US Pharm. 2019;44(5):22-25.
ABSTRACT: Fever is the most common clinical symptom treated by pediatricians and other healthcare practitioners. Community pharmacists play a key role in helping parents manage fever in otherwise healthy children, particularly given the prevalence of fever phobia. Educating parents on the differences between fever and heatstroke can alleviate their fears. Although tympanic thermometry is preferred for measuring temperature in most pediatric patients, the goal of therapy is not to treat to a number but rather to relieve discomfort from fever-related symptoms. Acetaminophen and ibuprofen are the agents of choice for relieving symptomatic discomfort in children. The pharmacist should give parents a calculated weight-based dose and counsel them on proper dose administration.
Fever is the most common clinical symptom treated by pediatricians and other healthcare practitioners. Nearly one-third of all patient visits to a pediatrician are related to fever, and fever is the leading cause of emergency-department visits among children younger than 15 years.1 It is likely that the community pharmacist, as the patient’s first-line source of information, on a daily basis will field parents’ questions about how to treat their child’s fever. This article aims to answer the most commonly asked questions about treating fever in otherwise healthy children, debunk management myths, and help alleviate fears about fever (i.e., fever phobia).
The disparity between a child’s skin and core temperatures during a fever denotes the inaccuracy of touch for gauging fever; however, this method remains a common screening tool for parents. Thermometry is the best means of detecting elevations in core temperature. Body temperature can be measured at various sites, depending on the child’s age and personal preference. The use of fever strips and pacifier thermometers should be avoided; these devices are inaccurate and should not be offered to parents. Rectal temperature, which is not influenced by ambient temperature, was long held to be the gold standard but has fallen out of favor for home monitoring. Rectal temperature readings may lag in a child with a rapidly changing core temperature, the method may be uncomfortable, and improper use may result in bowel perforation.2 A 2018 study demonstrated that infrared tympanic thermometry had greater than 90% sensitivity for temperature detection.3 Therefore, tympanic measurement is now considered the preferred method because of its accuracy and ease of administration. Tympanic thermometers are built for the adult ear, so to increase accuracy of measurement in a child, these tips should be followed3:
1. Take the child’s temperature twice in each ear. Record the highest reading obtained.
2. For children younger than 3 years: Pull the earlobe back and down, and then aim the tip of the thermometer toward the child’s opposite eye so that the infrared sensor aligns with the tympanic membrane.
The American Academy of Pediatrics is less concerned with treating fever to a certain number and generally does not recommend seeking treatment for a child with fever. Parents of infants younger than 3 months who have rectal-equivalent temperature readings above 100.4°F should contact the child’s pediatrician for a visit. These infants are at higher risk for underlying bacterial infection and may require treatment beyond symptom management.3
See TABLE 1 for key notes on thermometry.
Pathophysiology of Fever
Fever (pyrexia) is defined as a temporary rise in body temperature that exceeds the normal core temperature. Increases in body temperature are regulated by the hypothalamus and indicate elevation of the body’s thermoregulatory set point. Changes in the set point and the body’s physiological response are managed via a feedback loop.4 An increase in the set point usually occurs in response to fever-inducing substances called pyrogens. Common exogenous pyrogens include bacterial endotoxins, antigen-antibody complexes, and viruses. As the thermal set point increases, the body attempts to restore homeostasis, raising the core temperature to match.5 Vasoconstriction at the periphery allows the body to reduce heat loss from the extremities, resulting in chills. Clinically, a child may experience increased respiratory and heart rates, shivering, and loss of appetite; these symptoms often precede fever onset. Fever resolution, which occurs once the body reverts to a lower set point, is associated with infection resolution or administration of antipyretic therapy. To cool the core temperature, the body uses vasodilation and sweating, and the child will appear flushed.4
One of the most persistent misconceptions surrounding fever in children is that fever can lead to seizures, brain damage, and death. Fevers do not cause brain damage or death, and it is important for parents to understand that fever differs from heatstroke. Fever is the body’s protective mechanism for fighting an infection. Febrile seizures, which occur in 2% to 4% of all children, are more closely associated with risk factors such as genetic predisposition, neonatal ICU stay, and infectious etiology.6 Febrile seizures are most likely in children aged 12 to 18 months, but they can occur in children up to 5 years of age.6 Questions continue to be raised about the etiology of febrile seizures and whether they can be attributed to a rapid escalation in body temperature or are related to a specific temperature. A possible mechanism for febrile seizures is the release of interleukin-1 beta, a cytokine that can disrupt the developing brain in children under 3 years old.7 Compared with the general population, the risk of developing epilepsy is just 0.5% higher in children who experience febrile seizures.6 Parents need reassurance that a fever is not going to cause their child permanent harm.
