Antipyretic efficacy of an initial 30-mg/kg loading dose of acetaminophen versus a 15-mg/kg maintenance dose

Intermittent rapamycin feeding recapitulates some effects of continuous treatment while maintaining lifespan extension

OBJECTIVE

Rapamycin, a powerful geroprotective drug, can have detrimental effects when administered chronically. We determined whether intermittent treatment of mice can reduce negative effects while maintaining benefits of chronic treatment.

METHODS

From 6 months of age, male and female C3B6F1 hybrid mice were either continuously fed with 42 mg/kg rapamycin, or intermittently fed by alternating weekly feeding of 42 mg/kg rapamycin food with weekly control feeding. Survival of these mice compared to control animals was measured. Furthermore, longitudinal phenotyping including metabolic (body composition, GTT, ITT, indirect calorimetry) and fitness phenotypes (treadmil, rotarod, electrocardiography and open field) was performed. Organ specific pathology was assessed at 24 months of age.

RESULTS

Chronic rapamycin treatment induced glucose intolerance, which was partially ameliorated by intermittent treatment. Chronic and intermittent rapamycin treatments increased lifespan equally in males, while in females chronic treatment resulted in slightly higher survival. The two treatments had equivalent effects on testicular degeneration, heart fibrosis and liver lipidosis. In males, the two treatment regimes led to a similar increase in motor coordination, heart rate and Q-T interval, and reduction in spleen weight, while in females, they equally reduced BAT inflammation and spleen weight and maintained heart rate and Q-T interval. However, other health parameters, including age related pathologies, were better prevented by continuous treatment.

CONCLUSIONS

Intermittent rapamycin treatment is effective in prolonging lifespan and reduces some side-effects of chronic treatment, but chronic treatment is more beneficial to healthspan.

The Antipyretic Effect of High-Dose Paracetamol Versus Mefenamic Acid in the Treatment of Febrile Children: A Randomized Control Trial

Introduction

Fever is the most common presenting symptom in children and causes distress in patients and parents. Although nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used as antipyretics, they should be reserved for pain or chronic inflammatory conditions due to safety concerns. If we can safely achieve the same antipyretic effect using a higher dose (20 mg/kg) of paracetamol, NSAIDs may be avoided for treating fever. There is a paucity of literature comparing the antipyretic effect of mefenamic acid and high-dose paracetamol. We hypothesized that there would be no difference in the antipyretic effect of high-dose paracetamol and mefenamic acid.

Methods

In this randomized control trial, 165 febrile children were randomly allocated to one of the following three groups: standard-dose (15 mg/kg) paracetamol (SDPCM) as the control group and high-dose (20 mg/kg) paracetamol (HDPCM) and mefenamic acid (6 mg/kg) (MFN) as the intervention groups. The temperature was measured using a digital thermometer at the start of drug dosage and every 15 minutes until it reached normal. One-way between-group analysis of variance (ANOVA) was used to compare outcome measures such as time for temperature to reach normal, fall of temperature in 60 minutes, and time for the next fever. Post hoc analysis was performed to compare mean differences. Patients were monitored for adverse effects.

Results

Out of 165 enrolled patients, 159 were analyzed. The baseline demographic data were comparable among the groups. There was a statistically significant difference in the mean time taken for the temperature to reach normal (F-value (F) (2,156)=3.184, p<0.05) and the mean reduction in temperature at 60 minutes (F (2,156)=23.40, p<0.001) among the groups. The mean time for temperature to reach normal in the SDPCM group (97.50±26.60 minutes) was longer than that in the HDPCM (85.09±31.43 minutes) and MFN (84.90±30.42 minutes) groups. The decrease in temperature over 60 minutes was greater in the HDPCM (0.46°C±0.19°C) and MFN (0.45°C±0.11°C) groups than in the SDPCM (0.33°C±0.10°C) group. The time to the next fever spike was shorter for the SDPCM group (5.07±2.66 hours) than for the HDPCM (7.20±3.08 hours) and MFN (8.82±3.83 hours) groups. Post hoc analysis demonstrated that high-dose paracetamol and mefenamic acid had similar and faster antipyretic effects than standard-dose paracetamol. Although the duration of action was found to be longer in the mefenamic acid group, the difference was not statistically significant. There were negligible adverse effects in the groups.

