using structured questionnaire interviews with parents. The questionnaire consisted of 'yes/no' responses and multiple-response questions. Descriptive statistics were used.

RESULTS

Overall, 402 parents were interviewed. All parents believed that fever could cause at least one harmful effect if left untreated. The harmful effects most frequently reported by parents were brain damage (38.1%), dehydration (15.7%), and other organs damage such as liver and kidney damage (14.2%). The study showed that 65.4% of parents would recognise fever by only touching the child, 31.6% would measure the temperature and 3.0% would assess temperature by touching and measuring the child. Antipyretic was preferred to be used by 34.8% of parents, while 49.8% stated that they preferred cold sponges, and 3.2% stated that they preferred homeopathic methods to treat fever. The most common factors influencing frequency of medication administration included physician's instruction (61.7%), the degree of elevated temperature (14.9%) and instructions on the medication leaflet (13.7%). Of the participant parents, 53.2% believed antipyretics used to reduce fever were harmful. Parents reported the most harmful outcomes from these antipyretics to be allergic reactions (20.9%), effects on the stomach (16.9%), kidney damage (16.2%) and overdose (11.4%).

CONCLUSIONS

Parents were anxious when dealing with a feverish child, which resulted in incorrect or inappropriate practices. Parents require reliable evidence-based information about the care of feverish children. These results indicate a need to develop and evaluate educational programs in our setting that will provide parents with education on fever and fever management.

Intramuscular Dipyrone versus Oral Ibuprofen or Nimesulide for Reduction of Fever in the Outpatient Setting

OBJECTIVE

To compare the effectiveness and rate of temperature reduction of three antipyretic medications in febrile children.

DESIGN

A single-dose, randomised, prospective, modified double-blind, parallel clinical trial.

SETTING

The paediatric emergency department of a university hospital that has 13 000 annual visits.

STUDY PARTICIPANTS

252 otherwise healthy children aged 6 months to 14 years with acute, intercurrent, febrile illness.

INTERVENTIONS

Enrolled children were assigned to receive a single dose of oral ibuprofen 10 mg/kg, oral nimesulide 2.5 mg/kg, or parenteral dipyrone 10 mg/kg.

MAIN OUTCOME MEASURES AND RESULTS

Axillary temperature was measured at the time of antipyretic administration and at 30, 45, 60 and 120 minutes thereafter. All three medications were effective in reducing the axillary temperature during the 2-hour testing period. The rates of axillary temperature change between the three medications were significantly different for the ibuprofen and dipyrone groups (p = 0.023). In addition, the axillary temperature in the dipyrone group was significantly lower than that in the ibuprofen group (p = 0.036) at 120 minutes. There was no significant difference in antipyretic effect between the nimesulide group and the other two groups during the testing period. Within each group the difference between initial temperature and the temperature at the end of the testing period was statistically significant (p = 0.036) for the dipyrone group only.

CONCLUSIONS

All three antipyretic medications were effective in reducing the axillary temperature in febrile children. Although administration of intramuscular dipyrone seemed to be more effective than ibuprofen, this relationship was not significant when nimesulide was considered. In addition, in view of its known side effects and the problems associated with intramuscular administration in children, the preference for orally administered nimesulide or ibuprofen over dipyrone in the setting of the emergency department seems more logical provided that the child accepts oral therapy.

What Greek mothers know about evaluation and treatment of fever in children: an interview study

BACKGROUND

Fever is one of the most common symptoms in childhood. Mothers' insufficient knowledge about its evaluation and treatment frequently leads to excessive fear and anxiety.

OBJECTIVES

To explore mothers' knowledge concerning management of fever in their children, at home.

DESIGN

Descriptive, correlational.

SETTINGS

An emergency department of a pediatric hospital.

PARTICIPANTS

A total of 327 mothers with febrile children randomly selected in the waiting room.

METHODS

Data collection was based on interviews by using a questionnaire which was specifically developed for this study.

RESULTS

Almost one out of three mothers (32.4%) evaluated fever as a temperature between 37-38 degrees C and the 38.1% of them considered that side effects could be a result of these temperatures. The majority of the mothers (73.7%) administered antipyretics at body temperatures of 37-38.5 degrees C, usually without a medical instruction (49.2%). Younger mothers with lower education levels and those who admitted to hospital for the first time with children less than 12 months of age showed the poorest level of Knowledge about fever evaluation and treatment.

CONCLUSIONS

Educational interventions by health care professionals aiming at educating young mothers with a low educational level and those with a child younger than 12 months old who seek medical attention at hospital, for the first time, are needed to dispel misconceptions about fever and to promote the appropriate management of the febrile child.

