Clinical experience with bromocriptine for central hyperthermia after brain insult

INTRODUCTION

Bromocriptine is a dopamine receptor agonist used for central hyperthermia with limited data. We describe our single-center experience utilizing bromocriptine for central hyperthermia, including the population treated, most common dosing regimens, adverse events, and discontinuation reasons.

METHODS

A retrospective study was conducted screening patients who were admitted to intensive care units for acute neurological insults and administered bromocriptine for central hyperthermia between April 2016 and September 2022. Baseline characteristics, disease severity markers, and bromocriptine doses were collected. Body temperatures prior to the first dose of bromocriptine, at the time of dose, and after each dose were recorded. Co-administration of additional hyperthermia management therapies was noted.

RESULTS

Thirty patients were included. The most common diagnosis was traumatic brain injury (TBI) (N = 14). The most common reason for discontinuation was resolution of indication (N = 14). Discontinuation due to mild adverse effects occurred in four patients; hepatotoxicity was the most common. There was a paired mean difference of -0.37°C (p = 0.005) between temperatures before and after bromocriptine initiation.

CONCLUSION

Bromocriptine is a potential therapy for the management of central hyperthermia in patients with severe acute neurologic insults who have failed other therapies. Bromocriptine was well tolerated and associated with a low incidence of adverse events.

Parents' Knowledge and Management of Fever: "Parents Versus Fever!"

OBJECTIVE

Parents' lack of knowledge about fever causes fear and incorrect practices. This study aims to investigate the fever knowledge level, concerns, and practices of parents of preschool children.

MATERIALS AND METHODS

In this descriptive, cross-sectional study, conducted between July 2021 and July 2022, a survey was conducted among parents of children aged 6 months to 5 years who did not have a history of febrile seizure and/or chronic disease, either in themselves or their siblings.

RESULTS

A total of 386 parents, with a mean age of 33.6 ± 6.38 years and a mean number of children of 1.85 ± 0.9, participated in the study. Approximately one-third of parents started giving antipyretics to their child before the body temperature reached 38°C (32.4%) and/or used them alternately (34.5%). Moreover, approximately two-thirds (67.1%) tended to seek medical help within the first 12 hours. Parents who could not define fever correctly (66.6%) were more likely to start giving antipyretics before the child's body temperature reached 38°C [odds ratio (OR) 2.83 (1.70-4.71), P .001] and seek medical help within the first 12 hours [OR 1.81 (1.16-2.82), P = .008]. As the number of children or length of parenting increased, parents started giving antipyretics before the body temperature reached 38°C [OR 1.61 (1.26-2.06), P < .001; OR 1.04 (1.01-1.08), P = .048] and used them alternately [OR 1.07 (1.03-1.11), P = .001; OR 1.28 (1.02-1.62), P = .031].

CONCLUSION

This study demonstrates that a substantial proportion of parents still cannot define fever correctly, and inappropriate antipyretic use is more prevalent among experienced parents with multiple children and/or longer lengths of parenting.

Clinical chorioamnionitis at term: definition, pathogenesis, microbiology, diagnosis, and treatment

Clinical chorioamnionitis, the most common infection-related diagnosis in labor and delivery units, is an antecedent of puerperal infection and neonatal sepsis. The condition is suspected when intrapartum fever is associated with two other maternal and fetal signs of local or systemic inflammation (eg, maternal tachycardia, uterine tenderness, maternal leukocytosis, malodorous vaginal discharge or amniotic fluid, and fetal tachycardia). Clinical chorioamnionitis is a syndrome caused by intraamniotic infection, sterile intraamniotic inflammation (inflammation without bacteria), or systemic maternal inflammation induced by epidural analgesia. In cases of uncertainty, a definitive diagnosis can be made by analyzing amniotic fluid with methods to detect bacteria (Gram stain, culture, or microbial nucleic acid) and inflammation (white blood cell count, glucose concentration, interleukin-6, interleukin-8, matrix metalloproteinase-8). The most common microorganisms are Ureaplasma species, and polymicrobial infections occur in 70% of cases. The fetal attack rate is low, and the rate of positive neonatal blood cultures ranges between 0.2% and 4%. Intrapartum antibiotic administration is the standard treatment to reduce neonatal sepsis. Treatment with ampicillin and gentamicin have been recommended by professional societies, although other antibiotic regimens, eg, cephalosporins, have been used. Given the importance of Ureaplasma species as a cause of intraamniotic infection, consideration needs to be given to the administration of antimicrobial agents effective against these microorganisms such as azithromycin or clarithromycin. We have used the combination of ceftriaxone, clarithromycin, and metronidazole, which has been shown to eradicate intraamniotic infection with microbiologic studies. Routine testing of neonates born to affected mothers for genital mycoplasmas could improve the detection of neonatal sepsis. Clinical chorioamnionitis is associated with decreased uterine activity, failure to progress in labor, and postpartum hemorrhage; however, clinical chorioamnionitis by itself is not an indication for cesarean delivery. Oxytocin is often administered for labor augmentation, and it is prudent to have uterotonic agents at hand to manage postpartum hemorrhage. Infants born to mothers with clinical chorioamnionitis near term are at risk for early-onset neonatal sepsis and for long-term disability such as cerebral palsy. A frontier is the noninvasive assessment of amniotic fluid to diagnose intraamniotic inflammation with a transcervical amniotic fluid collector and a rapid bedside test for IL-8 for patients with ruptured membranes. This approach promises to improve diagnostic accuracy and to provide a basis for antimicrobial administration.

Antipyretic Use in Noncritically Ill Patients With Fever: A Review

Antipyretics are one of the most frequently used agents in medicine. Numerous pharmacological agents, such as acetaminophen, non-steroidal anti-inflammatory agents (NSAIDs), salicylates, and selective cyclooxygenase 2 (COX-2) inhibitors, and nonpharmacological treatment modalities, such as tepid sponging and cooling blankets, are available for temperature reduction. There is a scarcity of definitive clinical guidelines on the choice of various agents in noncritically ill febrile patients. Our review examined the various modalities available for antipyresis and compared their safety and efficacy. The rationale for the choice of a particular pharmacological agent and route of administration were scrutinized. Our review also envisaged the perceived beneficial effects of antipyretics against the harmful side effects, including the evaluation of morbidity or mortality advantage conferred by antipyretics. The various toxicities associated with these agents were also highlighted.

Current State of Knowledge on the Definition, Pathophysiology, Etiology, Outcomes, and Management of Fever in the Intensive Care Unit

Fever-an elevated body temperature-is a prominent feature of a wide range of disease conditions and is a common finding in intensive care, affecting up to 70% of patients in the intensive care unit (ICU). The causes of fever in the ICU are multifactorial, and it can be due to a number of infective and noninfective etiologies. The production of fever represents a complex physiological, adaptive host response that is beneficial for host defense and survival but can be maladaptive and harmful if left unabated. Despite any cause, fever is associated with a wide range of cellular, local, and systemic effects, including multiorgan dysfunction, systemic inflammation, poor neurological recovery, and an increased risk of mortality. This narrative review presents the current state-of-the-art knowledge on the definition, pathophysiology, etiology, and outcomes of fever in the ICU and highlights evidence-based findings regarding the management of fever in the intensive care setting.

Knowledge, attitudes, and practices toward over-the-counter antipyretics among fever patients: a cross-sectional study in the context of a policy change KAP of OTC antipyretics

Background

On January 8, 2023, a change in the control policy for COVID-19 was implemented in China, whereby patient self-management of fever typically entails the utilization of over-the-counter fever-reducing medications.

