1. “Fever Phobia” Dawn S. Tuell, M.D. Associate Professor of Pediatrics Quillen College of Medicine

2. Disclosure Statement of Financial Interest I do not have a financial interest or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation

5. What is a fever? Depends on who you ask… Where you take it… The type of thermometer used… The time of day… Age of the child…

6. FEVER An increase in the body’s temperature above normal

7. What is a normal temperature? Range 97.2° (36.2°) – 99.5° (37.5°) Normal diurnal variation in temperature 0.5°C from the mean Vary based on age, gender, physical activity, ambient air temperature Vary with anatomic site Core body temperature is measured most accurately at the pulmonary artery There is no single value for normal body temperature

8. Which of the following children have a fever? 1.3 year old with an axillary temperature of 99° 2.An 18 month old with a pacifier temperature of 99.8° 3.6 month old who felt hot last night 4.9 month old with tympanic temperature of 100° 5.None of the above

9. AAP Definition Rectal temp > 100.4° Oral temp > 100° Axillary temp > 99° Tympanic > 100.4° Forehead/temporal artery > 100.4°

10. You should add a degree to an axillary temperature to reflect core body temperature 1.True 2.False

11. Axillary vs. Rectal Rectal temperatures are the gold standard for temperature measurement Axillary temperatures are not as reliable as rectal and are generally lower However “one degree rule” not appropriate due to variability Literature shows axillary thermometers did pick up all fevers No false positives with axillary temperature

12. Oral Thermometers Safe and comfortable for children older than 5 years Less lag time More accurate than axillary thermometers Affected by temperature of recently consumed fluids or mouth breathing

13. Tympanic Thermometer Quick, comfortable, cost effective Infrared ear thermometer does not accurately predict rectal temperature Fails to diagnose fever in 3-4 out of every 10 febrile children Difficulty in aiming thermometer at TM, especially in infants younger than 2 months of age Home use thermometers may be less accurate than clinical use thermometers

14. “Tactile” Temperature Child “feels warm to the touch” Subjective, can vary with environmental factors Sensitivity by parents 71-89% Specificity and positive predictive value <50% More useful to exclude rather than confirm presence of a fever

15. What is the best way to measure temperature? The way that works for you… Use a consistent form of measurement Make the measurement at the same site to monitor changes in body temperature

16. What is a low grade fever? 1.98.8°-99° 2.99°-100° 3.99°-101° 4.100°-102° 5.101°-103°

17. Low grade fever 100° (37.8°)- 102° (39°)

18. What is a high fever? 1.<100° (37.8°) 2.100°-102° (37.9°- 38.9°) 3.102.1°-104° (39°- 40°) 4.>104° (40°)

19. Parental definition of a high fever

20. Temperature at Which Pediatricians Consider Infants to Have Mild, Moderate and Serious Fever by Infant Age

22. Why Does My Child Have a Fever? Temperature control lies in the thermoregulatory center of the hypothalamus Complex set of cytokine-mediated responses and production of acute phase reactants change hypothalamus set point Body temperature elevates via heat generation and heat conservation Pyrogens are substances that produce fever Cryogens limit temperature height during fever

23. The febrile response. Avner J R Pediatrics in Review 2009;30:5-13 ©2009 by American Academy of Pediatrics

24. How high a fever can go if left untreated. Crocetti M et al. Pediatrics 2001;107:1241-1246 ©2001 by American Academy of Pediatrics

25. Is Fever a Symptom or a Disease? 1.Symptom 2.Disease

26. Do we treat as a disease? Counsel parents on how to “control” a fever Order blood tests to evaluate fever 50% of HCPs report pressure to prescribe antibiotics for a fever Parents perceive treatment of fever is antibiotics

27. The height of the fever predicts a more serious illness 1.True 2.False

28. Height of Fever Pre-pneumococcal conjugate vaccine this was likely a true statement Some studies show that hyperpyrexia (T>106/41.1) is associated with a higher incidence of serious illness Clinical appearance rather than height of fever is a more powerful predictor of serious illness Thorough H&P to guide decision matrix

29. A response to antipyretic medication lowers likelihood of serious bacterial infection 1.True 2.False

30. A response to antipyretic medication does not change the likelihood of a child having serious bacterial infection and should not be used for clinical decision making.

