Tuesday March 1 2011
“Parents should not give children with a mild fever regular spoonfuls of paracetamol and ibuprofen, doctors advise today, as they warn that doing so could extend their illness or put their health at risk,” reported The Daily Telegraph.
The newspaper report is based on an opinion piece written by expert paediatricians. The article is aimed at discouraging ‘fever phobia’ in parents, doctors and nurses by reminding them that there is little evidence that fever itself causes harm, and that a more important aspect of fever management is to be vigilant for signs of serious illness. The experts sensibly call for the judicious use of medications, and they highlight the greater risk of dosing problems when combined drugs are given.
The National Institute for Health and Clinical Excellence (NICE) advises against combining ibuprofen and paracetamol to treat fever in children. It says either paracetamol or ibuprofen can be used to reduce temperature. They should not be administered at the same time or routinely given alternately. However, use of the alternate drug may be considered if the child does not respond to the first drug.
It is important that parents read dosing information carefully. With over-the-counter medicines, it is also important that the ingredients are studied to ensure that children do not receive two doses of the same drug from different preparations.
Where did the story come from?
The article was prepared by the American Academy of Pediatrics and published in the Academy’s official, peer-reviewed medical journal Pediatrics. There is no mention of external funding or support.
Although the newspaper articles are generally accurate, the headlines may give the wrong impression that current guidance for parents is incorrect or has been changed. The main aim of the AAP article was to bring attention to this issue and to challenge the current emphasis on treating fever to normalise a child’s body temperature rather than focusing on improving their comfort and being vigilant for signs of serious disease.
What kind of research was this?
This is an expert commentary prepared by the American Academy of Pediatrics. The authors, who are paediatricians (children’s doctors) discuss the issue of fever and its management in children. It is not a systematic review, which would have involved searching the global literature to identify all studies relating to the harms and benefits of antipyretics (medication to reduce fever, such as ibuprofen and paracetamol) in children. The commentary discusses when antipyretics should be used; it talks about the physiology of fever and the goals of treatment with both paracetamol and ibuprofen. It also looks at what the guidance says about the alternate use and combined use of these drugs.
What does the article discuss?
The authors introduce the topic by explaining that fever is one of the most common clinical symptoms managed by paediatricians and that it results in many unscheduled visits to the doctor, as well as telephone calls by parents for advice and widespread use of over-the-counter antipyretics. They raise their concern that as many as half of parents give the incorrect dosages of these drugs, some giving too much paracetamol or ibuprofen. They say that nurses and doctors are the most common sources of information about when to give anti-fever medicines, and that this is usually recommended when the temperature is greater than 38.3°C and to improve the child’s comfort.
What is fever?
Normal body temperature is approximately 37°C but it can vary between individuals and it depends on where the temperature is measured. It is generally defined as an elevation of body temperature above that of normal daily variation. In research studies, it is usually more precisely defined as a temperature of 38°C or higher. Body temperature often rises in response to an infection with bacteria and viruses.
The authors of this article discuss the physiology of fever. They emphasise that fever is not an illness but a normal physiological response to infection, which in fact helps to fight infection. Fevers are often short-lived, and the severity of fever does not always correlate with how serious the illness is.
They say that there is no evidence that fever increases the risk of negative outcomes, such as brain damage. They say there is concern among some people that the effects on the body may be the same as those seen in cases of hyperthermia (severe overheating). But the authors believe that the two processes are completely different. They say that a child ‘with a temperature of 40°C (104°F) attributable to a simple febrile illness is quite different from a child with a temperature of 40°C (104°F) attributable to heat stroke’.
When to use antipyretics (such as ibuprofen and paracetamol)
The authors say that when doctors discuss the goals of treatment with parents, they should place the most emphasis on the child’s comfort and being aware of signs of serious illness, rather than focusing on normalising body temperature. The authors say there is not much evidence to suggest that using these drugs improves a child’s comfort levels, but it is likely that they do.
Paracetamol and ibuprofen are the most commonly used antipyretics. The reviewers discuss potential harms associated with higher doses. They also talk about the different practices relating to taking the drugs either alternately or in combination. They discuss research that has compared the two strategies, which suggests that combination treatment is better in terms of reducing fever but that ‘questions remain regarding the safety of this practice’. This is in line with their belief that fever reduction should not be the primary aim in treating children with fever.
What is the authors' take-home message?
In general, the authors are highlighting ‘fever phobia’, i.e. the significant concerns of parents, doctors and nurses about the adverse effects of a fever. They say that there is no clearly established relationship between a high temperature and an increased risk of brain damage, seizures and death, which are often a major concern of parents. They say there is also no evidence that temperature reduction in and of itself should be the primary goal of antipyretic therapy.
The authors add that it is ‘critical’ to give a safe dosage of ibuprofen and paracetamol. They say that ‘there is insufficient evidence to support or refute the routine use of combination treatment with both acetaminophen [paracetamol] and ibuprofen’. Overall, they call for better advice to be given to parents, better labelling on medications and the development of simplified dosing methods and standardised drug concentrations.
This article was written by expert paediatricians, and its intended audience is other health professionals. The aim is to encourage a change in the thinking about fever, i.e. away from focusing on normalisation of body temperature, towards a focus on the comfort of the child, attention to signs of serious illness and avoiding dehydration. Paracetamol and ibuprofen are safe and effective for children when used at the appropriate doses. They must be used judiciously to avoid negative effects.
Although the Telegraph reports that reducing fever with drugs can actually prolong a child’s illness, such a claim is not made in this article. It is likely to have originated from one of the author’s comments, i.e. ‘limited data have revealed that fever actually helps the body recover more quickly from viral infections, although the fever may result in discomfort in children’.
Overall, the observations within this article are sensible, as are the authors’ calls to give parents better information and to shift priorities in fever management. The newspaper headlines may give the wrong impression that recommendations for fever management, or specifically for the use of particular drugs, have changed. Importantly, no new research has been conducted. Nor does the article focus on new harms or a lack of effectiveness of paracetamol or ibuprofen.
- Antipyretic agents should be considered in children with fever who appear distressed or unwell. They should not routinely be used with the sole aim of reducing body temperature in children with fever who are otherwise well.
- Either paracetamol or ibuprofen can be used to reduce temperature in children with fever. They should not be administered at the same time.
- Paracetamol and ibuprofen should not routinely be given alternately to children with fever. However, use of the other drug may be considered if the child does not respond to the first agent.