If you weren’t already aware, the American Academy of Pediatrics recently published a policy statement concerning the use of antipyretics to reduce temperature in a febrile child.
Don’t do it.
The available evidence is treatment of fever may ultimately attenuate the body’s natural immune defenses, while parents inadvertently place their children at risk by using inappropriate dosages. The only goal of antipyretic use is to improve overall patient comfort.
And, as this study shows, we have a long, long way to go in educating our patients.
This is a survey of 100 patients – 54 from a private clinic and 46 from a county clinic – and, within the bounds of the small sample, there is essentially no difference in the perception of fever. Nearly 75% failed to correctly identify the temperature range constituting fever (>38°C). 93% thought high fever results in brain damage. 89% would give antipyretics to a comfortable child with temperature >38°C, and 86% would go ahead and schedule a clinic visit. Equally surprising (or not), 59% would dose a comfortable child with temperature 37.4-37.8°C with antipyretics, and 38% would schedule a clinic visit.
Given the volume of ambulatory visits for fever – both in the Emergency Department and community Pediatrics – it would seem continued education regarding “fever phobia” has the potential for significant cost savings.
Brain damage, by the way, is not usually a concern until 42°C.
“Fever Literacy and Fever Phobia”
http://www.ncbi.nlm.nih.gov/pubmed/23349363
Your post suggests the AAP policy statement (from 2011) advises against the use of antipyretics for fever. It does not. It states they are safe and may be used for patient comfort, but does discuss the need for caution about dosage. If you are aware of evidence of adverse outcomes from fever reduction, I'd be interested in reading it, of course.
Hi Ryan
Question – what is the incidence of fever-induced brain injury as a result of common extracranial pathology? It must be vanishingly small as have never heard of, met anyone who has seen it? Is t the ultimate urban myth?
We know febrile convulsions don't harm, so s there any serious outcome we need to be worried about? Can we be completely reassuring?
Casey
I've absolutely seen environmental causes of elevated core temperature – and poor neurologic outcomes as sequelae, as you'd expect. But, clearly, your non-encephalopathic, fully-immunized child with a fever is exhibiting a normal immune response that ought not harm the child – or we wouldn't have made it these millions of years as human beings.
You are correct to clarify my artistic hyperbole – the AAP policy statement has words of caution, but certainly nothing as definitive as "don't do it!". I agree antipyretics have a role in patient comfort.
But, yes, I am as aggressive about enforcing this myth with my trainees as I come across in this post – the look of horror and confusion when I ask them "why?"
Nicely done as always, Ryan!
I agree with Dr Parker and tell parents (in the setting of non-exposure, non-endocrine, non-drug-induced hyperpyrexia in a well appearing vaccinated child, after we have decided that there is no apparent serious bacterial illness) that "your child's body takes care of itself — your child's body won't cause a fever that will damage his brain".
Maybe overly simplified, but I see the physical and psychological anguish drain from parents in a long exhalation after directly addressing the issue. A calm, confident, informed parent takes better care of the child, and this confidence translates to less repeat ED visits for the same and a happier, less anxious family
I counsel them that I am more concerned about dehydration with fever (in lay terms, explain convective/evaporation fluid loss, increased metabolic demand, increased respiratory rate). A fussy infant/toddler/young child often will not drink, eat, etc, despite himself — depending on the parents' understanding, I couch the discussion with points like: "acetaminophen (paracetamol) or ibuprofen are really for comfort, not to 'control' the temperature — it's alright that the 'fever comes back' in between doses, that is expected, the effect is meant to be temporary — give something for comfort, but if he is eating/drinking/eliminating/happy, don't worry so much about controlling the number reading on the thermometer" or something like that. Sounds basic to us, but parents really need to hear it when they need it the most — they are often at their wit's end when they come in to see us. The extra 2-3 minutes on counseling, education, support are (after your good assessment that nothing serious is going on) the most important intervention of the visit.
Thanks for your great posts!
Well, if Ryan is backing away from it, I'll say it!
The AAP basically does say that you should not treat a fever. A fever, after all, is just a number, and as they point out "there is no evidence that reducing fever reduces morbidity or mortality from a febrile illness."
They do, of course, suggest treating discomfort: "The primary goal of treating the febrile child should be to improve the child's overall comfort rather than focus on the normalization of body temperature." But treating the fever qua fever is discouraged.
(ref http://pediatrics.aappublications.org/content/127/3/580.full)