31. Systematic Review of Evidence Temperature Response Bacteremic Nonbacteremic AuthorsYearStudy DesignAntipyretic AgentAge of Subjects, y No. ∗ T,† °C (°F)↓T‡No. ∗ T,† °C (°F)↓T‡P§ Torrey et al221985Prospective/observationalAcetaminophen/aspirin≤2 1640.1 (104.2)1.323939.9 (103.8)1.05.14 Weisse et al231987Prospective/observationalAcetaminophen≤17 11NG1.416NG1.2.37 Baker et al241987Prospective/observationalAcetaminophen≤6 1040.1 (104.2)1.522539.6 (103.3)1.0NG Mazur et al251989Retrospective/case controlAcetaminophen≤6 3439.8 (103.6)1.06839.8 (103.6)1.5<.001 Baker et al261989Prospective/observationalAcetaminophen≤2 1940.1 (104.2)1.713540.0 (104)1.6>.05 Yamamoto et al271987Prospective/observationalAcetaminophen≤2 1740.5 (104.9)1.621640.4 (104.7)1.6.85

32. Which of the following is not a known complication of fever associated with infection? 1.Cerebral damage 2.Increased catabolism 3.Seizure 4.Tachycardia 5.Tachypnea

33. Parental Report of Harmful Effects of Seizures Type Schmitt (n = 81)Crocetti et al (n= 340) * Seizure15%32% Brain damage45%21% Death8%14% Dehydration4%4% Really sick1%2% Coma4%2% Delirium12%1% Blindness3%1% No response6%9% Other–14% Total100%100%

34. Benefits of a Fever Enhance leukocyte mobility and activity Activates T lymphocytes Stimulates production of interferon Inhibit bacterial and viral function Shortens duration of illness by creating an unfavorable host environment Likely beneficial in children with normal host responses

35. Disadvantages of a fever Increased metabolic demand Increased insensible fluid loss General discomfort

36. Hyperthermia vs. Fever Fever is a normal physiologic response that results in increase in hypothalamus set point Hyperthermia is rare response with failure of normal homeostasis that results in heat production that exceeds capability to dissipate heat Characteristics – hot, dry skin, CNS dysfunction, delirium, convulsions, coma Should be addressed promptly Temperature above 41°-42°C can have adverse physiologic effects Cannot extract hyperthermia data to apply to fever outcomes

37. Fever Most febrile illnesses last 3-5 days Treatment of febrile children without a source subject to great debate Majority have benign, self-limited illness Serious bacterial illness can be difficult to diagnose and has a high morbidity

38. A 3 week old term newborn presents with a fever of 38°C. What should be done next? 1.Draw a blood culture, CBC and start oral antibiotics 2.Risk stratification approach based on WBC count and appearance 3.Reassure and reassess tomorrow 4.Admit for cultures and IV antibiotics 5.None of the above

39. Fever < 1 month Febrile infant < 1 months of age immature immune response Up to 10% of febrile infants have serious bacterial illness Not yet developed many clinical signs to judge clinical appearance Most management strategies recommend routine hospitalization and empiric antibiotics pending results of blood, urine, and CSF cultures

40. Fever 1-2 months Risk stratification using WBC, UA and often CSF to determine need for hospitalization and empiric antibiotics

41. A 10 month old girl has a temperature of 102° (38.9 °) for 2 days. Her parents deny any other symptoms except increase in fussiness. Immunizations are UTD. Findings on PE are normal. Which test is most helpful in establishing a diagnosis in this child? 1.Blood culture 2.Chest radiograph 3.Complete blood count 4.C-reactive protein 5.Urine culture

42. Fever 3-36 months Usually benign viral origin CBC, blood culture, urine culture – utility is diminshing With S. pneumo and Hib vaccines occult bacteremia decreased from 3% to <0.7% in this vaccinated age group Occult UTI much more likely with a prevalence of 2.1- 8.7% - highest in girls younger than 1 year