Conclusion 

Standard-dose paracetamol (15 mg/kg/dose) had a slower and shorter antipyretic effect than high-dose paracetamol (20 mg/kg/dose) and mefenamic acid (6 mg/kg/dose). A single dose of high-dose paracetamol was safe and had a similar antipyretic effect as mefenamic acid. Mefenamic acid may be avoided as an antipyretic and spared for pain and anti-inflammatory indications. Multicentered double-blind clinical trials with larger sample sizes and comparisons of other NSAIDs will be required to confirm these findings.

Comparison of Oral Loading Dose to Intravenous Acetaminophen in Children for Analgesia After Tonsillectomy and Adenoidectomy: A Randomized Clinical Trial

BACKGROUND

Acetaminophen is a frequently used adjunct analgesic in pediatric patients undergoing tonsillectomy and adenoidectomy. We compared opioid administration following preoperative intravenous (IV) or oral acetaminophen in addition to a standard multimodal regimen to test the hypothesis that 1 loading dose approach would provide superior opioid sparing effects among pediatric surgical patients undergoing tonsillectomy and adenoidectomy.

METHODS

This single-center, double-blind, double-dummy prospective randomized study was conducted in patients ages 3 to 15 years undergoing tonsillectomy and adenoidectomy with or without myringotomy and tube placement between September 2017 and July 2019. Subjects received 1 dose of either oral acetaminophen 30 mg/kg with IV placebo (oral group) or IV acetaminophen 15 mg/kg with oral placebo (IV group). Acetaminophen plasma levels were measured at 2 timepoints to evaluate safety and determine plasma levels attained by each dosing regimen. Intraoperative opioid administration and postoperative analgesia were standardized. Standardized postoperative multimodal analgesia included opioid if needed to control pain assessed by standardized validated pediatric pain scales. The primary outcome measure was total opioid administration in the first 24 hours after surgery. Continuous data were not normally distributed and were analyzed using the Wilcoxon rank sum test and the Hodges-Lehman estimator of the median difference. Clinical significance was defined as a 100 µg/kg IV morphine equivalents per day difference.

RESULTS

Sixty-six subjects were randomized into and completed the study (29 women, 37 men; age 5.9 ± 3.0 years; percentile weight for age 49.5 ± 30.2; no differences between groups). There was no opioid dose difference between oral (median 147.6; interquartile range [IQR], 119.6-193.0 µg/kg) and IV groups (median 125.4; IQR, 102.8-150.9 µg/kg; median difference 21.3; 95% confidence interval [CI] -2.5 to 44.2 µg/kg IV morphine equivalents; P = .13). No acetaminophen levels exceeded the predefined safety threshold (40 mg/L). No difference was found in the percentage of patients with severe pain: 50.0% oral group, 47.2% IV group; relative risk of severe pain in IV 0.94; 95% CI, 0.57-1.6; P = .82. Postoperative plasma acetaminophen levels were higher in oral (22; IQR, 16-28 mg/L) than IV (20; IQR, 17-22 mg/L) group (median difference 7.0; 4.0-8.0 mg/L; P = .0001).

CONCLUSIONS

Opioid-sparing effects did not differ following an oral or standard IV acetaminophen loading dose with no identified acetaminophen toxicity in pediatric patients undergoing tonsillectomy and adenoidectomy who received standardized multimodal postoperative analgesia. An oral loading dose may provide more consistent serum acetaminophen levels at lower cost compared to a standard IV dose.

Intermittent Versus Continuous and Intermittent Medications for Pain and Sedation After Pediatric Cardiothoracic Surgery; A Randomized Controlled Trial

OBJECTIVES

Compare continuous infusions of morphine and midazolam in addition to intermittent doses with an intermittent only strategy for pain and sedation after pediatric cardiac surgery.

DESIGN

Randomized controlled trial.

SETTING

Advocate Children's Hospital, Oak Lawn, IL.

PATIENTS

Sixty patients 3 months to 4 years old with early extubation after pediatric cardiac surgery.

INTERVENTIONS

Patients received a continuous infusion of morphine and midazolam or placebo for 24 hours. Both groups received intermittent morphine and midazolam doses as needed.