Objective

This study aimed to investigate the knowledge, attitudes, and practices (KAP) toward over-the-counter (OTC) antipyretics among fever patients.

Methods

This cross-sectional study was conducted between October 2022 and February 2023 at author's hospital in Wuhan, China, among fever patients on OTC antipyretics, using a self-administered questionnaire.

Results

A total of 481 valid questionnaires were collected, with the age of 36.05 ± 12.10 years, including 240 (49.90%) males, and 209 (43.45%) collected before policy change. The knowledge, attitudes, precautions for medication administration and decision-making practices scores were 6.86 ± 3.30 (possible range: 0-12), 16.67 ± 2.46 (possible range: 7-35), 29.98 ± 5.41 (possible range: 7-35) and 27.87 ± 1.28 (possible range: 8-40), respectively. The multivariable logistic regression analysis showed that knowledge (OR = 0.83, 95%CI: 0.81-0.92, p < 0.001) was independently associated with positive attitude. Knowledge (OR = 1.41, 95%CI: 1.28-1.56, p < 0.001), attitude (OR = 0.87, 95%CI: 0.79-0.95, p = 0.004), suburban (OR = 0.45, 95%CI: 0.23-0.88, p = 0.019) were independently associated with proactive precautions for medication administration practices. Knowledge (OR = 1.14, 95%CI: 1.07-1.22, p < 0.001), attitude (OR = 0.90, 95%CI: 0.82-0.98, p = 0.018), responding after policy change, 2023 (OR = 1.70, 95%CI: 1.10-2.63, p = 0.016) were independently associated with proactive decision making practices.

Conclusion

Fever patients had moderate knowledge, negative attitude, proactive precautions for medication administration practices, moderate decision-making practices. After the policy change, there was a significant increase in knowledge regarding medication administration precautions and decision-making.

Temperature control in sepsis

Fever can be viewed as an adaptive response to infection. Temperature control in sepsis is aimed at preventing potential harms associated with high temperature (tachycardia, vasodilation, electrolyte and water loss) and therapeutic hypothermia may be aimed at slowing metabolic activities and protecting organs from inflammation. Although high fever (>39.5°C) control is usually performed in critically ill patients, available cohorts and randomized controlled trials do not support its use to improve sepsis prognosis. Finally, both spontaneous and therapeutic hypothermia are associated with poor outcomes in sepsis.

Effectiveness of Traditional Chinese Medicine on coronavirus disease 2019 in 92 patients: a retrospective study

OBJECTIVE

To investigate the antipyretic effect of early treatment with Traditional Chinese Medicine (TCM) on coronavirus disease 2019 (COVID-19) patients.

METHODS

We retrospectively analyzed 369 patients from January 26th, 2020 to April 15th, 2020, who had been diagnosed with COVID-19. Among 92 eligible cases, 45 cases were identified as treatment group Ⅰ ( 45) and 47 cases were identified as treatment group Ⅱ. Patients in the treatment group Ⅰ were treated with TCM herbal decoction within 5 d after admission. Patients in the treatment group Ⅱ were treated with TCM herbal decoction after the 6th admission day. The onset time of antipyretic effect, the antipyretic time, the time of negative oropharyngeal swab nucleic acid conversion, and the changes of cell count in blood routine test were compared.

RESULTS

The treatment group I showed shorter average antipyretic duration (4 7 d; <0.05), and shorter average time for polymerase chain reaction (PCR) nucleic acid test results to turn negative (7 11 d; <0.05) than the treatment group II. For patients ( 54) with body temperature>38 ℃, patients in the treatment group I had shorter median onset time of antipyretic effect than those in the treatment group II (3 4 d; <0.05). The absolute lymphocyte (LYMPH) count and absolute eosinophil (EOS) count on the 3rd day after admission and the neutrophil/lymphocyte ratio on the 6th day after admission of patients in the treatment group I were notably different from those in the treatment group II at the same time point (0.05). Based on Spearman's rank correlation analysis, the change of body temperature on the 3rd day after admission was positively correlated with the increase of EOS count and the increase of EOS count and LYMPH counts on the 6th day after admission (0.01).

CONCLUSIONS

Early TCM intervention within 5 d after hospital admission shortened the onset time of antipyretic effect and fever duration of COVID-19 patients, reduced the time required for PCR test results to turn negative. Moreover, early TCM intervention also improved the results of inflammatory markers for COVID-19 patients. LYMPH and EOS counts can be used as indicators of TCM antipyretic effect.

Maternal fever during pregnancy and male offspring reproductive health: A longitudinal cohort study in young Danish males

BACKGROUND

Maternal fever during pregnancy has been associated with an increased risk of genital malformations, but the implication for long-term reproductive health in the offspring is unknown.

OBJECTIVES

To investigate associations between timing, duration, and temperature of fetal exposure to maternal fever and sons' semen quality, testicular volume, and levels of reproductive hormones in early adulthood. Further, to examine whether concurrent use of antipyretics and/or antibiotics modified the effect.

MATERIALS AND METHODS

We used the Fetal Programming of Semen Quality cohort consisting of men born to women enrolled in the Danish National Birth Cohort. Self-reported information on maternal fever was collected twice during pregnancy (median 16 and 31 pregnancy weeks) and categorized as any fever during pregnancy, fever during early pregnancy (weeks 1-15), and fever exclusively during late pregnancy (weeks 16-42). Semen quality and concentrations of reproductive hormones were measured at a clinical examination at the age of 18.9 years. We used negative binomial regression to examine the associations, adjusting for maternal age at birth, maternal smoking, family occupational status, and precision variables related to semen quality and hormonal levels, for example, abstinence time.

RESULTS

986 men were included in the study, of which 23% had mothers reporting at least one episode of fever. We found no strong indications of associations between maternal fever during pregnancy and male reproductive health in young men. Concurrent use of antipyretics and antibiotics did not modify the association.

DISCUSSION

Strengths include the large sample size, prospectively collected data, and the adjustment for maternal factors during pregnancy and important precision variables. A limitation is the crude self-reported information on maternal fever.

CONCLUSION

We found no evidence to support that timing, duration, or temperature of maternal fever during pregnancy has a long-term impact on semen characteristics, testicular volume, or level of reproductive hormones in male offspring.

The Three W's of Acetaminophen In Children: Who, Why, and Which Administration Mode

Acetaminophen is one of the oldest medications commonly administered in children. Its efficacy in treating fever and pain is well accepted among clinicians. However, the available evidence supporting the use of acetaminophen's different modes of administration remains relatively scarce and poorly known. This short report summarizes the available evidence and provides a framework to guide clinicians regarding a rational use of acetaminophen in children.

Resolution of Fever in the Pediatric Emergency Department and Bacteremia

To determine whether a lack of response to antipyretics was associated with bacteremia, we performed a cross-sectional study involving children with an initial temperature ≥38°C presenting to a pediatric emergency department (ED) from 2012 to 2020 who received an antipyretic and had a blood culture obtained. We assessed the association of resolution of fever at specific time points after antipyretic administration with bacteremia adjusting for age, complex chronic condition, blood culture source, type of antipyretic, and height of temperature. Among 6319 febrile children, 242 (3.8%) had bacteremia. The adjusted odds ratio of bacteremia was 1.6 (95% confidence interval: 1.2-2.2) among children who remained febrile at 180 minutes and 1.7 (1.2-2.4) among children who remained febrile at 240 minutes. Among febrile children presenting to a tertiary care ED for whom a blood culture was obtained, the response to an antipyretic varies based on the presence or absence of bacteremia.