Pyrexia differs from hyperthermia caused by heatstroke, which is defined as a core body temperature exceeding 104°F plus impaired central nervous system function attributable to either exposure to high environmental temperatures or exertional fatigue in high ambient temperatures. In heatstroke, the hypothalamic set point remains normal and the child is unable to dissipate the heat or cool down. Children with heatstroke frequently present with seizures, delirium, and coma. Exercise and hot weather are the main causes of heatstroke.8
According to the American Academy of Pediatrics, a febrile child should receive symptomatic care, meaning that only the secondary discomfort that accompanies the fever should be treated. A sleeping child should not be woken up for treatment of a fever, and medication should be used to treat a fever only when the fever is causing the child discomfort. Parents should be advised to focus on comfort care rather than treatment intended to maintain a normal temperature. Comfort care centers on improving the child’s well-being, monitoring for changes in activity level, and maintaining adequate hydration.9 To prevent dehydration, fluid intake should be increased by 1 to 2 oz per hour in order to compensate for potential fluid loss. Balanced electrolyte formulations (e.g., Pedialyte), water, and sports drinks are considered acceptable fluids for maintaining hydration; however, caution should be used with sports drinks, which can worsen diarrhea.
An infant should be unbundled, and cool cloths should be placed on the infant or child’s forehead and neck to help improve the comfort level. Sponging or bathing with tepid water have shown limited utility in the management of fever and may precipitate febrile seizures.4 Bathing temporarily lowers the core temperature but fails to change the thermoregulatory set point; once the child or infant is out of the water, he or she may experience a rapid temperature rebound, increasing the likelihood of a febrile seizure. Also, rubbing alcohol or povidone-iodine baths should not be used in infants or children because of the risk of toxicity from absorbing these agents through the skin.4,9
Antipyretic therapy is a mainstay of fever management in patients with discomfort from fever. This therapy prevents prostaglandin synthesis by inhibiting cyclooxygenase enzymes, thereby reducing feedback between thermoregulatory neurons and the hypothalamus. This break in the feedback loop allows the hypothalamic temperature set point to return to normal.4
Acetaminophen and ibuprofen are the agents of choice for relieving symptomatic discomfort in children. It has historically been common practice to alternate these two antipyretics, but the American Academy of Pediatrics does not recommend cycling these agents because of the risks of overdose, medication errors, and increased side effects.10,11
Acetaminophen and ibuprofen are equally efficacious for treating a fever. Ibuprofen provides longer coverage, lasting 6 hours compared with 4 hours for acetaminophen. Acetaminophen may be used in children of any age; however, ibuprofen is recommended for children older than 6 months.4
One study examining the dosing of acetaminophen and ibuprofen in fever management found that more than one-half of all parents and caregivers administered an incorrect dose of antipyretic medication, with 15% giving a supratherapeutic dose of acetaminophen or ibuprofen.12 The pharmacist must calculate a specific dose for each individual patient. Often, pediatricians instruct parents to use the product label for dosing instructions, not realizing that the label does not give directions for children younger than 2 years or weighing less than 24 pounds. Additionally, the simplified dosing instructions on product labels may result in underdosing of children as they reach the top of any particular range. For example, instructions on the acetaminophen package suggest that a child weighing 47 lb or 21.4 kg receive 7.5 mL (240 mg). However, with a specific pharmacist-calculated dose based on 15 mg/kg, the same patient would receive 10 mL or 320 mg. See TABLE 2 for dosing information for these agents. Parents should be counseled to use the enclosed dosing cup (although an oral syringe should be supplied for younger children). If a syringe is being provided, the pharmacist should demonstrate how far the plunger is to be drawn back for the patient’s specific dose.4