MEASUREMENTS AND MAIN RESULTS

Gender, age, bypass time, and surgical complexity were not different between groups. Scheduled ketorolac and acetaminophen were used in both groups and were not associated with adverse events. The mean, median, and maximum Faces, Legs, Activity, Cry, And Consolability score were not different between groups. There was no significant difference in number of intermittent doses received between groups. The total morphine dose was higher in the continuous/intermittent group (0.90 vs 0.23 mg/kg; p < 0.01). The total midazolam dose was also higher in the continuous/intermittent group (0.90 vs 0.18 mg/kg; p < 0.01). The hospital length of stay was longer in the continuous/intermittent group (8.4 vs 4.9 d; p = 0.04).

CONCLUSIONS

Pain was not better controlled with the addition of continuous infusions of morphine and midazolam when compared with intermittent dosing only. Use of continuous infusions resulted in a significantly higher total dosage of these medications and a longer length of stay.

Effectiveness of paracetamol versus ibuprofen administration in febrile children: A systematic literature review

AIM

The use of antipyretics to manage the febrile child is becoming increasingly popular. Paracetamol and ibuprofen are the most commonly used interventions to manage fever in children; however, there have been no comparative analyses. The aim of the study is to evaluate the evidence comparing paracetamol to ibuprofen in the treatment of fever in children.

METHODS

A systematic review of randomised controlled trials investigating the administration of oral paracetamol and ibuprofen to reduce fever in children. Children aged 1 month to 12 years with a temperature between 37.5 and 41°C were included. A total of 3023 papers were identified. After removal of duplications, application of inclusion criteria and screening, eight papers were subjected to critical appraisal and included in this study.

RESULTS

Six of the studies identified that ibuprofen was slightly, but not significantly, better at reducing fever in children than paracetamol. Dosage variances and route of temperature measurement ranged between studies, limiting the comparability of studies. While ibuprofen was reported to be marginally more effective at reducing fever and fever associated discomfort in children, there is insufficient data to conclude that ibuprofen is superior to paracetamol.

CONCLUSION

There is little evidence supporting the superior efficacy of paracetamol or ibuprofen in the treatment of fever in children with indications that both drugs are equally effective.

Comparison of the Efficacy and Safety of 2 Acetaminophen Dosing Regimens in Febrile Infants and Children: A Report on 3 Legacy Studies

OBJECTIVE

Compare efficacy and safety of 10 to 15 mg/kg with 20 to 30 mg/kg acetaminophen in febrile children 6 months to ≤ 11 years from 3 double-blind, randomized, single or multiple dose studies.

METHODS

Doses were compared on sum of the temperature differences (SUMDIFF), maximum temperature difference (MAXDIFF), temperature differences at each time point, and dose by time interactions. Alanine aminotransferase (ALT) was evaluated in the 72-hour duration study.

RESULTS

A single dose of acetaminophen 20 to 30 mg/kg produced a greater effect on temperature decrement and duration of antipyretic effect over 8 hours than a single dose of 10 to 15 mg/kg. When equivalent total doses (i.e., 2 doses of 10 to 15 mg/kg given at 4-hour intervals and 1 dose of 20 to 30 mg/kg) were given over the initial 8-hour period, there were no significant temperature differences. Over a 72-hour period, 10 to 15 mg/kg acetaminophen administered every 4 hours maintained a more consistent temperature decrement than 20 to 30 mg/kg acetaminophen administered every 8 hours. Following doses of 60 to 90 mg/kg/day for up to 72 hours, no child had a clinically important increase in ALT from baseline. The number of children with reported adverse events was similar between doses.

CONCLUSIONS

Data demonstrate the antipyretic effect of acetaminophen is dependent on total dose over a given time interval. These 3 studies provide clinical evidence that the recommended standard acetaminophen dose of 10 to 15 mg/kg is a safe and effective dose for treating fever in pediatric patients when administered as a single dose or as multiple doses for up to 72 hours.

Recent Advances in Pediatric Use of Oral Paracetamol in Fever and Pain Management

