Analgesia and Fever Control in Common Pediatric Disease

1
Analgesia and Fever Control in Common Pediatric
Disease

• Dion Neame
• M.B., B.Ch., B.Sc., F.R.C.P.c, F.A.A.P.
• Assistant Clinical Professor
• McMaster Childrens Hospital
• Chief of Pediatrics, Joseph Brant Memorial
  Hospital

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Objectives

• Acetaminophen, Codeine, and Ibuprofen.
• Ibuprofen association with Reye syndrome?
• Ibuprofen is an Anti-inflammatory.
• Ibuprofen, Acetaminophen and Codeine in the
  Pediatric practice.
• Review of systems approach to numerous uses of
  analgesia in the pediatric patient.
• Conclusions

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Acetaminophen, the drug
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Acetaminophen, the drug

• Mechanism of action
• Inhibits the synthesis of prostaglandins in the
  central nervous system and peripherally blocks
  pain impulse generation.
• Acetaminophen produces antipyresis from
  inhibition of the hypothalamic heat regulating
  centre.
• Dosage
• 15 mg/kg every 4 to 6 hours P.O.

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Codeine, the drug
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Codeine, the drug

• Codeine is an alkaloid obtained from opium, or
  prepared from morphine by methylation.
• Codeine is a centrally active analgesic
• Side effect profile is similar to morphine
  respiratory depression, depression of cough,
  activation of vomiting, and constipation.
• Dosage
• 0.5 mg/kg every 4 to 6 hours P.O.

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Ibuprofen, the drug
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Ibuprofen, the drug

• Nonsteroidal Anti-inflammatory Drug (NSAID)
• Mechanism of Action competitive inhibitor
  reversibly binding to the arachidonic acid
  binding site of the cyclooxygenase enzyme.
• Dosage
• 3 months to 23 months
• 5 mg/kg every 6 to 8 hrs P.O.
• gt 23 months
• 10 mg/kg every 6 to 8 hrs P.O.

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Ibuprofen, the drug

• Prevents the conversion of arachidonic acid to
  PGH2

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Ibuprofen versus Acetaminophen

• Multiple studies comparing both drugs for
  efficacy and safety have found both drugs equal
  for fever and mild to moderate pain.
• Acetaminophen is embraced by Pediatric societies
  due to duration of usage versus efficacy and
  safety data.
• Fear of an association with Ibuprofen and Reye
  syndrome has limited support.

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Ibuprofen versus Reye syndrome

• There is only a theoretical risk of a link
  between ibuprofen and Reye syndrome.
• Childrens Analgesic Medicine Project and Boston
  Fever Study
• In approximately 75,000 cases, no cases of Reye
  syndrome were documented.

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Summary of Core Differences in the Mechanisms of
Actions

• Ibuprofen Acetaminophen Codeine
• Analgesic Analgesic Analgesic
• Antipyretic Antipyretic
• Anti-inflammatory

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What is Inflammation again?

• Inflammation is a normal response of the body to
  protect tissues from infection, injury or
  disease.
• The hallmarks are, pain, redness, swelling, heat,
  and loss of function.

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Inflammatory Mechanism
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Acetaminophen, Ibuprofen, Both??

• Archives Pediatric Adolescent Medicine
• Feb 2006
• Patients using alternating acetaminophen and
  ibuprofen q 4 hourly.
• Significantly lower mean temperatures and lower
  scores on the pain checklist, compared to those
  receiving either agent alone.

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Quick summary

• Ibuprofen is as good as acetaminophen for fever
  and mild to moderate pain.
• Codeine is the best analgesic, but no effect on
  fever.
• Ibuprofen has not been found to be associated
  with Reye syndrome in recent studies.
• Ibuprofen is a NSAID, which aids in inflammatory
  symptom relief which acetaminophen and codeine do
  not provide.
• Acetaminophen Ibuprofen gives better control.

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Analgesia in the Pediatric Practice

• Practical Points in Common Pediatric Disease

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Analgesia in the Pediatric Practice

• Ibuprofen, Acetaminophen, and Codeine have
  multiple uses in the pediatric age group, far
  beyond fever and mild to moderate analgesia.
• If you follow a systems review of pediatric
  disease, there are over twenty indications for
  their use above and beyond fever and analgesia.
• Also common day to day pediatric procedures are
  aided by Ibuprofen, Acetaminophen, Codeine and
  combinations of these medications.

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Ear, Nose, and Throat

• Serous otitis media
• Acute otitis media
• Otitis externa
• Sinusitis
• Acute pharyngitis

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Serous Otitis Media

• Blockage of the Eustachian tube leads to bacteria
  free fluid build up in middle ear.
• Ibuprofen or acetaminophen can aid the parents to
  treat the pain.
• If pain breaks through medication dosing, the
  parent should seek medical attention to reassess
  for acute otitis media.

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Acute Otitis Media

• Second most common reason for a child to visit
  the doctor.
• Pain is due to the inflammatory response within
  the middle ear.
• Antibiotics will kill the bacteria, but will do
  nothing in the first 48 hours to relieve the
  pain.
• Ibuprofen should be used to reduce the
  inflammatory response ie. pain.

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Otitis Externa

• Commonly known as swimmers ear
• Caused by bacterial overgrowth in water trapped
  in the external auditory canal.
• Otitis externa can be extremely painful.
• In the first 48 hours, antibiotics ear drops
  combined with ibuprofen can limit pain and aid in
  the administration of drops

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Acute Purulent Sinusitis

• Acute sinusitis is relatively rare in children
• If an upper respiratory tract infection persists
  for more than 10 days, with fever gt 39, facial
  pain, periorbital edema, post nasal drip,
  halitosis and cough, try
• Antibiotics and ibuprofen or acetaminophen will
  reduce symptoms.

