Indian Pediatr 2009;46: 124-125
Fever: A Return to Basics!
Associate Professor of Paediatrics, University of
Toronto; Vice-Chair, Research Ethics Board; and Staff Physician,
Divisions of Paediatric Emergency Medicine and Clinical Pharmacology and
Toxicology, Hospital for Sick Children, Toronto, Canada.
Fever is a
physiological response to infection which seems to have evolved and been
preserved in humans over eons of time. It is a protective mechanism and,
except for the rare circumstance of a central nervous system condition
such as hypothalamic disease, the body will not allow lethal hyperpyrexia
so long as (a) hydration remains adequate and (b) the body
is provided an environment which allows for heat loss(1). As such, the
primary question should actually be not how to best treat fever but
whether to treat it at all!
The main aim in treating fever, therefore, shifts from
clinical and medical concern to one of patient comfort. Providing this
comfort should be balanced against the potential negative sequel of fever
treatment: dulling a physiologically positive response to infection,
diverting parental and medical attention away from concentrating on the
cause of the fever rather than the fever itself, and even the possibility
of increased nosocomial infections and serious poisoning(2,3). Some
authors maintain that febrile seizures actually occur with increased
frequency in children who have been exposed to sponging(4), possibly due
to intense vasoconstriction diverting blood centrally and leading to a
sudden or marked rise in core temperature. Vigorous attempts at
antipyresis have failed to prevent recurrence of febrile seizures.
This being said, the article by Thomas, et al.(5)
in this month’s Indian Pediatrics revisits the interesting question
of how best to reduce fever. Utilization of axillary temperature as their
primary endpoint reflects common practice, but it must be remembered that
although a temperature gradient exists from axillary to oral to rectal
temperature on a population basis; within an individual, patient
correlation between axillary and core temperature is very poor(6). Thus
their endpoint may not truly reflect changes in core temperature.
Secondly, these authors used a dose of 10 mg/kg of paracetamol despite the
fact that 15 mg/kg is the recommended antipyretic dose(7). Thirdly, the
change of 0.4°F which they used for their power calculations is probably
not of great clinical significance.
Thomas, et al. show that tepid sponging added
nothing to the antipyretic effect of paracetamol after two hours; even
though a more rapid initial fall in temperature was noted. Furthermore,
they stress that tepid sponging was uncomfortable for patients. Their
findings and conclusions support the idea that the aim of therapy in
febrile children should be to concentrate on the investigation and
treatment of the cause of the fever while ensuring adequate hydration,
minimal loose clothing and patient comfort. At a more universal level,
their findings could be used to try and counter the fever phobia which
seems to be consuming not only parents but the medical community as well!
Competing interests: None stated.
1. Kluger MJ. Fever revisited. Pediatrics 1992; 90:
2. Heubi JE, Barbacci MB, Zimmerman HJ. Therapeutic
misadventures with acetaminophen: hepatoxicity after multiple doses in
children. J Pediatr 1998; 132: 22-27.
3. Ulinki T, Bensman A. Renal complications of
non-steroidal anti-inflammatories. Arch Pediatr 2004; 11: 885-888.
4. Berg AT. Are febrile seizures provoked by a rapid
rise in temperature? Am J Dis Child 1993; 147: 1101-1103.
5. Thomas S, Vijaykumar C, Naik R, Moses PD, Antonisamy
B. Comparative effectiveness of tepid sponging and antipyretic drug versus
only anitpyretic drug in the management of fever among children: A
randomized controlled trial. Indian Pediatr 2009; 46: 133-136.
6. Falzon A, Grech V, Caruana B, Magro A,
Attard-Montalto S. How reliable is axillary temperature measurement? Acta
Paediatr 2003; 92: 309-313.
7. Fleisher GR. Textbook of Pediatric Emergency Medicine, 5th ed.
Philadelphia: Lippincott Williams & Wilkins; 2006.