are antipyretics beneficial in febrile children? dennis scolnik msc, mb, chb, dch, frcp(c) divisions...
TRANSCRIPT
Are Antipyretics Beneficial in Febrile Children?
Dennis ScolnikMSc, MB, ChB, DCH, FRCP(C)
Divisions of Emergency Services &Clinical Pharmacology & ToxicologyProject Director, Research Institute
Hospital for Sick Children
Associate Professor of PaediatricsUniversity of Toronto, Canada
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)
Fever
Good …
rarely harmful(malignant hyperthermia)
Fever Phobia
• ‘New’ phenomenon
• Association with:– seizures
• febrile seizures• Rx does not → ↓
– CNS infections• rare that no other signs & clinician not able to
identify
Are Antipyretics Beneficial in Febrile Children?
• Symptomatic (at best)!!– makes child feel better
• NOT necessary for the medical condition
• Empowers parents
Primum Non Nocere
• Harmless symptom …
• Is it harmless to treat fever?
Downsides of Treating Fever
1. Perpetuates fever phobia2. ‘Medicalisation’ (Hay 2006)
3. Increased use of medical facilities
Downsides of Treating Fever
4. ↑ nosocomial infection
5. Side-tracks parents (& some physicians!) from more important signs of illness
6. POISONING!!
Poisoning
• Physician error
• Parent error
Physician Error Acetaminophen/Paracetamol (Kozer, Scolnik et al 2002)
• Emergency Department
• 1678 drug orders/prescriptions
Physician Error Acetaminophen/Paracetamol (Kozer, Scolnik et al 2002)
10% in ED
c.f.
6.6 - 11.7% in paediatric intensive care units
Physician Error Acetaminophen/Paracetamol (Kozer, Scolnik et al 2002)
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
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
Parent Error (Acetaminophen/Paracetamol Rivera-Penera 1998)
• Over 10 yrs
• ≤ 19 yrs age
• Parts of California
• Overdose with previous normal LFT’s
Parent Error (Acetaminophen/Paracetamol Rivera-Penera 1998)
• 28/73 (38%) abnormal LFT’s
• All 28 severe hepatotoxicity– 6 (21%) liver transplantation
Parent Error (Acetaminophen/Paracetamol Rivera-Penera 1998)
• 14/73 ≤ 10 yrs age– 71% (10/14) of these had abnormal LFT’s
(versus 31% in older)
These 10 had all been overdosed by parents in error
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
What Should We Do?
Education >>> treatment
Education
1. Fever is a symptom not a disease
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
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!!
Education
1. Fever is a symptom not a disease2. A child can have meningitis with a low fever or a viral
upper respiratory tract infection with a high fever3. The difference is in how sick the child is!!
4. MINIMAL CLOTHES & COOL ENVIRONMENT
5. FLUIDS
Are Antipyretics Beneficial in Febrile Children?
NO
May make child feel better
Cause more harm than good
Therefore antipyretics are NOT beneficial in
febrile children
Thank you!
J Pediatrics 1997:130(2);300-304
J Pediatrics 1998:
132(1);22-27