Paracetamol is a common analgesic and antipyretic drug for management of fever and mild-to-moderate pain in infants and children, and it is considered as first-line therapy for the treatment of both according to international guidelines and recommendations. The mechanism of action of paracetamol is complex and multifactorial, and several aspects of the pharmacology impact its clinical use, especially in the selection of the correct analgesic and antipyretic dose. A systematic literature search was performed by following procedures for transparent reporting of systematic reviews and meta-analyses. To maximize efficacy and avoid delays in effect, use of the appropriate dose of paracetamol is paramount. Older clinical studies using paracetamol at subtherapeutic doses of ≤10 mg/kg generally show that it is less effective than non-steroidal anti-inflammatory drugs (NSAIDs). However, recent evidence shows that when used at dose of 15 mg/kg for fever and pain management, paracetamol is significantly more effective than placebo, and at least as effective as NSAIDs. Paracetamol 15 mg/kg has a tolerability profile similar to that of placebo and NSAIDs such as ibuprofen and ketoprofen used for short-term treatment of fever. However, when used at repetitive doses for consecutive days, paracetamol shows lower risk of adverse events compared to NSAIDs. Also, unlike NSAIDs, paracetamol is indicated for use in children of all ages. Overall, clinical evidence qualifies paracetamol 15 mg/kg a safe and effective option for treatment of pain and fever in children.

Paracetamol: a focus for the general pediatrician

Paracetamol (acetaminophen) is one of the most popular and widely used drugs for the treatment of pain and fever in children. This drug has multiple mechanisms of action, but its pharmacodynamic is still not well known. The central nervous system is the main site of action and it mirrors the paracetamol effect compartment. The recommended dosages and routes of administration should be different whether paracetamol is used for the treatment of pain or fever. For example, the rectal route, while being efficacious for the treatment of fever, should be avoided in pain management. Paracetamol is a safe drug, but some clinical conditions and concomitant drugs, which are frequent in clinical practice, may increase the risk of paracetamol toxicity. Therefore, it is important to optimize its administration to avoid overdoses and maximize its effect. The principal mediator of the paracetamol toxicity is the N-acetyl-p-benzo-quinone imine (NAPQI), a toxic product of the paracetamol metabolism, which could bind cysteine groups on proteins forming paracetamol-protein adduct in the liver.

CONCLUSION

Although frequently prescribed, the concept of "effect compartment concentration" and the possible co-factors that could cause toxicity at recommended doses are not familiar to all pediatricians and general practitioners. We reviewed the literature concerning paracetamol mechanisms of action, we highlighted some relevant pharmacodynamic concepts for clinical practice, and we summarized the possible risk factors for toxicity at therapeutic dosages.

Randomized controlled study of the antipyretic efficacy of oral paracetamol, intravenous paracetamol, and intramuscular diclofenac in patients presenting with fever to the emergency department

Background

Fever is a common problem in adults visiting the emergency department. Extensive studies have been done in children comparing the efficacy of various antipyretics. However, studies on the efficacy of antipyretic drugs in adults are very scarce. To the best of our knowledge, no controlled trial has been carried out comparing the antipyretic efficacy of paracetamol (oral and intravenous) and intramuscular diclofenac in adults.

Methods

In this parallel-group, open-label trial, participants aged 14–75 years presenting with fever who had a temperature of more than 38.5°C were enrolled and treated. Participants were randomly allocated to receive treatment with 1,000 mg oral paracetamol (n = 145), 1,000 mg intravenous paracetamol (n = 139), or 75 mg intramuscular diclofenac (n = 150). The primary outcome was degree of reduction in mean oral temperature at 90 minutes. The efficacy of diclofenac versus oral and intravenous paracetamol was assessed by superiority comparison. Analysis was done using intention to treat principles.

Results

After 90 minutes, all three groups showed a significant reduction in mean temperature, with intramuscular diclofenac showing the greatest reduction (−1.44 ± 0.43, 95% confidence interval [CI] −1.4 to −2.5) and oral paracetamol the least (−1.08 ± 0.51, 95% CI −0.99 to −2.2). After 120 minutes, there was a significant difference observed in the mean change from baseline temperature between the three treatment groups (P < 0.0001). Significant changes in temperature were observed in favor of intramuscular diclofenac over oral and intravenous paracetamol at each time point from 60 minutes through 120 minutes inclusive.

Conclusion

Both intramuscular diclofenac and intravenous paracetamol showed superior antipyretic activity than oral paracetamol. However, in view of its ease of administration, intramuscular diclofenac can be used as a first-choice antipyretic in febrile adults in the emergency department.

Dosing and antipyretic efficacy of oral acetaminophen in children

BACKGROUND

A standardized approach to dosing acetaminophen in pediatric populations was published in 1983. That review proposed specific weight-related dosing for infants and children weighing 6 through 95 lb and an age-based schedule for children aged <4 months through 11 years. Subsequent clinical studies evaluating these and alternative doses of acetaminophen supported the recommended 10-15-mg/kg dose.

