Myth #9: With treatment, fevers should come down to normal…
We hear this one all the time. Parents are often uncomfortable taking their child home from the Emergency Department if they still have a fever. So, if the child still has a fever after Tylenol and Motrin, does this mean the infection is more serious? Should we be worried if the fever does not normalize after antipyretics? This is part 9 of a 10-part series where I will be busting what I consider to be the top 10 myths involving pediatric fever.
We are going to review just 3 studies on this topic…and actually…these are all studies we already discussed looking at combination vs alternating antipyretics.
We just need to take a closer look to get the info we are interested in…
Vyas FI, et al., 20141
- They looked at a dosing 15 mg/kg Tylenol alone vs 10 mg/kg Motrin alone vs combination Tylenol plus Motrin
- Mean reduction at 4 hours was pretty equal in all groups
- The maximum degree of fever reduction was seen with the alternating regimen,
- What we are interested in is the fact that the fever only decreased about 2-3 degrees maximum.
So, sometimes you just aren’t going to get the fever to normalize prior to discharge.
Kramer LC, 20082
- 38 outpatient visits of children age 6 mo – 6 yrs
- Given Tylenol alone vs alternating Tylenol and Motrin
- Mean temps were checked at 0, 3, 4, 5 and 6 hours
- There was a significant decrease in fever at hour 4-5 in the alternating group
- However, the degree of fever reduction was again maxed out at about 2 degrees.
Nabulsi MM, et al,. 20063
- 70 febrile children
- Motrin alone vs alternating with Tylenol at 4 hours
- The alternating regimen had a nearly 1 C further reduction in fever after 8 hours
- Again, we only see a maximum fever decrease of about 2 degrees
Are you starting to recognize a theme?
Paul IM, et al,. 20104
- 60 febrile episodes in children
- Assessed Motrin alone (top line on chart) vs Motrin combined with Tylenol (middle line) vs Motrin alternating with Tylenol (bottom line)
- Temperatures were measured hourly for 6 hours
- They found that the alternating doses showed greatest reduction of fever at 6 hours
- Again, maximum fever decrease maxed out at around 2 degrees
Thomas S, et al,. 20095
- This 2009 study of 150 children age 6 mo – 12 yr with fever of 101 looked at Tylenol alone vs Tylenol with Tepid Sponging for fever reduction
- Tepid sponging had a more rapid reduction at 15 minutes and caused more discomfort than Tylenol
- However, there was no change in fever reduction at 2 hours
- Again, investigators only observed about 2 degrees of maximum fever reduction
Let’s summarize the evidence…
They are all similar. They all show that regardless of the regimen you choose, you will only decrease the fever by about 2 degrees maximum. So, getting a child fever free before they leave the Emergency Department, or leave your office, just isn’t realistic. And as we discussed earlier, the age of the child is more predictive of the degree of fever reduction than the antipyretic used.
So, for our ninth myth questioning if temperatures should come down to normal with treatment…I would consider this one BUSTED
References
- Vyas FI, et al., 2014. Randomized comparative trial of efficacy of paracetamol, ibuprofen and parcetamol-ibuprofen combination for treatment of febrile children. Perspect Clin Res. 2014 Jan;5(1):25-31. doi: 10.4103/2229-3485.124567.
- Kramer LC, Richards PA,. 2008. Alternating antipyretics: antipyretic efficacy of acetaminophen versus acetaminophen alternated with ibuprofen in children. Clin Pediatr (Phila). 47(9):907-11
- Nabulsi MM, Tamim H, et al,. 2006. Alternating ibuprofen and acetaminophen in the treatment of febrile children: a pilot study. BMC Med. 2006 Mar 4;4:4
- Paul IM, Sturgis SA, et al,. 2010. Efficacy of standard doses of ibuprofen alone, alternating, and combined with acetaminophen for the treatment of febrile children. Clin Ther. 32(14):2433-40
- Thomas S, Vjaykumar C, et al,. 2009. Comparative effectiveness of tepid sponging and antipyretic drug versus only antipyretic drug in the management of fever among children: a randomized controlled trial. Indian Pediatr. 46(2):133-6
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