Parental Confidence in Relation to Antipyretic Use, Warning Signs, Symptoms and Well-Being in Fever Management-Results from an App-Based Registry

Parents' confidence regarding their children's fever is a key factor in its management and there is still unnecessary anxiety and associated antipyretic overuse. The FeverApp application collects naturalistic real-time data on febrile infections and educates parents on fever management. Logistic regression examined the associations between (1) parental confidence and (2) antipyretics use with fever relevant parameters. First entry data of 3721 children (mean age 21 months; SD 22.97) was assessed. A total of 58.0% of parents felt confident upon first fever documentation. Warning signs [OR = 0.49, 95% CI: 0.40-0.61], dehydration [OR = 0.65, 95% CI: 0.52-0.81], fever [OR = 0.67, 95% CI: 0.57-0.80] and having a female child [OR = 0.77, 95% CI: 0.66-0.90] had the highest negative association with parental confidence. Antipyretics were used initially in 14.7% of children. Fever had the highest positive [OR = 2.58, 95% CI: 1.89-3.50] and well-being the highest negative association with antipyretic use [OR = 0.37, 95% CI: 0.22-0.63). In the first entry data, parental confidence was related to children's health condition in a reasonable medical manner. The use of antipyretics was mostly associated with febrile temperature, but also low well-being. Thus, associations were partly in accordance with recent guidelines.

The abrogated role of premedication in the prevention of transfusion-associated adverse reactions in outpatients receiving leukocyte-reduced blood components

BACKGROUND AND OBJECTIVES

Although it remains controversial, premedication before transfusion is a common clinical practice to prevent transfusion-associated adverse reactions (TAARs) in Taiwan. Thus, we aimed to investigate whether premedication prevented outpatients from developing TAARs and whether an educational programme could improve the understanding of physicians related to the unnecessary use of premedication, and this could elicit changes in their prescribing activities without affecting the occurrence of TAARs.

MATERIALS AND METHODS

Clinical data from outpatients receiving transfusion therapy, including predisposing diseases, histories of transfusion and TAARs, premedication and the occurrence of TAARs in the period April 2017 to October 2018, were retrospectively obtained. The evidence-based transfusion programme implemented to educate physicians was started in January 2018.

RESULTS

A total of 5018 blood units were transfused to 803 outpatients, with 2493 transfusion events reported in the study interval. The most frequently transfused component was leukocyte-reduced packed red cells (n = 4338), followed by leukocyte-reduced apheresis platelets (n = 540) and other blood components. The overall premedication rate significantly decreased from 92.4% to 76.7% after the educational programme (p < 0.001). There was no remarkable change in the occurrence of TAARs per patient event between the periods before and after the educational programme (1.11% vs. 1.14%, p = 0.964). Besides, it was shown that the occurrence of TAARs was associated with the history of TAARs and inversely related to multiple transfusions, but not premedication.

CONCLUSION

Decreased premedication was not associated with increased incidence of TAARs in outpatients; these findings provide important evidence to support the need to revise clinical practices in the era of leukocyte-reduced blood products.

Analysis of Nurses' and Physicians' Attitudes, Knowledge, and Perceptions toward Fever in Children: A Systematic Review with Meta-Analysis

CONTEXT

Fever is a common symptom in children that nurses and pediatricians treat. Although it is a common sign in clinical practice, fever instills irrational fears in parents that health professionals share.

OBJECTIVE

To investigate whether doctors' and nurses' knowledge, perceptions, and attitudes toward fever influence how this sign is managed. Furthermore, it intends to evaluate whether educational programs increase knowledge and change attitudes and/or perceptions of nurses about children's fever.

DATA SOURCES

A systematic review with meta-analysis was conducted with PRISMA international standards and the Cochrane recommendations.

STUDY SELECTION

Articles examining health professionals' (doctors and/or nurses) knowledge, perceptions, and/or attitudes toward fever in children and the use of antipyretics were selected for the study.

DATA EXTRACTION

The qualitative analysis was carried out by classifying the articles according to the applied educational programs for nurses related to fever care for children that evaluated different outcomes to determine their efficacies.

RESULTS

For the qualitative synthesis, 41 articles were included, and 5 of these were taken in meta-analysis, which measured the effectiveness of educational programs for fever management in nurses.

LIMITATIONS

All of the included studies generally had a high risk of bias.

CONCLUSION

According to the evidence reviewed, nurses' and physicians' perceptions and attitudes regarding fever management in children indicate an overtreatment of this sign. We can give a recommendation grade of D on the use of educational programs to modify attitudes, perceptions, and knowledge about fever in children and improve clinical practice in nurses.

Managing fever in children: developing guidelines that turn evidence into practice

The importance of evidence-based practice has been emphasised in nursing in recent years. However, the process by which research evidence is turned into clinical recommendations is not always clear. This is important because understanding and communicating the rationale for clinical decisions is a vital part of the role of the children's nurse. This article discusses the methods by which nurses can turn evidence into practice using a framework devised by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group. The article uses the treatment of fever in children as an example of how nurses can apply the GRADE framework to ensure that their practice is evidence-based.

Over-the-counter antipyretics use among children from Southeastern Poland

BACKGROUND

Over-the-counter (OTC) drugs are becoming increasingly popular. However, little is known about parents' practices concerning the use of OTC antipyretics in children. This paper aimed to study the habits and knowledge of parents regarding the use of OTC antipyretics in their offspring, considering the demographic and socioeconomic characteristics of the families.

MATERIAL AND METHODS

A multiple-purpose survey was conducted anonymously among 229 parents of patients hospitalised in the Department of Paediatrics, University Children's Hospital, Krakow. Each parent answered 23 questions regarding OTC antipyretics use in his/her hospitalised child throughout the whole child's life. The data was statistically analysed.

RESULTS

OTC antipyretics are administered to their children by 92% of parents. In the vast majority (87%), health care professionals or a leaflet were the sources of information on the drug and its dosage. Parents also used information from TV or the Internet (27%) and friends and family (30%), especially those in the younger age group. Families with high socioeconomic status were more likely to use health care professionals' advice for drug knowledge. Parents of children with allergic diseases made less use of nonmedical sources of knowledge.

CONCLUSIONS

The majority of parents use OTC antipyretic drugs in their children. However, a high percentage of people using nonmedical sources of information is of concern. It is necessary to educate caregivers and to build the parents' awareness that they take an active role in their child's treatment. It would be useful to create generally available recommendations for home treatment.

Multifactorial causation of early onset colorectal cancer

The multiple-hit hypothesis of cancer, including colorectal cancer (CRC), states that neoplastic development requires a sequence of mutations and epigenetic changes in driver genes. We have previously proposed that obesity increases CRC risk by supporting neoplastic development through adipokine-induced signaling, and this proliferative signaling substitutes for specific driver gene mutations. In support of this hypothesis, analyses of The Cancer Genome Atlas (TCGA) mutation data have revealed that obese patients with microsatellite stable CRC exhibit fewer driver gene mutations than CRC patients with normal body mass index. The lower number of driver gene mutations required for cancer development may shorten the neoplastic process and lead to an early onset of CRC. Therefore, obesity could be one factor explaining the rise of CRC incidence among younger individuals (< 50 years of age); furthermore, early onset CRC has been associated with the increasing incidence of metabolic syndrome and obesity in this age group. However, CRC incidence among older individuals (> 50 years of age) is stable or declining, despite the high rates of metabolic syndrome and obesity in this age group. In search for explanations of this phenomenon, we discuss several factors that may contribute to the divergent CRC incidence trends in populations under, and above, the age of 50, despite the rising levels of metabolic syndrome and obesity across all ages. First, older individuals with metabolic dysregulation are more frequently on maintenance medications, such as aspirin, β-blockers, lipid-lowering drugs, ACE inhibitors, metformin, etc., compared to younger individuals. Such treatments may suppress specific adipokine-induced proliferative signaling pathways, and therefore counteract and slow down neoplastic development in medicated overweight/obese individuals. Second, in the past decades, the incidence of infectious diseases accompanied by febrile episodes has been decreasing and the use of antipyretics increasing. Compared to normal cells, neoplastic cells are more sensitive to high body temperature; therefore, the decreased number of febrile episodes in childhood and adolescence may contribute to increased cancer incidence before the age of 50. Third, obesity at younger age may expand the stem cell compartment. An increased number of intestinal stem cells and stem cell divisions translates into a higher probability of sporadic mutations in the stem cells, and therefore, a greater chance of neoplasia. In conclusion, we hypothesize that early onset CRC has multifactorial causation and the proposed associations could be examined through analyses of existing data.

