Pediatric emergency medicine trisk 0665 0665
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PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis),
familial Mediterranean fever, or cyclic neutropenia is in the differential for the
diagnosis of the child with recurrent, intermittent fevers. Additional noninfectious
causes of prolonged fever include neoplasms, rheumatologic diseases,
inflammatory bowel disease, drug fever, and factitious fever.
SYMPTOMATIC TREATMENT, DISPOSITION, AND PARENTAL
GUIDANCE
In general, antipyretic therapy should parallel the pathophysiologic basis of the
fever. When the fever is caused by altered hypothalamic set point, as in infection,
antigen–antibody reactions, and malignancy, attempts to reset the “thermostat”
with antipyretic medications are most likely to enhance patient comfort.
Antipyretics work via the inhibition of hypothalamic prostaglandin synthesis. If
fever is caused by imbalance of heat production and heat loss mechanisms, such
as in heat stroke, urgent cooling by physical removal of heat is necessary and
antipyretics will not help (see Chapter 90 Environmental Emergencies,
Radiological Emergencies, Bites and Stings ). However, children at risk for
recurrent febrile seizures do not, unfortunately, tend to be protected by rapid use
of “prophylactic” antipyretics at first sign of fever.
Acetaminophen and ibuprofen are currently the most commonly used pediatric
antipyretic medications in the United States (aspirin is no longer recommended
for routine antipyretic use in children because of its potential to cause severe
gastrointestinal bleeding and its implication as an etiologic risk factor for Reye
syndrome). The current dosage recommendation for acetaminophen is 10 to 15
mg/kg given every 4 to 6 hours, with a maximum of 4 doses/day, resulting in 40
to 60 mg/kg/day. Several reports and reviews have stressed that, although very
rare, repetitive dosing of acetaminophen at the upper limit of, or just slightly
above, recommended dosages may result in severe or fatal fulminant hepatic
failure. This is particularly the case for children who were fasting (because of
vomiting or diarrhea with febrile illness), younger than age 2 years, treated for
several days, or treated with adult-intended preparations.
Ibuprofen is typically dosed at 5 to 10 mg/kg/dose, given every 6 to 8 hours,
with a maximum of 4 doses/day (i.e., 30 to 40 mg/kg/day). Several studies have
found that ibuprofen is more effective than acetaminophen in reducing fever at
commonly used doses of each agent, especially in single-dose comparisons at 4
and 6 hours after administration. However, the difference narrows and is of little
clinical significance for most patients when antipyretic therapy is used
repetitively over 12 to 24 hours or more, as typically prescribed for most
