One of the things we could probably manage a little better as ED nurses is the management of children presenting with fever.

As soon as little Miss Molly presents with even a slightly elevated temperature, many of us react by immediately dousing it with doses of antipyretics or perhaps even tepid sponging in the belief that this will fix the problem or prevent possible febrile convulsions.

Is this evidence based? Should we be aiming to have a dosed up department full of afebrile children?
Lets see.

how hot is hot?

The first thing to say is that any paediatric patient presenting to the ED should not be discharged home without a thorough assessment and review by a senior ED doctor. ALL neonates less than 4 months old who present with fever should have expert assessment without delay.
Children’s temperatures are in a constant state of flux, but a normal temperature is usually less than 37.5C. Fever can be defined as a rectal temperature greater than 38.0C. (rectal temperatures are the gold standard, but taking tympanic, oral or per auxilla is common practice. As long as you are aware of the relative accuracies of these methods.)

The higher a child’s temperature, the more likely it is that they will have a serious bacterial infection. But not always. Seriously septic children may be afebrile or have low grade fevers.

why hot is hot.

Most causes of infection (bacteria and viruses) are quite fragile and only able to survive in a very narrow temperature range. Our immune systems are pretty clued on to this, and by raising the bodies temperature, it makes a pretty hostile environment for the enemy combatants.

The down side of this is that it takes a lot of energy to fire up out furnace which may lead to dehydration. It can also be quite uncomfortable.

Antipyretics: yea or nay?

In most cases the primary purpose of administering antipyretics is to increase the comfort of the child. Although in one well known study (Kramer et al.), parents were unable to tell the difference between panadol and placebo in improving the behaviour of their child.
The double-blind trial, based on the parents observations, analysed 225 febrile children’s mood, comfort, appetite, fluid intake, activity and alertness.
“In the paracetamol treated group, activity and alertness significantly improved by one grade, mood and eating improved but not significantly, while drinking was worse. The parents’ descriptions of comfort were equal in both groups. The duration of fever was the same in both groups.”

The most serious reported risk of administering paracetamol is hepatotoxicity. This can occur if too large a dose is given or too many doses are given (doses greater than 90mg/kg/day). Children under the age of two, or who have pre existing liver disease are at greater risk.

What about those febrile convulsions?

It is true that febrile convulsions are caused buy…well, febrile-ness. But studies seem to suggest that bringing the fever down has limited benefit in preventing recurrence or onset of seizures.
In a systematic review of the management of fever in children conducted by the Joanna Briggs Institute it was noted that:

Of the total sample of 821 only one febrile convulsion (0.12%) was reported as occurring during a study. This 12 month old child was in a “tepid sponging only” group and convulsed 90 minutes after commencing treatment when her temperature was 39.7°C, 0.7°C higher than when admitted. She had no history of febrile convulsions.

The review concludes that there is a lack of evidence in the literature to support the notion that paracetamol reduces the incidence of febrile convulsions.

conclusion?

If the infant or child has a low grade fever and is not dehydrated or unduly distressed I would consider their fever as part of their treatment. With the proviso that the parents are both informed (there is a parent information sheet here) and supportive with this strategy.

Very high fevers should be managed based on the clinical situation. But as I have said they must be reviewed by a senior ED doctor.
If paracetamol is to be administered: An initial paracetamol dose of 15- 20mg/kg could be given, followed by three doses of 15 mg/kg over the next 24 hours if irritability continues.

hot and bothered by this?

Please feel free to make any comments or criticisms, or to relate any experiences you have had with managing febrile children.
[References: NSW Department of Health Clinical practice guidelines.
Australian prescriber: Paracetamol, overused in childhood fever.
Kramer MS, Naimark LE, Roberts-Brauer R, McDougall A, Leduc DG. Risks and benefits of paracetamol antipyresis in young children with fever of presumed viral origin. Lancet 1991;337:591-4.
Joanna Briggs Institute: Management of the child with fever. ]