Evaluation of the Erosive and Cariogenic Potential of Over-the-Counter Pediatric Liquid Analgesics and Antipyretics

To evaluate the cariogenic and erosive potentials of over-the-counter pediatric oral liquid antipyretics and analgesics, we tested nine over-the-counter pediatric oral liquid medications classified as antipyretic or analgesic medicines available in Korea. For each substance, we measured the pH with a pH meter and the sugar content with a sugar content meter. We determined the titratable acidity (TA) levels based on the volumes of NaOH solution that had to be added to reach a pH of 7.0. We also evaluated the dental erosion potentials with an International Organization for Standardization method based on observing changes in the pH of a CaPO₄ solution upon introducing a small volume of the solution to be tested. The oral liquid medications had pH values of 3.40–5.68. In the TA assessments, several oral liquid medications required greater volumes of NaOH solution to reach a pH of 7.0. The dental erosion potentials varied but correlated strongly with the NaOH volumes needed to reach a neutral pH (r = 0.84; p < 0.0001). Many oral liquid antipyretics and analgesics have features that can promote dental erosion. A correct understanding of pediatric antipyretics and analgesics is required in dentistry for children’s oral health.

Secondary metabolite and antipyretic effects of Maja (Crescentia cujete L.) in fever-induced mice

OBJECTIVES

Fever is a condition when the body experiences an increase in average body temperature above normal level. Maja fruit (Crescentia cujete L.) contains chemical compounds including alkaloid, flavonoid, saponin, and terpenoid, suspected as potential antipyretics.

METHODS

The study aimed to determine the antipyretic activity of ethanol extract of Maja fruit. A total of 25 male white mice of the DDY strain (20-30 g). These treatments divided into three groups with a dose extract of 125, 250, 500 mg/kg BW, standard groups of ibuprofen 400 mg/kg BW, and control groups of CMC-Na 1%. Mice were injected intraperitoneally with 0.1 cc of DPT vaccine-induced. Observations were made by measuring the rectal temperatures of mice using a digital thermometer before DPT vaccine injected or average temperatures, at 0 min (after DPT vaccine injected), 60, 120, 180, and 240 min after administering the test material. The differences between the positive control group, test group, and the negative control group were compared using statistical analysis using one-way variance analysis (ANOVA). The results were considered statistically when the value is (p<0.05).

RESULTS

The above phytochemical screening results showed that alkaloids, flavonoids, and saponins were present in the Maja fruit powder and extract (C. cujete L.). Based on the results of the statistical analysis obtained, i.e., Group II was not significantly different from Group III and Group IV (p≤0.05) and was significantly different from Group I and Group V. Group I was significantly different from Group II, Group III and Group IV and was not significantly different from Group V (p≥0.05).

CONCLUSIONS

The study showed that Maja fruit mice's antipyretic behavior at doses of 125, 250, and 500 mg/kg BW was confirmed as a result in reducing the body temperature of male mice. The 500 mg/kg BW dosage of Maja fruit extract (C. cujete L) effectively reduced fever.

Fever phobia in caregivers presenting to New Zealand emergency departments

Objective

To determine the prevalence of fever phobia among caregivers of children presenting to New Zealand EDs.

Methods

A cross‐sectional survey was administered to caregivers of children <5 years of age presenting to three New Zealand EDs. We defined fever phobia as caregivers having a high level of concern regarding fever or having incorrect beliefs regarding the consequences of fever.

Results

A total of 502 caregivers completed the survey. Fever phobia was present in 365 (74.3% [95% confidence interval, CI 70.3–78.0%]) respondents, with 242 (49.3% [95% CI 44.9–53.7%]) caregivers reporting a high level of concern regarding fever, and 288 (61.8% [95% CI 57.3–66.1%]) caregivers reporting at least one incorrect belief regarding the consequences of fever. Majority of caregivers (n = 383, 87.6% [95% CI 84.2–90.4%]) knew the correct dosing interval for paracetamol, compared to less than half of caregivers (n = 179, 42.5% [95% CI 37.9–47.3%]) for ibuprofen. Caregivers reported non‐evidence‐based fever management practices such as sponging, always giving paracetamol and/or ibuprofen for fever, and waking children from sleep to give antipyretics. Over one‐third of caregivers identified ED doctors (n = 195, 40.2% [95% CI 34.7–43.2%]) and ED nurses (n = 173, 35.7% [95% CI 31.5–40.0%]) as sources of information regarding fever management. A higher level of education was associated with fever phobia (odds ratio 1.68 [95% CI 1.04–2.72], P = 0.04).

Conclusions

Fever phobia is prevalent among caregivers of children presenting to New Zealand EDs. Opportunistic caregiver education in the ED in conjunction with public health strategies are needed to dispel undue fears and misconceptions about fever.

Physical Activity Outdoors as an Alternative to Lockdown: the Three Cs Strategy

Basing on scientific evidence and discussions with many people about COVID-19, an outline of the Three Cs Strategy is presented as an alternative to lockdown. The suggested solutions - eg encouraging regular physical activity outdoors (also for symptomless quarantined people), frequent ventilation with fresh air, and more careful use of antipyretics - can markedly help to reduce the rate of transmission of this disease. The new strategy is also likely to lower the risk of mental disorders and various diseases, thanks to promotion of a healthy lifestyle. The outline should be discussed and refined in the future, to improve public health worldwide.

Hypothermia induced by therapeutic doses of antipyretics: misdiagnosis of cold sepsis

Fever is a natural and almost universal mammalian response to infection. There exists a fear amongst general public and healthcare providers regarding fever being harmful leading to its overzealous management with antipyretics. Although the National Institute for Health and Care Excellence (NICE) guidelines suggest the use of single antipyretic agent for management of fever, combination therapy with paracetamol, and ibuprofen is common in paediatric practice in the United Kingdom. These antipyretics at times can cause significant adverse events even when administered at regular therapeutic doses. We describe a young boy who presented with significant hypothermia (34.1°C) and was initially treated as cold sepsis. Once the boy got warmed up and as blood results became subsequently available, it became clearer that the hypothermia was secondary to therapeutic doses of antipyretics. In conclusion, we hope to improve awareness regarding this condition in clinical practice and educate health care professionals and caregivers with recommended NICE guidelines.

Mothers' false beliefs and myths associated with teething

BACKGROUND

Teething is a physiological process experienced by all children. However, many unrelated illnesses are blamed on teething.

OBJECTIVE

The aim of this study was to assess mothers' beliefs toward teething and to investigate the practices preferred by mothers to alleviate symptoms that might accompany the teething process.