Prehospital use of paracetamol among children attending the accident and emergency department

OBJECTIVES

To identify patterns of prehospital administration of paracetamol to children who were perceived to be feverish by their carers.

METHODS

A prospective cohort study of carers of children attending a paediatric accident and emergency (A&E) department. Carers of children completed a questionnaire to identify domestic patterns of paracetamol use. Data were collected on temperature of the child in the A&E department, administration of antipyretics in the A&E department, diagnosis, and disposal from the A&E department.

RESULTS

Seventy five adults attending the A&E department consented to involvement. Sixty five of the children were feverish on arrival in the A&E department. Twenty one children (32.3%) had not received paracetamol before attending. There was a significant relation between knowledge of the antipyretic properties of paracetamol and administration (chi(2)=5.0, p<0.05). There was a significant correlation between fever and administration of paracetamol in the A&E department (chi(2)=23.7, p<0.01), however, 15 feverish patients (24.6%) were not treated.

CONCLUSIONS

Most carers administer paracetamol appropriately in the prehospital setting. Administration correlates significantly with knowledge of its benefits. There is scope for education of carers and A&E department staff in the in the appropriate use of antipyretics such as paracetamol.

Symptomatic intravenous antipyretic therapy: efficacy of metamizol, diclofenac, and propacetamol

Fever is a common symptom in cancer patients. The most frequent causes of fever are infections, malignancy itself, various medications, transfusions, and allergy. Although it is necessary to treat the cause of fever, if possible, symptomatic fever management is also important. Surprisingly, little attention is paid to this topic in the medical literature, despite the fact that it is a very frequent problem. In order to support symptomatic fever therapy, we wanted to study the patients' discomfort accompanying fever and the beneficial effects of the symptomatic fever management. To the best of our knowledge, there is an absence of studies in this area, despite the fever discomfort can be an important reason for the antipyretic treatment, mainly in cancer patients. In this non-randomized open label pilot study, three intravenous antipyretics were tested in five groups of patients: diclofenac (75 mg, brief intravenous [IV] infusion) vs. metamizol (2500 mg or 1000 mg, brief IV infusion) vs. propacetamol (2000 mg or 1000 mg, slow IV injection or brief IV infusion). The study included 254 febrile episodes mainly in hemato-oncological patients with axillary temperature at least 38 degrees C. The main study endpoints were: changes in axillary temperature, improvement in patient comfort, and number and nature of adverse events. To support justification for symptomatic fever management in febrile patients, we asked the first 45 study subjects to fill in a questionnaire concerning their opinions about fever, fever-associated discomfort, and relief upon antipyretic therapy. All study medications had a significant antipyretic effect. However, metamizol at the dose 2500 mg was considered as the most effective, while propacetamol at the dose 1000 mg showed the lowest antipyretic efficacy. Concerning tolerability and adverse events, there were significant differences among the treatment groups. Diclofenac and metamizol (both 2500 mg and 1000 mg) were tolerated at best. All tested antipyretics significantly improved comfort in febrile patients. Overall, 87% of patients declared improvement in their comfort after administration of antipyretics. Based on the results of the present study, the choice of the antipyretic drug should depend on the clinical status of patient, contraindications, and potential adverse events and risks of the selected agent. It is advisable to use proparacetamol at the higher dosage and to administer it as a brief IV infusion in order to avoid injection-related adverse events. The symptomatic antipyretic treatment in febrile cancer patients is supported by patients themselves and has a significant role in the complex supportive care. Discomfort of patients during fever episodes may be greater than previously thought.

Hypothermic and antipyretic effects of 3-methyl- and 3-phenyl-5-hydroxy-5-trichloromethyl-4,5-dihydro-1H-pyrazole-1-carboxyamides in mice

The effect of novel pyrazolines, 3-methyl-5-hydroxy-5-trichloromethyl-4,5-dihydro-1H-pyrazole-1-carboxyamide (MPCA) and 3-phenyl-5-hydroxy-5-trichloromethyl-4,5-dihydro-1H-pyrazole-1-carboxyamide (PPCA) on body temperature and endotoxin-induced fever was investigated in mice. The subcutaneous (s.c.) administration of 1.5 mmol/kg dipyrone, MPCA or PPCA and the intracerebroventricular (i.c.v.) administration of 225 nmol dipyrone reduced basal rectal temperature. Intracerebroventricular administration of 225 nmol MPCA or PPCA did not alter basal rectal temperature. The administration of 0.15 mmol/kg (s.c.) or 25 nmol (5 microl) dipyrone (i.c.v.), MPCA or PPCA had no effect on basal rectal temperature, but reversed lipopolysaccharide-induced fever. These results suggest that MPCA and PPCA cause antipyresis, which is similar to that caused by dipyrone, and may be useful antipyretic agents.