OBJECTIVE

This article reviewed published and unpublished pediatric antipyretic data to provide a critical assessment of the 10-15-mg/kg oral dose and the current pediatric oral dosing schedules for acetaminophen.

METHODS

Published literature and unpublished clinical trials that evaluated the antipyretic efficacy of acetaminophen in children were reviewed. The PubMed database was searched using the term acetaminophen or paracetamol, with study criteria limited to randomized, controlled trials; oral dosing; patient age <12 years; and publication between 1982 and August 2012. All of the sponsor's unpublished antipyretic clinical studies completed between 1980 and August 2012 and involving at least 1 oral-formulation acetaminophen-only treatment arm were identified. Data from published literature containing sufficient detail to verify doses; dosing frequency; and, when necessary, estimates from figures, and from acetaminophen arms of the unpublished studies were analyzed.

RESULTS

Thirteen unpublished trials enrolled 705 children to receive an oral dose of 10-15 mg/kg of acetaminophen. This dose resulted in a rapid onset of temperature reduction, with a maximum temperature decrement of ~3 hours following administration. Results from 40 published clinical trials in which 2332 children received oral acetaminophen for fever support these findings. The most common adverse events reported in any of the reported studies were gastrointestinal in nature and generally mild in intensity.

CONCLUSIONS

Data support the recommended 10-15-mg/kg oral dose and demonstrate that the age and weight schedules for over-the-counter acetaminophen proposed in 1983 remain appropriate.

Acetaminophen pediatric dose selection: caregiver satisfaction regarding the antipyretic efficacy of acetaminophen in children

Acetaminophen-associated liver toxicity remains a serious concern, but guidance regarding dose selection is ambiguous, and the literature describing acetaminophen efficacy and toxicity in pediatrics is limited. Clinical investigation and reporting are needed. This study investigates caregiver satisfaction with 2 commonly prescribed dose levels. This nonrandomized, open-label, outpatient study included 37 moderately febrile pediatric patients prescribed acetaminophen at either 10 or 15 mg/kg every 4 hours. Patient caregivers indicated how well the acetaminophen reduced fever by completing a 5-point Likert scale. A 2-sample t test determined whether a statistically significant difference in satisfaction scores existed. Sufficient statistical power was achieved, and the mean satisfaction scores for both groups were not significantly different. Although further studies using more precise and objective end points are needed to provide optimal evidence-based guidance for acetaminophen pediatric dose selection, the findings in this study suggest that prescribers should consider a starting dose of only 10 mg/kg for moderately febrile pediatric patients.

Regulatory review of acetaminophen clinical pharmacology in young pediatric patients

The acetaminophen dosage schedule in pediatric patients below 12 years of age for the over-the-counter (OTC) monograph is one of the many issues being evaluated and discussed in the development of the Proposed Rule for Internal Analgesic, Antipyretic, and Anti-rheumatic drug products. The dosage regimen based on age and weight, with instructions that weight-based dosage should be used if a child's weight is known, is currently being assessed by the agency. This review summarizes the available pharmacokinetic and pharmacodynamic (fever reduction) data of oral acetaminophen in pediatric patients of 6 months to 12 years of age. Acetaminophen is metabolized in the liver mainly through glucuronidation, sulfation, and to a lesser extent oxidation. Because of the difference in the ontogeny of various metabolizing pathways, the relative contribution of each pathway to the overall acetaminophen metabolism in children changes with age. The sulfation pathway plays a more important role in metabolizing acetaminophen than the glucuronidation pathway in younger children as compared with older children and adults. The pharmacokinetic exposure of acetaminophen in pediatric patients of 6 months to 12 years of age given oral administration of 10-15 mg/kg is within the adult exposure range given the OTC monograph dose. The antipyretic effect of acetaminophen is dose dependent and appears to be better than placebo at the dose range of 10-15 mg/kg in pediatric patients of 6 months to 12 years of age.