METHODS

A cross-sectional study was conducted in Basra. The study population includes mothers of young children aged (6-30) months who had at least one erupted primary tooth, and who had no history of medical or systemic disease that might affect teething. Two hundred mothers of different age groups and educational backgrounds responded to a questionnaire that included information on the child's age and birth order, mother's age, level of education, occupation, number of children, beliefs toward teething symptoms, and the practices preferred to relieve the attributed symptoms. Data has been presented in numbers and percentages, the Chi-square test was performed where appropriate, and a p value of < 0.05 was considered significant.

RESULTS

All (100%) participants attributed at least one symptom or sign to the teething process. The most common symptoms reported were fever (70%), diarrhea (68.5%), and sleep disturbance (63.5%). Sixty-eight percent of mothers believed teething remedies were effective; only 10 (5%) did not give any treatment. Over half (62%) gave medications, such as antipyretics, antibiotics, and antidiarrheal agents. Some used teething gels (29%), pacifiers (50%), gum massage (22%), and hard foods such as biscuits and carrots (43.5%). Mothers of various educational levels reported attributed symptoms, and the result was statistically significant (p < 0.05). Mothers of a firstborn child were found to have a higher tendency to attribute symptoms to teething than those who had previous experience with children (p < 0.05).

DISCUSSION AND CONCLUSIONS

Teething myths and misconceptions are common among mothers. The study identified a significant number of doctors, dentists, and pharmacists still attribute many symptoms and signs to teething despite the lack of supporting evidence. Therefore, the findings of this study highlight the need for continuous medical education and nationwide prospective studies to eradicate these false beliefs.

Knowledge, Attitude, and Practice in Management of Childhood Fever Among Saudi Parents

Fever is considered as a frequent symptom in childhood and is the cause of almost 65% to 70% of pediatric visits. Saudi Arabia has about 10% of child population (under 4 years of age), imposing a high burden of childhood illnesses including fever. A total of 1700 questionnaires were distributed to Saudi parents with children visiting pediatric clinic. Most of the participants were mothers (77.4%). A temperature of 38.0 °C was defined fever by 42% of participants. The majority of parents (80%) believed seizure is the consequence of untreated high fever. A total of 72.5% indicated that 40.7 to 43.20°C is the highest temperature that can be reached if untreated. There was a statistically significant relationship between mothers and fathers for overall knowledge, attitude, and practice scores. This study indicates that numerous misconceptions still persist regarding fever as more than 90% of parents demonstrated undue fear of consequent body damage from fever and also believed antibiotics can reduce high temperature.

Beliefs, Practices and Health Care Seeking Behavior of Parents Regarding Fever in Children

Background and objectives: Fever in children is one of the most common reasons for seeking medical attention. Parents often have misconceptions about the effects to fever, which leads to inappropriate use of medication and nonurgent visits to emergency departments (ED). The aim of this study was to clarify the beliefs on the effects and management of fever and to identify healthcare seeking patterns among parents of febrile children in Latvia. Materials and Methods: Parents and legal guardians of children attending ED with febrile illness were included in the study. Participants were recruited in Children’s Clinical University Hospital (CCUH) in Riga, and in six regional hospitals in Latvia. Data on beliefs about fever, administration of antipyretics, healthcare-seeking behavior, and experience in communication with health care workers were collected via questionnaire. Results: In total, 355 participants were enrolled: 199 in CCUH and 156 in regional hospitals; 59.2% of participants considered fever itself as indicative of serious illness and 92.8% believed it could raise the child’s body temperature up to a dangerous level. Antipyretics were usually administered at median temperature of 38.0 °C, and the median temperature believed to be dangerous was 39.7 °C; 56.7% of parents usually contacted a doctor within the first 24 h of the illness. Parents who believed that lower temperatures are dangerous to a child were more likely to contact a doctor earlier and out-of-hours; 60.1% of participants had contacted their family doctor prior their visit to ED. Parental evaluation of satisfaction with the information and reassurance provided by the doctors at the hospital was higher than of that provided by their family doctor; 68.2% of participants felt safer when their febrile children were treated at the hospital. Conclusions: Fever itself was regarded as indicative of serious illness and potentially dangerous to the child’s life. These misconceptions lead to inappropriate administration of antipyretics and early-seeking of medical attention, even out-of-hours. Hospital environment was viewed as safer and more reassuring when dealing with febrile illness in children. More emphasis must be placed on parental education on proper management of fever, especially in primary care

Pharmacotherapy Literacy and Parental Practice in Use of Over-the-Counter Pediatric Medicines

Background and objectives: Pharmaceutical literacy skills of parents are crucial for appropriate and safe medication use in pre-school children (ages 1⁻7 years). A recent study on pharmacotherapy literacy from Serbia showed that one in five parents have difficulty understanding common information about the use of medicines. Because antipyretics are considered to be the most frequently used group of over-the-counter (OTC) medications during the pre-school period, we aimed to: (i) examine parental practice and expectations in antipyretic medication use, and (ii) analyze associations of parental practice and expectations related to socio-economic status and pharmacotherapy literacy. Materials and methods: A cross-sectional survey using a self- report validated specific instrument was conducted with the parents of pre-school children in kindergartens in Belgrade, Serbia. Pharmacotherapy literacy refers to the knowledge and personal skills needed to meet the complex demands of medicine use in both healthcare and non-healthcare settings. A comprehensive literature review, expert-focus group consultation, and pre-testing were employed in 4-item multiple-choice test development to explore practice and expectations related to the use of OTC pediatric antipyretic medicines. Results: The final analytical cohort was comprised of 813 participants, the majority (63.3%) chose a medicine based on a physician's suggestion and only 15.4% of parents reported they would follow the advice of a pharmacist. More than a half of parents (54.1%) would need advice about antipyretic medicine from a pharmacist, firstly in a simpler language. Parents satisfied with the information given by a pharmacist had higher pharmacotherapy literacy, compared to parents with lower levels (OR⁻0.718, 95%CI (0.597⁻0.865), p < 0.001). Men had a higher expectation of pharmacists to explain medicine use in a simpler language (OR⁻1.630, 95%CI (1.063⁻2.501), p = 0.025), as well as parents with three or more children (OR⁻2.527, 95%CI (1.43⁻4.459), p = 0.001). Parents with higher knowledge about medicine use were less likely to ask for simpler information (OR⁻0,707; 95%CI (0,583⁻0,856), p < 0,001). Conclusions: Our main finding is that practice in antipyretic OTC medicine use was associated with levels of parental pharmacotherapy literacy. The expectations of pharmacists were higher among parents with lower levels of pharmacotherapy literacy, who expected more information in a simpler and more precise language. This study highlighted the need for pharmacists to identify risks in parental practice and to provide information about medicines to parents of pre-school children in a simpler and more appropriate way.

A randomized controlled feasibility trial of paracetamol during febrile neutropenia in hemato-oncology patients

The efficacy of paracetamol (acetaminophen) as an antipyretic during febrile neutropenia (FN) has not previously been established. We conducted a randomized double-blind placebo-controlled feasibility trial: hemato-oncology patients at high FN risk were randomly assigned to six hourly oral paracetamol (1 g) or placebo during the first 42 hours of FN. Fifty-three participants were screened, thirty-seven enrolled; 22 developed FN and commenced treatment (13 paracetamol; 9 placebo); recruitment rates were below, and retention rates met, pre-defined feasibility criteria. During the first 24 hours of FN, paracetamol recipients had significantly lower peak temperature than placebo: mean 38.2 (standard deviation 0.8) °C versus 38.9 (0.4) °C; difference -0.78 °C (95% CI -1.38 to -0.18); p = .013. Bacterial load measurement was not informative. Paracetamol lowers body temperature during FN, and definitive trials to determine its impact on FN outcomes are needed. Australian New Zealand Clinical Trials Registry reference ACTRN12613000601730; funded by Health Research Council of New Zealand.