43. A previously healthy 12 month old has a fever of 101.2° You would recommend 1.Alternate Ibuprofen and Acetaminophen every 4 hours 2.Ibuprofen every 6-8 hours 3.Acetaminophen every 4-6 hours 4.Use antipyretic based on the appearance of the child 5.Sponging or bathing with tepid water

44. Sponging Bathing with cold water should not be used as it leads to vasoconstriction Rubbing alcohol can cause vasoconstriction and absorption through the skin leading to toxicity Tepid bathing provides only marginal temperature reduction but increases discomfort and shivering

45. Antipyretics Ibuprofen and Acetaminophen inhibit cyclo-oxygenase which converts arachidonic acid to prostaglandin Interleukin mediated steps continue to increase the hypothalamus set point Decreased prostaglandins work to override the interleukins Lower hypothalamus set point only in the febrile state

46. Caregiver's use of antipyretics. Crocetti M et al. Pediatrics 2001;107:1241-1246 ©2001 by American Academy of Pediatrics

47. Parental Antipyretic Practices A child must maintain a “normal” temperature at all times ½ of parents consider a temperature of <38 (100.4) to be a fever 25% of caregivers give antipyretics for temperature of <37.8 (100.4) 85% parents report awakening their child from sleep to give antipyretics Up to ½ administer incorrect doses of antipyretics

48. Acetaminophen Dose 10-15 mg/kg per dose q 4-6 hours Onset of antipyretic effect within 30-60 minutes Approximately 80% of children will experience a decreased temperature Hepatotoxicity most commonly seen with acute overdose Concern with supra-therapeutic doses and frequent administration

49. Acetaminophen use has been associated with the following: 1.May suppress immune response to rhinovirus 2.May be important risk factor for development and/or maintenance of asthma 3.Associated with rhinoconjunctivitis symptoms 4.Associated with eczema symptoms 5.All of the above

50. Ibuprofen Dose 5-10 mg/kg dose q 6-8 hours Recommended for infants > 6 months More effective antipyretic Longer duration of anti-pyresis Potential for gastritis Concern for nephrotoxicity, especially in dehydration or medically complex children Possible association between ibuprofen and varicella- related invasive group A streptococcal disease

51. Combination Antipyretics NOT recommended by AAP in 2011 Clinical Report 67% parents alternate antipyretics 50% pediatricians advocated this practice No conclusive proof alternating is safe May be more efficacious in reducing temperature in short term, no long term difference Can be confusing to parents Potential for incorrect dosing and increased risk of toxicity Primary endpoint, reduce discomfort, not normalize temperature

52. “Dump” the combo antipyretic practice

53. A 18 month old had his first febrile seizure last month, you would advise parents 1.Antipyretic therapy will reduce recurrence of febrile seizures 2.Febrile seizures have excellent long-term outcomes 3.The higher the fever, the more likely a seizure will occur 4.Give antipyretics for 24 hours after immunizations to prevent a seizure 5.Go to the ER anytime a seizure occurs

54. Febrile Seizures AAP Clinical Practice Guideline, 2008 & 2011 High rate of recurrence No greater risk for developmental delays, learning disabilities, or seizures without fever Antipyretics ineffective in preventing recurrent febrile seizures Regular vs. sporadic treatment does not influence outcome of febrile seizures

55. A 12 month old has an appointment for WCC and immunizations. You routinely advise 1.Pretreatment with acetaminophen or ibuprofen prior to immunizations to minimize discomfort and febrile response 2.Treatment with acetaminophen or ibuprofen after immunizations to minimize febrile response 3.Antipyretics are not routinely needed for immunizations

56. Recent study suggests possibility of decreased immune response to vaccines in patients treated early with antipyretics

57. Goal in treating a fever: child’s comfort not normalization of temperature

58. Fever Management Restore nutrients and water lost Proper hydration Comfortable environment

59. Parental Education Fever is a normal response to infection Fever is a symptom, not a disease Fever determination doesn’t always need to be exact Treat the child’s comfort rather than a specific temperature Fever will persist until disease process resolves Clinical appearance is important Use the term “fever therapy” instead of “fever control” Safe storage of antipyretics