FEVERPHOBIA

ICP ATHEN 2007		ICP ATHEN 2007

TO TREAT FEVER? DEBAT PRO

TO TREAT FEVER? DEBAT CON

TREATMENT OF THE FEBRILE CHILD: WHAT IS THE EVIDENCE? Mona Nabulsi-Khalil, MD, MSc Department of Pediatrics, American University of Beirut, Beirut, Lebanon Background: Despite being a beneficial immune host response, fever causes great anxiety among parents and care givers of febrile children, as well as among physicians. Fever however is believed to result in increased oxygen consumption, CO2 production, cardiac output and excessive fluid requirement. In addition, it may precipitate seizures in predisposed children, and can result in delirium, hallucination, coma and brain damage if it exceeds 410 C. Moreover, fever phobia may drive parents to abuse antipyretics thus exposing the child to drug toxicities that are potentially fatal. Treatment of the febrile response: Therapies of the febrile patient include pharmacologic and non-pharmacologic treatments. Available evidence suggests that sponging with tepid water is as effective as acetaminophen in reducing fever, while the combination of sponging and antipyretics is more effective than antipyretics alone. Currently, the two main antipyretics used in the pediatric age group are acetaminophen and ibuprofen, both shown to be effective and safe if used in appropriate dosages. Recent studies suggest that the combined or alternating regimen of acetaminophen/ibuprofen may be more effective than either drug alone. However, safety concerns regarding renal toxicity awaits further studies. Adverse effects of pharmacologic treatment: While the hepatic toxicity of acetaminophen and the renal and gastrointestinal toxicities of ibuprofen are well-established, other adverse effects attributed to either or both drugs are still a subject of much controversy. Recently, the association between ibuprofen and asthma exacerbation has been refuted, and both acetaminophen and ibuprofen are shown not to prevent febrile seizure recurrences. However, the association between ibuprofen therapy and group A â-hemolytic streptococcal invasive infections remains as equivocal. Conclusions: Despite available evidence on antipyretic effectiveness in fever reduction, antipyretic therapy should be reserved for children with great discomfort from fever or children at great risk of hemodynamic instability.

ARE ANTIPYRETICS BENEFICIAL IN FEBRILE CHILDREN?/ CON Dennis Scolnik University of Toronto, Research Institute, Divisions of Emergency Services & Clinical, Canada Fever is a physiological phenomenon which, in teleological terms, serves to enhance the body’s response to infection and disease. It is thought to combat disease by augmenting defensive enzyme reactions, and until relatively recently in history was not viewed as a negative manifestation of disease. Associations with seizures, and its obvious connection to some potentially devastating illnesses, led to its being interpreted as causing, rather than being associated with, poor outcomes. However the pendulum has now swung back to an understanding that, except for hyperpyrexia when host protective mechanisms fail with, for example, dehydration, fever is in itself harmless. Whilst it is acknowledged that some children may benefit from the symptomatic control of their fever, it is evident that parental anxiety and preoccupation with this symptom can have significantly negative consequences such as over-medication, which, even with over-the-counter medications, can lead to disastrous outcomes including death. It can lead to unnecessary medical visits which overburden medical resources and lead to cross-infection between patients. Furthermore, the argument that defervescence in response to antipyretics has prognostic value has been associated with serious misdiagnosis. The medical profession has a primary responsibility of ‘primum non nocere’ – our duty is to investigate and treat the cause of fever in a child and not to muddy the waters, and obfuscate both parents and medical students with a fixation on treating what is essentially a benign symptom. 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 – that is the message needing dissemination.