Prescribing Controversies: An Updated Review and Meta-Analysis on Combined/Alternating Use of Ibuprofen and Paracetamol in Febrile Children

Background: Ibuprofen and paracetamol are the only antipyretics recommended in febrile children. According to international guidelines the choice of the drug should rely on the child's individual characteristics, while a controversial issue regards the combined or alternate use of the two drugs. Objective: To compare the efficacy and safety of combined or alternating use of ibuprofen and paracetamol in children. Methods: A systematic review of literature was performed on Medline and Embase databases. The included studies were randomized controlled trials analyzing the efficacy of combined or alternating therapy with antipyretics in febrile children vs. monotherapy. A meta-analysis was performed to measure the effect of treatment on child's temperature and discomfort. Adverse effects were analyzed as secondary outcome. Results: Nine studies were included, involving 2,026 children. Mean temperature was lower in the combined therapy group at 1 h (mean difference: -0.29°C; 95%CI: -0.45 to -0.13) after the initial administration of therapy. No statistical difference was found in mean temperature at 4 and 6 h from baseline. A significant difference was found in the proportion of children reaching apyrexia at 4 and 6 h with the combined treatment (RR: 0.18, 95%CI: 0.06 to 0.53, and 0.10, 95%CI: 0.01-0.71, respectively) and at 6 h with alternating treatment (RR: 0.30, 95% CI: 0.15-0.57), compared to children treated with monotherapy. The child's discomfort score was slightly lower with alternating therapy vs. monotherapy. The pooled mean difference in the number of medication doses per child used during the first 24 h was not significantly different among groups. Discussion: Combined or alternating therapy resulted more effective than monotherapy in reducing body temperature. However, the benefit appeared modest and probably not clinically relevant. The effect on child discomfort and number of doses of medication was modest as well. According to our findings, evidences are not robust enough to encourage combined or alternating paracetamol and ibuprofen instead of monotherapy to treat febrile children, reinforcing the current recommendation of most of the international guidelines.

Febrile seizures: an overview

Background

Febrile seizures are the most common neurologic disorder in childhood. Physicians should be familiar with the proper evaluation and management of this common condition.

Objective

To provide an update on the current understanding, evaluation, and management of febrile seizures.

Methods

A PubMed search was completed in Clinical Queries using the key terms ‘febrile convulsions’ and ‘febrile seizures’. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews.

Results

Febrile seizures, with a peak incidence between 12 and 18 months of age, likely result from a vulnerability of the developing central nervous system to the effects of fever, in combination with an underlying genetic predisposition and environmental factors. The majority of febrile seizures occur within 24 hours of the onset of the fever. Febrile seizures can be simple or complex. Clinical judgment based on variable presentations must direct the diagnostic studies which are usually not necessary in the majority of cases. A lumbar puncture should be considered in children younger than 12 months of age or with suspected meningitis. Children with complex febrile seizures are at risk of subsequent epilepsy. Approximately 30–40% of children with a febrile seizure will have a recurrence during early childhood. The prognosis is favorable as the condition is usually benign and self-limiting. Intervention to stop the seizure often is unnecessary.

Conclusion

Continuous preventative antiepileptic therapy for the prevention of recurrent febrile seizures is not recommended. The use of intermittent anticonvulsant therapy is not routinely indicated. Antipyretics have no role in the prevention of febrile seizures.

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.

Guidelines for the symptomatic management of fever in children: systematic review of the literature and quality appraisal with AGREE II

INTRODUCTION

Several societies have produced and disseminated clinical practice guidelines (CPGs) for the symptomatic management of fever in children. However, to date, the quality of such guidelines has not been appraised.

OBJECTIVE

To identify and evaluate guidelines for the symptomatic management of fever in children.

METHODS

The research was conducted using PubMed, guideline websites, and Google (January 2010 to July 2016). The quality of the CPGs was independently assessed by two assessors using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument, and specific recommendations in guidelines were summarised and evaluated. Domain scores were considered of sufficient quality when >60% and of good quality when >80%.

RESULTS

Seven guidelines were retrieved. The median score for the scope and purpose domain was 85.3% (range 66.6-100%). The median score for the stakeholder involvement domain was 57.5% (range 33.3-83.3%) and four guidelines scored >60%. The median score for the rigour of development domain was 52.0% (range 14.6-98.9%), and only three guidelines scored >60%. The median score for the clarity of presentation domain was 80.9% (range 50.0-94.4%). The median score for the applicability domain was 39.3% (8.3-100%). Only one guideline scored >60%. The median score for the editorial independence domain was 48.84% (0-91.6%); only three guidelines scored >60%.

CONCLUSION

Most guidelines were recommended for use even if with modification, especially in the methodology, the applicability and the editorial independence domains. Our results could help improve reporting of future guidelines, and affect the selection and use of guidelines in clinical practice.

Parental Approach to the Prevention and Management of Fever and Pain Following Childhood Immunizations: A Survey Study

Antipyretic analgesics are commonly used to prevent and treat adverse events following immunizations. Current practice discourages routine use due to possible blunting of vaccine immune responses. We surveyed 150 parents/caregivers of recently vaccinated 6- and 15-month-old children to determine the prevalence of and beliefs regarding antipyretic analgesics use around vaccinations. 11% used them prophylactically, before vaccination. Use in the first 48 hours after vaccination was 64%, primarily to prevent and/or treat fever and pain. Acetaminophen was administered 2.6 times more frequently than ibuprofen. Ibuprofen was used more in the 15-month compared with the 6-month-old children (28% vs 7.4%, respectively, P = .001). The majority of caregivers disagreed with their use for fever (53%) or pain (59%). Antipyretic analgesic use, including prophylaxis, around vaccinations was common in our study population. Effective interventions are needed to target parents/caregivers to eliminate unnecessary antipyretic analgesic use around vaccination time and foster nonmedication alternatives.

Antipyretic Therapy in Critically Ill Septic Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

This meta-analysis aimed to examine the impact of antipyretic therapy on mortality in critically ill septic adults.

DATA SOURCES

Literature searches were implemented in Ovid Medline, Embase, Scopus, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, and ClinicalTrials.gov through February 2016.

STUDY SELECTION

Inclusion criteria were observational or randomized studies of septic patients, evaluation of antipyretic treatment, mortality reported, and English-language version available. Studies were excluded if they enrolled pediatric patients, patients with neurologic injury, or healthy volunteers. Criteria were applied by two independent reviewers.

DATA EXTRACTION

Two reviewers independently extracted data and evaluated methodologic quality. Outcomes included mortality, frequency of shock reversal, acquisition of nosocomial infections, and changes in body temperature, heart rate, and minute ventilation. Randomized and observational studies were analyzed separately.

DATA SYNTHESIS

Eight randomized studies (1,507 patients) and eight observational studies (17,432 patients) were analyzed. Antipyretic therapy did not reduce 28-day/hospital mortality in the randomized studies (relative risk, 0.93; 95% CI, 0.77-1.13; I = 0.0%) or observational studies (odds ratio, 0.90; 95% CI, 0.54-1.51; I = 76.1%). Shock reversal (relative risk, 1.13; 95% CI, 0.68-1.90; I = 51.6%) and acquisition of nosocomial infections (relative risk, 1.13; 95% CI, 0.61-2.09; I = 61.0%) were also unchanged. Antipyretic therapy decreased body temperature (mean difference, -0.38°C; 95% CI, -0.63 to -0.13; I = 84.0%), but not heart rate or minute ventilation.

CONCLUSIONS

Antipyretic treatment does not significantly improve 28-day/hospital mortality in adult patients with sepsis.