Paracetamol-induced hypothermia is independent of cannabinoids and transient receptor potential vanilloid-1 and is not mediated by AM404

In recent years, there has been increasing interest in hypothermia induced by paracetamol for therapeutic purposes, which, in some instances, has been reported as a side effect. Understanding the mechanism by which paracetamol induces hypothermia is therefore an important question. In this study, we investigated whether the novel metabolite of paracetamol, N-(4-hydroxyphenyl)arachidonylamide (AM404), which activates the cannabinoid (CB) and transient receptor potential vanilloid-1 (TRPV1) systems, mediates the paracetamol-induced hypothermia. The hypothermic response to 300 mg/kg paracetamol in CB(1) receptor (CB(1)R) and TRPV1 knockout mice was compared to wild-type mice. Hypothermia induced by paracetamol was also investigated in animals pretreated with the CB(1)R or TRPV1 antagonist 1-(2,4-dichlorophenyl)-5-(4-iodophenyl)-4-methyl-N-1-piperdinyl-1H-pyrazole-3-carboxamide trifluoroacetate salt (AM251) or 4'-chloro-3-methoxycinnamanilide (SB366791), respectively. In CB(1)R or TRPV1 knockout mice, paracetamol induced hypothermia to the same extent as in wild-type mice. In addition, in C57BL/6 mice pretreated with AM251 or SB366791, paracetamol induced hypothermia to the same extent as in control mice. AM404 failed to induce hypothermia at pharmacological doses. Inhibition of fatty acid amide hydrolase (FAAH), which is involved in the metabolism of paracetamol to AM404, did not prevent the development of hypothermia with paracetamol. Paracetamol also induced hypothermia in FAAH knockout mice to the same extent as wild-type mice. We conclude that paracetamol induces hypothermia independent of cannabinoids and TRPV1 and that AM404 does not mediate this response. In addition, potential therapeutic value of combinational drug-induced hypothermia is supported by experimental evidence.

Fever and antipyretic use in children

Fever in a child is one of the most common clinical symptoms managed by pediatricians and other health care providers and a frequent cause of parental concern. Many parents administer antipyretics even when there is minimal or no fever, because they are concerned that the child must maintain a "normal" temperature. Fever, however, is not the primary illness but is a physiologic mechanism that has beneficial effects in fighting infection. There is no evidence that fever itself worsens the course of an illness or that it causes long-term neurologic complications. Thus, the primary goal of treating the febrile child should be to improve the child's overall comfort rather than focus on the normalization of body temperature. When counseling the parents or caregivers of a febrile child, the general well-being of the child, the importance of monitoring activity, observing for signs of serious illness, encouraging appropriate fluid intake, and the safe storage of 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 concerns that combined treatment may be more complicated and contribute to the unsafe use of these drugs. Pediatricians should also promote patient safety by advocating for simplified formulations, dosing instructions, and dosing devices.

Therapeutic acetaminophen is not associated with liver injury in children: a systematic review

BACKGROUND

Concern exists about the potential for liver injury with therapeutic dosing of acetaminophen in children.

OBJECTIVE

We systematically reviewed the medical literature to determine the rate at which liver injury has been reported for children prescribed therapeutic doses of acetaminophen (≤75 mg/kg per day orally or intravenously or ≤100 mg/kg per day rectally).

METHODS

We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials to locate all studies in which acetaminophen was administered to a defined pediatric population for ≥24 hours and for all case reports of liver injury after therapeutic acetaminophen dosing. Trained reviewers extracted data from each report. Major and minor hepatic adverse events (AEs) were defined prospectively. Causality was assessed by using the Naranjo algorithm.

RESULTS

A total of 62 studies that enrolled 32,414 children were included. No child (0% [95% confidence interval: 0.000-0.009]) was reported to have exhibited signs or symptoms of liver disease, to have received an antidote or transplantation, or to have died. Major or minor hepatic AEs were reported for 10 children (0.031% [95% confidence interval: 0.015-0.057]). The highest transaminase value reported was 600 IU/L. Naranjo scores (2-3) suggested "possible" causation. Twenty-two case reports were identified. In 9 cases, the Naranjo score suggested "probable" causation (5-6).

CONCLUSIONS

Hepatoxicity after therapeutic dosing of acetaminophen in children is rarely reported in defined-population studies. Case reports suggest that this phenomenon may occur, but few reports contain sufficient data to support a probable causal relationship.

Management of fever in children: summary of the Italian Pediatric Society guidelines

OBJECTIVE

This article summarizes the Italian Pediatric Society guideline on the management of the signs and symptoms of fever in children, prepared as part of the National Guideline Program (NGLP).

