Are Antipyretics Beneficial in Febrile Children?

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Are Antipyretics Beneficial in Febrile Children?

• Dennis Scolnik
• MSc, MB, ChB, DCH, FRCP(C)
• Divisions of Emergency Services
• Clinical Pharmacology Toxicology
• Project Director, Research Institute
• Hospital for Sick Children
• Associate Professor of Paediatrics
• University of Toronto, Canada

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I am arguing against this proposition!!
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Fever

• Physiological response (Adam 1996)
• Body does not allow lethal temperature if
• no dehydration
• open environment
• no neurological abnormalities (Kluger 1992, Adam
  1996)
• Purposeful protective (Kluger 1991,1992,
  Roberts 1991)

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Fever

• Good
• rarely harmful
• (malignant hyperthermia)

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Fever Phobia

• New phenomenon
• Association with
• seizures
• febrile seizures
• Rx does not ? ?
• CNS infections
• rare that no other signs clinician not able to
  identify

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Fever Phobia

• Association versus Cause

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Are Antipyretics Beneficial in Febrile Children?

• Symptomatic (at best)!!
• makes child feel better
• NOT necessary for the medical condition
• Empowers parents

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Primum Non Nocere

• Harmless symptom
• Is it harmless to treat fever?

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Downsides of Treating Fever

• 1. Perpetuates fever phobia
• Medicalisation (Hay 2006)
• Increased use of medical facilities

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Downsides of Treating Fever

• 4. ? nosocomial infection
• Side-tracks parents ( some physicians!) from
  more important signs of illness
• POISONING!!

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Poisoning

• Physician error
• Parent error

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Physician Error Acetaminophen/Paracetamol
(Kozer, Scolnik et al 2002)

• Emergency Department
• 1678 drug orders/prescriptions

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Physician Error Acetaminophen/Paracetamol
(Kozer, Scolnik et al 2002)

• 10 in ED
• c.f.
• 6.6 - 11.7 in paediatric intensive care units

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Physician Error Acetaminophen/Paracetamol
(Kozer, Scolnik et al 2002)
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Physician Error Acetaminophen/Paracetamol
(Kozer, Scolnik et al 2002)

• Insignificant/minimal
• minimal likelihood harm
• e.g. 5 mg dexamethasone instead of 3 mg
• Significant
• non-life-threatening consequences/less effective
  treatment
• e.g. 10x lower dose of amoxicillin for otitis
  media
• Severe
• could cause death/decrease chance successful
  treatment of life-threatening condition
• e.g. 10x error insulin dosage

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Parent Error Acetaminophen/Paracetamol (Heubi
1998)

• Published, FDA, own hospital with therapeutic
  intent
• 47 patients
• 5 wks - 10 yrs
• 60 - 420 mg/kg/day for 1 - 42 days
• 24/43 patients (55) died
• 3 survived after transplant

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Parent Error (Acetaminophen/Paracetamol
Rivera-Penera 1998)

• Over 10 yrs
• 19 yrs age
• Parts of California
• Overdose with previous normal LFTs

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Parent Error (Acetaminophen/Paracetamol
Rivera-Penera 1998)

• 28/73 (38) abnormal LFTs
• All 28 severe hepatotoxicity
• 6 (21) liver transplantation

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Parent Error (Acetaminophen/Paracetamol
Rivera-Penera 1998)

• 14/73 10 yrs age
• 71 (10/14) of these had abnormal LFTs (versus
  31 in older)
• These 10 had all been overdosed by parents in
  error

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Drug Error Ibuprofen(Ulinski 2004, Paediatric
Nephrology, Hôpital Trousseau, Paris)

• 20 months in 1 centre
• 7 children with diarrhoea /or vomiting fever
• therapeutic doses (11.5 32 mg/kg/day)
• 1 - 3 days ? ACUTE RENAL FAILURE
• 1 dialyzed

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What Should We Do?

• Education gtgtgt treatment

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Education

• 1. Fever is a symptom not a disease

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Education

1. Fever is a symptom not a disease
2. A child can have meningitis with a low fever or a
   viral URTI with a high fever

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Education

1. Fever is a symptom not a disease
2. A child can have meningitis with a low fever or a
   viral upper respiratory tract infection with a
   high fever
3. The difference is in how sick the child is!!

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Education

• Fever is a symptom not a disease
• A child can have meningitis with a low fever or a
  viral upper respiratory tract infection with a
  high fever
• The difference is in how sick the child is!!
• 4. MINIMAL CLOTHES
• COOL ENVIRONMENT
• 5. FLUIDS

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Are Antipyretics Beneficial in Febrile Children?

• NO
• May make child feel better
• Cause more harm than good

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Therefore antipyretics are NOT beneficial in
febrile children
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Thank you!
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J Pediatrics 1997130(2)300-304
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J Pediatrics 1998 132(1)22-27