Recognition and management of febrile convulsion in children

Febrile convulsion is characterised by convulsion associated with fever in an infant or child aged between six months and six years. The febrile illness causing the convulsion should not be secondary to an intracranial infection (meningitis or encephalitis) or acute electrolyte imbalance. Most cases of febrile convulsion are short lived and self-terminating. However, a few cases of prolonged febrile convulsion may need anticonvulsant medication to stop the seizure. Management is mainly symptomatic, although anticonvulsants may have a role in a small number of children with complex or recurrent febrile convulsion. Referral to paediatric neurologists may be necessary in cases of complex or recurrent febrile convulsion, or in those where a pre-existing neurological disorder exists. One third of children will develop a further febrile convulsion during subsequent febrile illness. Nurses have a vital role in managing children with febrile convulsion, educating parents about the condition and dispelling myths. This article outlines the presentation, management, investigations and prognosis for febrile convulsion, indicating how nurses working in different clinical areas can help to manage this common childhood condition.

Association of Acetaminophen and Ibuprofen Use With Wheezing in Children With Acute Febrile Illness

BACKGROUND

Many infants and children receive acetaminophen and/or ibuprofen during febrile illness. Previously, some studies have linked acetaminophen and ibuprofen use to wheezing and exacerbation of asthma symptoms in infants and children.

OBJECTIVE

To assess whether acetaminophen or ibuprofen use are associated with wheezing in children presenting to the emergency department (ED) with febrile illness.

METHODS

This was a cross-sectional study of children who presented with fever to the pediatric ED between 2009 and 2013. The data were collected from questionnaires and from the children's medical files. Patients with wheezing in the ED were compared with nonwheezing patients. Associations between medication use and wheezing were assessed using univariate and multivariate analyses. The multivariate analysis adjusted for potential confounding variables (ie, age, atopic dermatitis, allergies, smoking, antibiotics use, etc) via propensity scores.

RESULTS

During the study period, 534 children admitted to the ED met our inclusion criteria, of whom 347 (65%) were included in the study. The use of acetaminophen was similar in children diagnosed with wheezing compared with those without wheezing (n = 39, 81.3%, vs n = 229, 82.7%, respectively). Ibuprofen use was significantly lower in children diagnosed with wheezing (n = 22, 52.4%, vs n = 168, 69.4%, respectively). In multivariate analysis, acetaminophen was not associated with a higher rate of wheezing during acute febrile illness (adjusted odds ratio [OR] = 0.76, 95% CI = 0.24- 2.39), whereas ibuprofen was associated with a lower risk of wheezing (adjusted OR = 0.36, 95% CI = 0.13-0.96).

CONCLUSIONS

Our study suggests that acetaminophen and ibuprofen are not associated with increased risk for wheezing during acute febrile illness.

Fever and Pain Management in Childhood: Healthcare Providers' and Parents' Adherence to Current Recommendations

In order to evaluate the adherence of healthcare providers and parents to the current recommendations concerning fever and pain management, randomized samples of 500 healthcare providers caring for children and 500 families were asked to complete an anonymous questionnaire. The 378 health care providers (HCPs) responding to the survey (75.6%) included 144 primary care pediatricians (38.1%), 98 hospital pediatricians (25.9%), 62 pediatric residents (16.4%), and 71 pediatric nurses (19.6%); the 464 responding parents (92.8%) included 175 whose youngest (or only) child was ≤5 years old (37.7%), 175 whose youngest (or only) child was aged 6–10 years (37.7%), and 114 whose youngest (or only) child was aged 11–14 years (24.6%). There were gaps in the knowledge of both healthcare providers and parents. Global adherence to the guidelines was lower among the pediatric nurses than the other healthcare providers (odds ratio 0.875; 95% confidence interval 0.795–0.964). Among the parents, those of children aged 6–10 and 11–14 years old, those who were older, and those without a degree answered the questions correctly significantly less frequently than the others. These findings suggest that there is an urgent need to improve the dissemination of the current recommendations concerning fever and pain management among healthcare providers and parents in order to avoid mistaken and sometimes risky attitudes, common therapeutic errors, and the unnecessary overloading of emergency department resources. Pediatric nurses and parents with older children, those who are older, and those with a lower educational level should be the priority targets of educational programmes.

Patients' Knowledge About Analgesic-Antipyretic Medications Purchased in Community Pharmacies: A Descriptive Study

The objective of this study was to describe the level of knowledge about paracetamol (acetaminophen), ibuprofen, and aspirin of subjects who purchased nonprescription medications containing one of these drugs. We conducted this cross-sectional descriptive study in 42 community pharmacies located in southwestern France between July and November 2013. A six-item self-administered questionnaire was used. Participants were asked to identify the active ingredient contained in 14 brand-name analgesic-antipyretics, to state the maximum daily dose of paracetamol, ibuprofen, and aspirin, the recommended first-line analgesic, and precautions of use or contraindications for paracetamol, ibuprofen, and aspirin. Among 576 participants, the identification of paracetamol ranged from 58% (for Dafalgan or Efferalgan) to 90% (for Doliprane), the identification of ibuprofen from 34% (for Nureflex) to 63% (for Nurofen), and the identification of aspirin was 70% (for Aspegic). The maximum recommended daily dose of paracetamol, ibuprofen, and aspirin was known by 58.3%, 17.7%, and 19.3% of participants, respectively, whereas 6.8%, 17.2%, and 13.2% stated supratherapeutic daily doses. Paracetamol was correctly stated as the first-line analgesic-antipyretic by 76.2% of participants. Knowledge on major precautions of use or contraindications was poor (45.8% and 53.6% for ibuprofen and aspirin use during pregnancy, and 14.1% for concurrent use of anticoagulants and ibuprofen). Purchasers of nonprescription analgesic-antipyretics had poor knowledge on the medication they purchased.

Parents' knowledge, attitudes, and practice in childhood fever: an internet-based survey

BACKGROUND

Fever in children is common and mostly caused by self-limiting infections. However, the number of (re)consultations in primary care is high, driven by lack of knowledge and fear among parents. These drivers have only been studied in parents when consulting with their sick child.

AIM

To study knowledge, attitudes, and practice in childhood fever in parents within the general population.

DESIGN AND SETTING

Internet-based survey of a sample of 1000 parents from the general population of the Netherlands.

METHOD

A 26-item cross-sectional survey was conducted of parents with one or more children aged < 5 years.

RESULTS

Of 625 responders (average age 34.9 years), 63.4% and 43.7% indicated ever visiting their GP or GP's out-of-hours centre with a febrile child, respectively: 88.3% knew the definition of fever (>38°C), 55.2% correctly stated that antibiotics are effective in treating bacterial infections and not viral infections, and 72.0% knew that not every child with a fever needs treatment with antibiotics or paracetamol. When asked to prioritise aspects of a GP's consultation, 53.6% considered physical examination as most important. Obtaining a prescription for antibiotics or antipyretics was considered least important.

CONCLUSION

Knowledge, attitudes, and practices concerning childhood fever varied among parents with young children. Parents generally expect thorough physical examination and information, but not a prescription for medication (antibiotics or antipyretics) when consulting with a feverish child. GPs must be aware of these expectations as these provide opportunities to enhance consultations in general and prescription strategies in particular.