METHODS

Relevant publications in English and Italian were identified through searches of MEDLINE and the Cochrane Database of Systematic Reviews from their inception through December 31, 2007. Based on the consensus of a multidisciplinary expert panel, the strength of the recommendations was categorized into 5 grades (A-E) according to NGLP methodology.

SUMMARY

In the health care setting, axillary measurement of body temperature using a digital thermometer is recommended in children aged <4 weeks; for children aged > or =4 weeks, axillary measurement using a digital thermometer or tympanic measurement using an infrared thermometer is recommended. When body temperature is measured at home by parents or care-givers, axillary measurement using a digital thermometer is recommended for all children. Children who are afebrile when seen by the clinician but are reported to have had fever by their caregivers should be considered febrile. In special circumstances, high fever may be a predictive factor for severe bacterial infection. Use of physical methods of reducing fever is discouraged, except in the case of hyperthermia. Use of antipyretics-paracetamol (acetaminophen) or ibuprofen-is recommended only when fever is associated with discomfort. Combined or alternating use of antipyretics is discouraged. The dose of antipyretic should be based on the child's weight rather than age. Whenever possible, oral administration of paracetamol is preferable to rectal administration. Use of ibuprofen is not recommended in febrile children with chickenpox or dehydration. Use of ibuprofen or paracetamol is not contraindicated in febrile children with asthma. There is insufficient evidence to form any recommendations concerning fever in children with other chronic conditions, but caution is advised in cases of severe hepatic/renal failure or severe malnutrition. Newborns with fever should always be hospitalized because of the elevated risk of severe disease; paracetamol may be used, with the dose adjusted to gestational age. Use of paracetamol or ibuprofen is not effective in preventing febrile convulsion or the adverse effects of vaccines.

Repeated supratherapeutic doses of paracetamol in children--a literature review and suggested clinical approach

The safety of paracetamol when given in the recommended dosage is well documented. However, in recent years there have been many reports of liver failure associated with repeated exposure to supratherapeutic doses of paracetamol. This paper reviews the literature on chronic supratherapeutic paracetamol exposure in children and the different dosing guidelines. Based on which, we suggest the following approach: liver injury secondary to repeated dosing of paracetamol should be considered when a child has received more than 75 mg/kg/d for at least 2 d, or if risk factors for paracetamol toxicity have been identified. Liver transaminases, coagulation factors, and paracetamol serum concentrations should be measured in these children and in symptomatic children with vomiting, right upper quadrant abdominal pain, and jaundice who have taken paracetamol. Treatment with N-acetyl cysteine should be started regardless of paracetamol concentrations if transaminases or INR are elevated.

CONCLUSION

Liver injury secondary to repeated dosing of paracetamol is rare but may result in severe morbidity and mortality. The cumulative dose of paracetamol should not exceed 75 mg/kg/d. Children treated with higher doses for more than 2 d should be evaluated for possible liver injury and treated with N-acetyl cysteine if evidence of liver injury is found.

[Analgesic/Antipyretic treatment: ibuprofen or acetaminophen? An update]

Because of the adverse effects associated with aspirin, especially Reye's syndrome in children, practitioners currently use as first line therapy drugs such as ibuprofen or acetaminophen. Their pharmacokinetic characteristics are not quite identical: both are absorbed rapidly and have high bioavailability, however, unlike acetaminophen, ibuprofen is characterized by high plasma protein binding and a limited distribution volume. Both drugs are metabolized essentially in the liver into inactive hydroxylated or glucoronidated metabolites by conjugation but acetaminophen is also transformed into an oxidation compound--normally reduced by glutathione--which, in the case of acute overdosing with depletion of endogenous glutathione stores, may lead to severe hepatotoxicity. Old age and light to moderate renal or hepatic failure do not significantly modify their pharmacokinetic parameters, and thus do not call for dose adjustment. Clinical trials have shown both drugs to have comparable efficacy on pain and fever, with perhaps a slight advantage for ibuprofen. In practice, the choice will depend on the prescription habits of the practitioner, patient's (or parents') preferences and, above all, the pathological context and possible contra-indications.

[Parents' attitudes towards childhood fever. A cross-sectional survey in the Lyon metropolitan area (202 cases)]

INTRODUCTION

The patient overload in pediatric healthcare facilities is caused in part by parents bringing their children in for consultations for fever. We conducted a survey in the Lyon metropolitan area to improve our understanding of parents' attitudes towards their children's fever.