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Acute Pharyngitis

• Acute pharyngitis is generally caused by viruses.
• Group A beta-hemolytic streptococcus common.
• Strep. throat is associated with fever, headache,
  and sore throat.
• Antibiotics, chloraseptic spray, ibuprofen
  alleviate symptoms.

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Central Nervous System

• Fever
• Headache
• Febrile seizures

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Fever

• Fever occurs when the hypothalamic
  thermoregulatory set point has been increased
• Uncomplicated fever is a relatively harmless
  event, and promotes beneficial components of the
  immune response.
• Treatment is based on the childs discomfort.

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Headaches

• Most headaches are benign and require symptom
  relief only.
• For tension, stress, or migraines headaches
  ibuprofen is an appropriate treatment.
• If headaches persist, or the headaches are
  associated with neurological signs, further
  investigations are needed.

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Febrile seizures

• Intuition would suggest that to prevent a febrile
  seizure occurrence or reoccurrence the fever
  should be well controlled by anti pyuretics.
• Studies have not shown 100 success, yet it is
  still standard practice to fever control
  consistently throughout the febrile period.

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Gastrointestinal system

• Hand foot and mouth disease
• Herpes gingivostomatitis
• Teething

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Hand Foot and Mouth Disease

• HFMD is caused by Coxsackie Group A virus.
• Clinically 4 to 5 days of a flu-like illness is
  followed by painless rash/vesicles over the palms
  and soles.
• Painful mouth lesion may lead to anorexia and
  dehydration.
• Ibuprofen and/or codeine decreases pain and
  inflammation in the throat allowing the child to
  rehydrate.

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Herpes Gingivostomatitis

• 90 of primary herpes infection are sub
  clinical.
• The clinical infection is dramatic in the primary
  stage, presenting with multiple discrete
  superficial ulcers throughout the oral cavity.
• Pain ranges from mild to severe, with anorexia
  and dehydration complicating.
• Rxn Zovirax, viscous lidocaine, Ibuprofen and/or
  codeine.

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Teething

• The emersion of teeth occurs between 2 months and
  3 years.
• Symptoms are local and systemic.
• Local mouth pain, drooling, perioral irritation.
• Systemic fever, irritability, anorexia,
  diarrhea, diaper rash.
• Rxn Teething rings, Acetaminophen/Ibuprofen

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Musculoskeletal System

• Joint Trauma
• Muscular injury
• Growing pains
• Rheumatologic conditions

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Joint Trauma

• Repeated trauma to the joint will result in
  inflammation of the synovial membrane and joint
  capsule.
• The inflamed synovial membrane and leucocytes,
  release free radicals, cytokines, and
  prostaglandins, which may damage the articular
  cartilage.
• Rxn rest, ice, ibuprofen, consult your doctor

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Muscular Injury

• Hockey
• Basketball
• Soccer
• Football
• Tennis
• Gymnastics
• Volleyball
• Cycling
• Shoveling snow

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Growing Pains

• Normal occurrence in 25 of children.
• Two age groups, early childhood 3 to 5 yrs, late
  childhood 8 to 12 yrs.
• Etiology unclear
• Pain symptoms in the late afternoon, evening, or
  night waking the child. Frequency of 1 per week
  or less.
• Rxn massage, stretching, heat, Ibuprofen,
  support.

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Rheumatologic conditions

• These conditions must always be diagnosed,
  followed, and reviewed by a physician.
• Ibuprofen is an element of the treatment, yet the
  complexity of the disease requires multiple
  therapies.
• JRA, SLE, AS, HSP, Kawasaki disease,
  Dermatomyositis, etc.

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Dermatology

• Atopic dermatitis is common in children.
• Genetic predisposition, associated with asthma
  and allergies.
• Rxn avoid irritants,
• moisturize skin,
• topical steroids,
• immunomodulators,
• antibiotics,
• antihistamines,
• analgesics, Ibuprofen

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Gynecology

• Primary Dysmenorrhea
• Usually starts 1 to 2 yrs. after menarche, at 12
  to13 yrs. of age.
• Prostaglandins produce muscular contractions
  which cut off blood supply and oxygen causing
  pain.
• Antiprostaglandins Ibuprofen taken as the
  bleeding or cramping starts diminishes symptoms.

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Vaccinations

• Ibuprofen is effective pre and post vaccination.
• Analgesic given 30 minutes pre vaccination will
  reduce injection pain and vaccine solvent
  administration pain.
• Analgesic can be topical and/or oral.
• Topical lidocaine is now available. Ibuprofen is
  the oral choice.

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Vaccinations

• Common post vaccine side effects.
• Systemic fever, irritability, joint or muscle
  pain, and headache.
• Local swelling, induration, tenderness, redness
  or erythema at site of injection.
• These adverse events will be attenuated by
  Ibuprofen.

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Mild to Moderate Pain

• Post operative pain
• myringotomy tubes,
• tonsillectomy,
• adenoidectomy,
• cryotherapy wart removal,
• sutures,
• fractures,
• dental procedures,
• laser therapy,
• silver nitrate procedures.

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Observe Precautions

• Use caution in judicious use of ibuprofen
• Patients with renal disease
• Patients with dehydration
• Patients with chicken poxs
• Pre and post operatively
• Potentially with asthma

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Conclusion

• Ibuprofen Acetaminophen in fever and mild to
  moderate pain.
• Ibuprofen has not been related to Reye syndrome
  in recent literature.
• Ibuprofen gt Acetaminophen for common pediatric
  disease with an inflammatory component.
• Ibuprofen and Acetaminophen can be used
  effectively in an alternate dosing schedule.
• Codeine is by far your best oral analgesic.