Pediatric emergency medicine trisk 0666 0666
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childhood febrile illnesses. There is some evidence that combined or alternating
ibuprofen and acetaminophen may be more effective at reducing temperatures
compared with monotherapy with either agent. This small benefit must be
balanced with the potential for parental confusion regarding dosing and frequency
using these combined or alternating regimens. Acetaminophen is available in both
rectal and intravenous formulations, and thus can be an option in children who
cannot tolerate oral medication. The intravenous formulation of acetaminophen
has been shown to have similar pharmacokinetics to the oral form in phase I
trials, though there is minimal published experience in the ED setting. Although
intravenous acetaminophen has been shown to produce a more rapid reduction of
temperature compared with oral acetaminophen, cost must be considered, as the
intravenous formulation is currently significantly more expensive than the oral
and suppository formulations.
It is important to remember that many parents greatly fear even moderately
high fever in their children and require reassurance that the fever itself, in its
usual range of severity, does not cause damage. They need education about
appropriate indications for antipyretic treatment, particularly seeking to reduce
fever-associated discomfort, rather than a modestly elevated temperature itself.
They need further education about appropriate, safe antipyretic dosing regimens,
the lack of urgency in treating fever, and most important, the concept that the
overall well-being of the child, in context with age, is usually far more important
than the temperature per se. It is also important to describe the natural course of
febrile illnesses so that parents know what to expect. It is helpful to include that
fevers will come and go, that they typically last several days, and that the child
may have body aches or other symptoms that worsen in the setting of fever.
Emphasis should be placed on ongoing hydration, keeping children comfortable
and not on treating a number on the thermometer. Parents should keep children
out of school and day care until the child is feeling better and for at least 24 hours
after the last documented fever.
DISPOSITION AND DISCHARGE CONSIDERATIONS
Otherwise healthy children presenting to the ED may be considered for discharge
with the following parameters in mind: nontoxic appearance, normalized vital
signs after antipyretics or vital signs appropriate for presence of fever, and ability
to tolerate oral intake and keep up with ongoing losses. Providers should also
assure that parents have an understanding of follow-up instructions, including
expectant progression of the illness, plan of care, and specific reasons to return to
the ED. Reasons to consider returning to the ED include lack of playfulness or