Parents should be cautioned to avoid the use of aspirin in children, especially in the presence of viral symptoms, because of the risk of Reye syndrome. Additionally, parents should be informed to share this information with the child’s grandparents because aspirin was the standard therapy before ibuprofen and acetaminophen became available as OTC agents.9
Eligibility for Self-Care
Parents frequently seek the community pharmacist’s advice before purchasing a product for fever treatment. Assessment of the advisability of home treatment for the child should be made prior to a discussion of OTC modalities. It is imperative that the parents of a child who presents with the following signs and symptoms be advised to seek immediate medical attention: severe headache, seizure, inability to be roused, inability to walk or refusal to move the arm or leg, stiff neck, jellylike stools (a possible sign of intussusception), persistent fever for 5 or more days, fever in any patient aged 3 months or younger, fever for 2 or more days with worsening condition, diarrhea for more than 2 to 3 days, vomiting for more than a day, and continuous crying or inability to be soothed. These clinical manifestations, among other severe signs and symptoms, warrant urgent referral for appropriate evaluation and treatment.13
Pharmacists must educate parents on the difference between fever and heatstroke. Recommend the use of tympanic thermometry for measuring temperature in most pediatric patients. Remind parents that the goal of therapy is not treating to a number, but rather a child’s comfort. Acetaminophen and ibuprofen are the agents of choice for relieving symptomatic discomfort in children. Parents should be counseled on proper dose administration, including providing them with the calculated weight-based dose.
1. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report. 2010;(26):1-31.
2. El-Radhi AS, Barry W. Thermometry in paediatric practice. Arch Dis Child. 2006;91(4):351-356.
3. Mogensen CB, Wittenhoff L, Fruerhøj G, Hansen S. Forehead or ear temperature measurement cannot replace rectal measurements, except for screening purposes. BMC Pediatr. 2018;18(1):15.
4. Avner JR. Acute fever. Pediatr Rev. 2009;30(1):5-13.
5. Nield L, Kamat D. Fever. In: Kliegman R, Stanton B, eds. Nelson Textbook of Pediatrics. 20th ed. Philadelphia, PA: Elsevier; 2016:1276-1279.
6. Leung AK, Hon KL, Leung TN. Febrile seizures: an overview. Drugs Context. 2018;7:212536.
7. Dubé C, Vezzani A, Behrens M, et al. Interleukin-1beta contributes to the generation of experimental febrile seizures. Ann Neurol. 2005;57(1):152-155.
8. Bouchama A, Knochel J. Heat stroke. N Engl J Med. 2002;346(25):1978-1988.
9. Sullivan JE, Farrar HC. Fever and antipyretic use in children. Pediatrics. 2011;127(3):580-587.
10. Mayoral CE, Marino RV, Rosenfeld W, Greensher J. Alternating antipyretics: is this an alternative? Pediatrics. 2000;105(5):1009-1012.
11. Wright AD, Liebelt EL. Alternating antipyretics for fever reduction in children: an unfounded practice passed down to parents from pediatricians. Clin Pediatr (Phila). 2007;46(2):146-150.
12. Li SF, Lacher B, Crain EF. Acetaminophen and ibuprofen dosing by parents. Pediatr Emerg Care. 2000;16(6):394-397.
13. Healthychildren.org. Fever without fear: information for parents. www.healthychildren.org/English/health-issues/conditions/fever/Pages/Fever-Without-Fear.aspx. Accessed April 26, 2019.
14. Barbi E, Marzuillo P, Neri E, et al. Fever in children: pearls and pitfalls. Children (Basel). 2017;4(9):81.
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