Paracetamol for treating fever in children

BACKGROUND

Paracetamol (acetaminophen) is widely used for treating fever in children. Like ibuprofen, aspirin, and physical methods (such as fanning), paracetamol aims to provide relief from symptoms and prevent febrile convulsions. Uncertainty exists about the benefits of using it to treat fever in children.

OBJECTIVES

To assess the effects of paracetamol for treating fever in children in relation to fever clearance time, febrile convulsions, and resolution of associated symptoms.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group specialized trials register (November 2001), The Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2001), MEDLINE (1966 to November 2001), EMBASE (1988 to November 2001), LILACS (2001, 40a Edition CD-ROM), Science Citation Index (November 2001), and reference lists of articles. We also contacted researchers in the field.

SELECTION CRITERIA

Randomized and quasi-randomized trials of children with fever from infections comparing: (1) paracetamol with placebo or no treatment; and (2) paracetamol with physical cooling methods (eg, sponging, bathing, or fanning). The primary outcomes were fever clearance time and febrile convulsion.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data on methods, types of participants, interventions, and outcomes. The meta-analysis was conducted using Relative Risk with 95% confidence intervals for discrete variables, and weighted mean differences for continuous outcomes.

MAIN RESULTS

12 trials (n = 1509 participants) met the inclusion criteria. Outcomes varied between trials. No data were available on the primary outcome. There is insufficient evidence to show whether paracetamol influenced the risk of febrile convulsions. In a meta-analysis of two trials (n = 120), the proportion of children without fever by the second hour after treatment did not differ significantly between those given paracetamol and those sponged (Relative Risk 1.84; confidence interval 0.94 to 3.61, random effects model). The statistical test showed significant heterogeneity between the groups receiving paracetamol or physical methods. No severe adverse events were reported. The number of children with mild adverse events did not differ significantly between paracetamol and placebo, or paracetamol and physical methods, but numbers were small.

REVIEWER'S CONCLUSIONS

Trial evidence that paracetamol has a superior antipyretic effect than placebo is inconclusive. There is limited evidence that there is no difference between the antipyretic effect of paracetamol and physical methods. Data on adverse events in these trials were limited. Establishing standard outcomes will help comparisons between studies and meta-analysis.

Antipyretic effects of dipyrone versus ibuprofen versus acetaminophen in children: results of a multinational, randomized, modified double-blind study

This study compared the antipyretic effectiveness of acetaminophen, ibuprofen, and dipyrone in young children with fever. The results were based on a modified double-blind, randomized, multinational trial that evaluated 628 febrile children, aged 6 months to 6 years. All three drugs lowered temperature in the 555 patients completing the study. Temperature normalization rates in the ibuprofen and dipyrone groups (78% and 82%, respectively) were significantly higher than the acetaminophen group (68%, P = 0.004). After 4 to 6 hours, mean temperature in the dipyrone group was significantly lower than the other groups, demonstrating longer temperature normalization with dipyrone. All three drugs showed comparable tolerability profiles.

Parental perceptions of fever in children

BACKGROUND

Fever is a common medical problem in children which often prompts parents to seek immediate medical care. The objective of this study was to survey parents about their knowledge and attitude concerning fever in their children.

PATIENTS AND METHODS

The study involved the random selection of Saudi parents who brought their febrile children to the emergency rooms or walk-in clinics of four hospitals in Riyadh. Parents of 560 febrile children were interviewed using a standard questionnaire to obtain sociodemographic information and current knowledge of fever. Approximately 70% of the respondents were female, and the ages of the most were in the range of 20-40 years. More than 80% of the parents had two or more children.

RESULTS

More than 70% of parents demonstrated a poor understanding of the definition of fever, high fever, maximum temperature of untreated fever, and threshold temperature warranting antipyresis. About 25% of parents considered temperatures less than 38.0 o C to be fever, another 25% did not know the definition of fever, 64% felt that temperatures of less than 40.0 o C could be dangerous to a child, and 25% could not define high fever. Another 23% believed that if left untreated, temperatures could rise to 42.0 o C or higher, but 37% could not provide an answer, and 62% did not know the minimum temperature for administering antipyretics. Approximately 95% of parents demonstrated undue fear of consequent body damage from fever, including convulsion, brain damage or stroke, coma, serious vague illness, blindness, and even death.