A phase 2 randomized controlled trial of a multicomponent meningococcal serogroup B vaccine (I)

The novel meningococcal serogroup B vaccine (4CMenB, Bexsero(®)), recently approved in Europe and Australia, may soon be included in routine infant immunization schedules, subject to guidance from national or regional recommending bodies. In the development of 4CMenB and consistent with other newly introduced vaccines, clinical studies have shown concomitant administration with routine infant vaccines induces an incremental increase in some reactions, including fever. As this may hinder acceptability, we examined the impact of prophylactic paracetamol on the occurrence of fever and other solicited reactions, as well as the immune responses to study vaccines, in a prospectively designed study. 4CMenB was administered as a 4-dose series at 2, 3, 4, and 12 months of age concomitantly with routine infant vaccines: DTaP-HBV-IPV/Hib and PCV7, with or without prophylactic paracetamol; a third group received MenC vaccine. Immune responses to 4CMenB were not decreased by the use of paracetamol prophylaxis and there were no clinically relevant effects on immune responses to routine vaccines. Occurrence of fever was higher in infants co-administered with 4CMenB compared with those given MenC vaccine, but was significantly decreased by prophylactic paracetamol, as were other solicited reactions to vaccination, both local and systemic. Co-administration of 4CMenB had an acceptable tolerability profile, with no withdrawals due to vaccination-related adverse events. Inclusion of 4CMenB in routine infant immunization schedules will be a major advance in the control of meningococcal disease, and our study indicates that by using paracetamol prophylaxis, post-vaccination reactions are reduced without clinically relevant negative consequences on vaccine immunogenicity.

Combined and alternating paracetamol and ibuprofen therapy for febrile children

BACKGROUND

Health professionals frequently recommend fever treatment regimens for children that either combine paracetamol and ibuprofen or alternate them. However, there is uncertainty about whether these regimens are better than the use of single agents, and about the adverse effect profile of combination regimens.

OBJECTIVES

To assess the effects and side effects of combining paracetamol and ibuprofen, or alternating them on consecutive treatments, compared with monotherapy for treating fever in children.

SEARCH METHODS

In September 2013, we searched Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; LILACS; and International Pharmaceutical Abstracts (2009-2011).

SELECTION CRITERIA

We included randomized controlled trials comparing alternating or combined paracetamol and ibuprofen regimens with monotherapy in children with fever.

DATA COLLECTION AND ANALYSIS

One review author and two assistants independently screened the searches and applied inclusion criteria. Two authors assessed risk of bias and graded the evidence independently. We conducted separate analyses for different comparison groups (combined therapy versus monotherapy, alternating therapy versus monotherapy, combined therapy versus alternating therapy).

MAIN RESULTS

Six studies, enrolling 915 participants, are included.Compared to giving a single antipyretic alone, giving combined paracetamol and ibuprofen to febrile children can result in a lower mean temperature at one hour after treatment (MD -0.27 °Celsius, 95% CI -0.45 to -0.08, two trials, 163 participants, moderate quality evidence). If no further antipyretics are given, combined treatment probably also results in a lower mean temperature at four hours (MD -0.70 °Celsius, 95% CI -1.05 to -0.35, two trials, 196 participants, moderate quality evidence), and in fewer children remaining or becoming febrile for at least four hours after treatment (RR 0.08, 95% CI 0.02 to 0.42, two trials, 196 participants, moderate quality evidence). Only one trial assessed a measure of child discomfort (fever associated symptoms at 24 hours and 48 hours), but did not find a significant difference in this measure between the treatment regimens (one trial, 156 participants, evidence quality not graded).In practice, caregivers are often advised to initially give a single agent (paracetamol or ibuprofen), and then give a further dose of the alternative if the child's fever fails to resolve or recurs. Giving alternating treatment in this way may result in a lower mean temperature at one hour after the second dose (MD -0.60 °Celsius, 95% CI -0.94 to -0.26, two trials, 78 participants, low quality evidence), and may also result in fewer children remaining or becoming febrile for up to three hours after it is given (RR 0.25, 95% CI 0.11 to 0.55, two trials, 109 participants, low quality evidence). One trial assessed child discomfort (mean pain scores at 24, 48 and 72 hours), finding that these mean scores were lower, with alternating therapy, despite fewer doses of antipyretic being given overall (one trial, 480 participants, low quality evidence)Only one small trial compared alternating therapy with combined therapy. No statistically significant differences were seen in mean temperature, or the number of febrile children at one, four or six hours (one trial, 40 participants, very low quality evidence).There were no serious adverse events in the trials that were directly attributed to the medications used.

AUTHORS' CONCLUSIONS

There is some evidence that both alternating and combined antipyretic therapy may be more effective at reducing temperatures than monotherapy alone. However, the evidence for improvements in measures of child discomfort remains inconclusive. There is insufficient evidence to know which of combined or alternating therapy might be more beneficial.Future research needs to measure child discomfort using standardized tools, and assess the safety of combined and alternating antipyretic therapy.

Early antipyretic exposure does not increase mortality in patients with gram-negative severe sepsis: a retrospective cohort study

Existing data suggest that antipyretic medications may have deleterious effects on immune function and may increase mortality in human infection. This study was designed to evaluate the impact of antipyretic therapy on 28-day in-hospital mortality when administered early in the course of gram-negative severe sepsis or septic shock. This study was a single-center retrospective cohort study at a 1,111-bed academic medical center of all febrile patients with gram-negative bacteremia hospitalized with severe sepsis or septic shock (n = 278) between Jan 2002 and Feb 2008. Although the raw mortality was lower in the group that received an early antipyretic medication (22 vs. 35 %, p = 0.01), patients in the early antipyretic group had higher mean arterial pressure (58.0 vs. 52.7, p = 0.01) and higher 24-h T (max) (39.3 vs. 39.0, p < 0.01). Early antipyretic therapy was not significantly associated with 28-day in-hospital mortality (adjusted OR 0.55, 0.29-1.03) in a multivariable logistic regression model controlling for APACHE-II score, hypotension, pneumonia, surgery during hospitalization, persistent fever, and in-hospital dialysis. In conclusion, early antipyretic therapy is not associated with increased mortality.

Antipyretic and antinociceptive effects of Nauclea latifolia root decoction and possible mechanisms of action

CONTEXT

 Nauclea latifolia Smith (Rubiaceae) is a small tree found in tropical areas in Africa. It is used in traditional medicine to treat malaria, epilepsy, anxiety, pain, fever, etc.

OBJECTIVE

 The aim of this study was to investigate the effects of Nauclea latifolia roots decoction on the peripheral and central nervous systems and its possible mechanisms of action.

MATERIALS AND METHODS

 The analgesic investigation was carried out against acetic acid-induced writhing, formalin-induced pain, hot-plate and tail immersion tests. The antipyretic activity was studied in Brewer's yeast-induced pyrexia in mice. Rota-rod test and bicuculline-induced hyperactivity were used for the assessment of locomotor activity.

RESULTS

 Nauclea latifolia induced hypothermia and had antipyretic effects in mice. The plant decoction produced significant antinociceptive activity in all analgesia animal models used. The antinociceptive effect exhibited by the decoction in the formalin test was reversed by the systemic administration of naloxone, N(ω)-L-nitro-arginine methyl ester or glibenclamide. In contrast, theophylline did not reverse this effect. Nauclea latifolia (antinociceptive doses) did not exhibit a significant effect on motor coordination of the mice in Rota-rod performance. Nauclea latifolia protected mice against bicuculline-induced behavioral excitation.

DISCUSSION AND CONCLUSION

 Overall, these results demonstrate that the central and peripheral effects of Nauclea latifolia root decoction might partially or wholly be due to the stimulation of peripheric opioid receptors through the action of the nitric oxide/cyclic monophosphate guanosin/triphosphate adenosine (NO/cGMP/ATP)-sensitive- K(+) channel pathway and/or facilitation of the GABAergic transmission.