OBJECTIVE

To assess the frequency and characteristics of healthcare utilization and evaluate parents' knowledge and attitudes before consulting.

METHODS

A random sample of families with at least one child under 6 years of age and living in the Lyon metropolitan area was surveyed by telephone, according to a closed questionnaire that was answered by the person usually responsible for the child's health.

RESULTS

202 families were questioned: 58.9% defined fever as a temperature over 38 degrees C, and 82% used rectal thermometers to measure temperature. Among 144 parents of children with an episode of fever within the previous 12 months, 73% called a physician during the episode, 44% of them immediately. Working-class parents called more frequently (90%) than parents who were professionals or managers (74%). Most parents (94%) administered medication to the child several times before calling the physician. Paracetamol and ibuprofen were mentioned most often. 93% of fever episodes led to consultations.

DISCUSSION

Our results show that 59% of the sample defined fever as a temperature equal to 38 degrees C and that fever episodes lead commonly and quickly to physician visits, but that parents do use physical methods and drugs to reduce fever before calling a physician.

How much acetaminophen do paediatricians prescribe? A survey among Israeli paediatricians

OBJECTIVE

To describe the current practice of Israeli paediatricians regarding acetaminophen dosing.

METHODS

A cross-sectional survey among 200 paediatricians. The paediatricians were questioned of the recommended dose of acetaminophen, and whether they give prescriptions for acetaminophen and instruct their patients how to use it.

RESULTS

The response rate was 36%. When asked on the recommended dose of acetaminophen, 30 (42%) physicians gave doses different from the dose recommended by the Israeli formulary. Thirty (42%) of the paediatricians answered that they usually or always give prescriptions for antipyretics.

CONCLUSIONS

A large percentage of Israeli paediatricians do not provide parents proper instructions regarding the correct dosing of acetaminophen.

Bupivacaine versus lidocaine analgesia for neonatal circumcision

Background

Analgesia for neonatal circumcision was recently advocated for every male infant, and its use is considered essential by the American Academy of Pediatrics. We compared the post-operative analgesic quality of bupivacaine to that of lidocaine for achieving dorsal penile nerve block (DPNB) when performing neonatal circumcision.

Methods

Data were obtained from 38 neonates following neonatal circumcision. The infants had received DPNB analgesia with either lidocaine or bupivacaine. The outcome variable was the administration by the parents of acetaminophen during the ensuing 24 hours.

Results

Seventeen infants received lidocaine and 19 received bupivacaine DPNB. Ten infants in the lidocaine group (59%) were given acetaminophen following circumcision compared to only 3 (16%) in the bupivacaine group (P < 0.01). Regression analysis showed that the only significant variable associated with the need for acetaminophen was the use of lidocaine (R² = 20.6; P = 0.006).

Conclusion

DPNB with bupivacaine for neonatal circumcision apparently confers better analgesia than lidocaine as judged by the requirement of acetaminophen over the ensuing 24-hour period.

Fever in children less than 36 months of age--questions and strategies for management in the emergency department

Fever is a common pediatric complaint in the Emergency Department. Emergency Physicians often must be conservative in their management of febrile children, as patient follow-up is not always available. A unified approach for the management of febrile infants will be discussed in this article.

Comparison of oral versus normal and high-dose rectal acetaminophen in the treatment of febrile children

OBJECTIVES

To compare the defervescent effect of high-dose rectal suppository acetaminophen with the recommended oral and rectal dosages and to evaluate acceptability of rectal acetaminophen.

METHODS

A randomized, controlled trial was performed in 70 patients aged 6 months to 6 years with fever > or =39 degrees C. Group A received rectal acetaminophen 15 mg/kg, group B received rectal acetaminophen 30 mg/kg, and group C received oral acetaminophen 15 mg/kg. Primary outcome was maximal change in temperature during the 3-hour study period after initial treatment.

RESULTS

There were 24 patients in group A, 23 in group B, and 23 in group C. There was no significant difference in temperature change between the groups during the 3 hours or in the maximum drop in temperature or final temperature. Visual analog scores for satisfaction of parents did not reveal any significant differences between the oral and rectal routes.

CONCLUSIONS

There was no difference between the temperature decrement in patients treated with 15 mg/kg oral acetaminophen and the same or double dose rectally. Thus, there seems to be no evidence to support the use of higher doses of rectal acetaminophen for the treatment of fever in children. The rectal route proved to be as acceptable as the oral among parents.