CONCLUSION

Parental misconceptions about fever reflect the lack of active health education in our community. Health professionals have apparently not done enough to educate parents on the condition of fever and its consequences, a common problem.

Mother's knowledge of, attitudes toward, and management of fever in preschool children in Italy

BACKGROUND

We examined mothers' knowledge of, attitudes toward, and management of fever in their children.

METHODS

Interviews of mothers of preschool children were performed using a structured questionnaire administered by interviewers with no specific medical competence.

RESULTS

Of a total of 1,237 mothers who were interviewed, data were analyzed for the 707 mothers who had coped with a febrile episode in their children during the previous month. Of these, 59% were concerned about fever in their children and 17% were very worried. At the onset of fever, 48% of the mothers gave their child an antipyretic and 18% called the physician immediately. In logistic regression analysis, five variables were significantly associated with mothers' concern: the absence of previous information on the management of fever, temperature > 39 degrees C, an only child, mother's low educational level, and mother's residency in the south of Italy. For the request for a physician's visit, of the variables entered, the only explanatory ones were the mother's concern and the absence of previous information on the management of fever.

CONCLUSIONS

These findings suggest that informing mothers on the definition, consequences, and treatment of fever can significantly improve their confidence in managing fever, as reflected by fewer requests for physicians' visits.

Effect of paracetamol on parasite clearance time in Plasmodium falciparum malaria

BACKGROUND

Routine antipyretic therapy in children with infectious diseases has long been the source of controversy. Each year, in addition to antimalarial medication, millions of children with Plasmodium falciparum malaria receive paracetamol to reduce fever. However, the usefulness of this practice has not been proven.

METHODS

In a randomised trial in Lambaréné, Gabon, 50 children with P falciparum malaria were treated with intravenous quinine, and received either mechanical antipyresis alone, or in combination with paracetamol. Rectal body temperature and parasitaemia were recorded every 6 h for 4 days. Plasma concentrations and inducible concentrations of tumour necrosis factor (TNF) and interleukin-6 were measured every 24 h. In addition, production of oxygen radicals was measured in both groups.

FINDINGS

The mean fever clearance time was 32 h for children treated with paracetamol and 43 h for those who received mechanical antipyresis alone; however, this 11 h difference was not significant (95% CI -2 to 24 h; p = 0.176). Parasite clearance time was significantly prolonged in patients who received paracetamol with a difference of 16 h (8-24 h; p = 0.004). Plasma concentrations of TNF and interleukin-6 were similar in both groups during the study. However, the induced concentrations of TNF, and the production of oxygen radicals, were significantly lower in children treated with paracetamol than those who received mechanical antipyresis alone.

INTERPRETATION

These data suggest that paracetamol has no antipyretic benefits over mechanical antipyresis alone in P falciparum malaria. Moreover, paracetamol prolongs parasite clearance time, possibly by decreased production of TNF and oxygen radicals.

Analgesic efficacy and safety of paracetamol-codeine combinations versus paracetamol alone: a systematic review

OBJECTIVES

To assess whether adding codeine to paracetamol has an additive analgesic effect; to assess the safety of paracetamol-codeine combinations versus paracetamol alone.

DESIGN

Systematic literature review with meta-analysis, methodological quality of published trials being scored by means of 13 predefined criteria.

TRIALS

24 of 29 trials that met the inclusion criteria. Models studied in the trials were postsurgical pain (21), postpartum pain (one), osteoarthritic pain (one), and experimentally induced pain (one).

INTERVENTIONS

Dosages ranged from 400 to 1000 mg paracetamol and 10 to 60 mg codeine.

MAIN OUTCOME MEASURES

The sum pain intensity difference (efficacy analysis) and the proportion of patients reporting a side effect (safety analysis).

RESULTS

Most trials were considered of good to very good quality. Only the single dose studies could be combined for analysis of analgesic efficacy. Pooled efficacy results indicated that codeine added to paracetamol provided a 5% increase in analgesia on the sum pain intensity difference. This effect was comparable to the difference in analgesic effect between codeine and placebo. The cumulative incidence of side effects with each treatment was comparable in the single dose trials. In the multidose studies a significantly higher proportion of side effects occurred with paracetamol-codeine preparations.

CONCLUSION

The difference is analgesic effect between paracetamol-codeine combinations and paracetamol alone was small but statistically significant. In the multidose studies the proportion of patients reporting a side effect was significantly higher with paracetamol-codeine combinations. For occasional pain relief a paracetamol-codeine combination might be appropriate but repeated use increases the occurrence of side effects.