E-DRUG: Antipyretic drugs for children?
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[Below comments from Andy Gray, moderator of DRUGINFO on a recent editorial in BMJ, whether fever in children should be treated with ibuprofen and paracetamol in combination or alternatingly. The conclusion: There's still not enough evidence to support prescribing paracetamol and ibuprofen in combination or alternately" Copied as fair use. WB]
Hi all
Although there's nothing startlingly new in this BMJ editorial, it has elicited quite a number of electronic responses - see http://bmj.bmjjournals.com/cgi/eletters/333/7557/4 - including this trenchant comment from a retired oethopaedic surgeon: "Thomas Sydenham, the famous seventeenth century physician wrote:. "Fever is nature's engine which she brings into the field to remove her enemy." How is it that, more than 300 years later, physicians are still treating fever as a disorder rather than a defence mechanism? Do we still believe that Molly Malone 'died of a fever', rather than from the typhoid bugs in her cockles and musssels?!".
The contrary view is as strongly held - this is from an Indian paediatric consultant: "Use of antipyretics for fever in children has a definite place. All types of fever , viral and bacterial are more frequent in infants than older children.While children at school age can tolerate fever better than infants it is infants who need drugs early to bring down fevers.Use of one or more antipyretics depends on child,s response to fever. Most children respond to either paracetamol or brufen ,often second drug have to be given to bring down the fever. With high fever,infants who are symptomatic(irritability,lethargic,refusal to eat or drink etc)besides being at risk for febrile convulsions, should be given drugs to bring down the fever.Infants can not be put to same practise as older children as they tolerate fevers less. As soon as fever is down a child starts playing and oral intake increases. Even neonates in nicu with rise of temperature of >99 dgerees become symptomatic (increase of o2 requirement, poor perfusion, irritability ,tachycardia etc)and they respond well to paracetamol given orally or as rectal suppository.Only parents know the agony of a febrile infant with pyrexia , hence efforts shold be made for containing temperature by drugs, environmental change etc, of course which drug to choose is personal preferance."
regards
Andy
E-DRUG: Antipyretic drugs for children? (2)
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The current teaching, as I understand it, is that fever in children should
only be treated if it is making the child very uncomfortable. It is also not even clear that it is lowering the fever that makes the child feel better, it may be the relief from pain, e.g., from otitis media that makes the child more comfortable. The lowering of the temperature goes along with the pain relief.
It is also a myth that it is a high fever per se that leads to febrile
convulsions. It is the rate of increase in the temperature that seems to be
the factor and then only in a small percentage of children. Treating a fever does not decrease the risk of a febrile convulsion.
Joel Lexchin
--
Joel Lexchin MD
Associate Professor
School of Health Policy and Management
York University
4700 Keele St.
Toronto ON
Canada M3J 1P3
Tel: 416-736-2100 x 22119
Fax: 416-736-5227
E mail: jlexchin@yorku.ca
E-DRUG: Antipyretic drugs for children? (3)
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As a pharmacist, I am a strong believer in evidence based medicine.
However, as a parent to a two and a half year old who has suffered a number
of normal viral infections in his short lifetime, I can say that treating a
higher grade fever on a number of occasions with acetaminophen (paracetamol) allowed my son to play or sleep peacefully for about 3 and 1/2 hours while one dose of ibuprofen provided him with peaceful sleep throughout the night. We have always tried to go medication free early on in a fever (because I too read the literature), which invariably seems to keep my son miserable, irritable and unwilling to eat or drink. The visible changes in my son's demeanor that match the half-life of the drug (his demeanor deteriorating when drug wears off, improvement when second dose is given), speaks volumes to me, the parent. I don't think we can just dismiss the parent's interest in providing medications as simply "wanting to do something for their child" when it is clear to me that there is improvement in the child's demeanor, at least on a case by case basis.
Lisa DeVos
Intelliscope Consulting
Alberta, Canada
ldevos@shaw.ca
E-DRUG: Antipyretic drugs for children? (4)
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NSAIDs may be more harmful than paracetamol: based on the best evidence available.
I was also surprised to read the editorial on antipyretic drugs for children that did not mention the causal relation of salicylate to Reye's syndrome in human and higher mortality in infected animals treated with non-steroidal anti-inflammatory drugs (NSAIDs) compared with vehicle control.
I have collected nine papers which reported 15 animal experiments to investigate the effects of NSAIDs on mortality in infected animals. Various NSAIDs were used including ibuprofen, flurubiprofen, mefenamic acid, indomethacin, salicylate and so on. Mantel-Haenztel pooled odds ratio for NSAIDs use on mortality was 10.00 (95% confidence interval (CI): 6.12-30.06, p<0.00000001) [1].
Another evidence available is a case-controlled study reported in the Japanese Task Force's case control study on factors related to onset and severity of influenza-related encephalopathy [2]. Strong relation between the NSAIDs use and fatal influenza-related encephalopathy was observed: crude odd ratio was 47. 4 (95%CI; 3.29-1458, p=0.0019)[1,2], though the task force reported that the study could not demonstrate any definite relation of NSAIDs to occurrence of influenza-related encephalopathy. Odd ratio for paracetamol was not significant (OR 2.25; 95%CI; 0.19-58.6) [1,2].
Please read the following and the references at:
http://bmj.bmjjournals.com/cgi/eletters/333/7557/4#137649
(BJM rapid response)
Kusuri-no-Check
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The Informed Prescriber
Rokuro Hama
HAMA, Rokuro MD Chairman
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E-DRUG: Antipyretic drugs for children? (5)
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At least in North America salicylates are very rarely, if ever, used in
children because of the possibility of Reye's.
[Same in Scandinavia. Moderator]
Joel Lexchin
--
Joel Lexchin MD
121 Walmer Rd.
Toronto ON
Canada M5R 2X8
Tel: 416-964-7186
Fax: 416-736-5227
E mail: joel.lexchin@utoronto.ca