Management of uncomplicated fever in children - Essay Example

for practice change: Management of uncomplicated fever in children Introduction I would like to bring to the notice of the directorof nursing that, I have come across a case scenario where in different nurses were managing uncomplicated fever in a child in different ways. Some were administering paracetamol every 4 hours, while others were just observing the child and giving paracetamol as and when required. Following this incident, I looked in to the Best Practice Information Sheet entitled “Management of the Child with Fever” at the web site of The Joanna Briggs Institute and there by decided upon submitting for practice change in the management of uncomplicated fever in children. For this, I also searched for other studies pertaining to this because; evidence-based practice attempts to apply more uniformly the standards of evidence gained from scientific methods. Literature review     Fever is a cardinal manifestation of infection in all ages. It is a manifestation of defense mechanisms to the infection. However it causes discomfort and a great deal of anxiety to the parents. It may precipitate convulsions in some children prone to it (Tejani 2006). In children, it constitutes 30% of emergency department visits (JBI, 2001). In most of them, the cause is usually a self limiting viral infection.      Fever may be defined as rectal temperature of 38 deg C (100.4 deg F) (Luszczak 2001, Barclay 2007). Other definitions include oral temperature of > 99.3 deg C and axillary temperature of > 37.4 deg C (Kwok 2006).      Most of the uncomplicated fevers are managed with just bringing down the temperature. At this juncture, it is important to know what complicated fever is. Children who are very young, who are toxic looking, lethargic, pale or cyanotic, with tachypnoea and tachycardia beyond the degree of temperature may be considered having complicated fever (Luszczak, 2001). Also, those in whom the focus of infection is in organs, bones or meninges can also be considered having complicated fever. Other than these, those children with infections like malaria, leptospirosis, typhoid, etc; those with known chronic illnesses, those who have been given antibiotics recently and those with convulsions may be considered to have complicated fever (Luszczak, 2001). Such children will need more aggressive management of both fever and the disease. Here we want to discuss about management of uncomplicated fever.      What is the need to bring down fever? The study by JBI has shown that fever reduction is important to decrease childs discomfort, decrease parental anxiety and prevent febrile seizures. Meremikwu and Oyo-Ita (2002), in their review, reported that febrile seizures are caused due to sudden rise in temperature and that antipyretics can not prevent seizures. Fever can be managed with antipyretics like paracetamol and other environmental methods like sponging, bathing, fanning, good hydration, etc (JBI, 2001). In the present case scenario, it is evident that there are no clear guidelines in the management of uncomplicated fever in children amongst nurses. Some nurses are treating the fever aggressively with paracetamol, while others are just observing the child and administering paracetamol only as and when required. This is a common scenario. This is the case with not only nurses but also with parents and doctors (Impicciatore 1997).      The question is whether it is necessary to treat fever in uncomplicated cases, if so which the best method to do so. From the study by JBI (2001), it is evident that though it is not necessary to treat fever in these cases, one might want to increase childs comfort and decrease parent’s anxiety. Various studies have been done to find out the best method of bringing down fever. Some studies have used only paracetamol, some others only sponging; while others studied both paracetamol and sponging (JBI 2001). It is a well known fact that paracetamol causes hepatotoxicity. At what minimum doses this can occur is not yet known. Some studies have shown that a dose of 150mg /kg/day can cause hepatic toxicity (JBI 2001). The normal dose given in children in current practice is 90 mg/kg/day. Of late, it is recommended to give 60mg/kg/day (JBI 2001). Considering the fact that paracetamol can get accumulated in the body, even 90mg/kg/day can lead to 150 mg/kg/day after 3-4 days of treatment (JBI 2001). Hence cautious use of paracetamol is warranted. This drug has more pronounced effect in children less than 2 years, or who are sick and receiving doses every 4th hourly (JBI 2001). Shann (1995) has reported that it is helpful to give paracetamol in those who are febrile and have cardiac or respiratory failure because paracetamol reduces oxygen consumption, carbon dioxide production and cardiac output. But, in those with normal heart or lung disease it is not necessary to give paracetamol because fever is harmful only at temperatures over 41 deg C and in practice such high temperatures are usually caused by heat stroke or brain injury. The question here as per the scenario is whether fever in children should be treated with paracetamol every four hours or less frequently. I have retrieved 2 sources on this topic to form a policy. 1. Meremikwu, M., & Oyo-Ita, A. 2002. Paracetamol for treating fever in children (Cochrane Review). The Cochrane Library, Issue 4, Oxford Update Software. 2. Huang, S.Y., & Bavid, S.G., 2004. Effect of Recent Antipyretic Use on Measured Fever in the Pediatric Emergency Department. Arch Pediatr Adolesc Med., 158, pp. 972-976. The first article by Meremikwu and Oyo-Ita (2002) is a systematic review to evaluate the benefits and harms of various methods of managing fever in children from randomised controlled trials. This study can be categorized in the Level 1 of the JB hierarchy. By knowing this hierarchy level, one can assess the validity of recommendations for clinical guidelines, focuses and the effectiveness of treatment. According to this article, there are controversies regarding the effectiveness and safety of various methods for treating fever. Of all the antipyretics (paracetamol, ibuprofen, aspirin, nimisulide), paracetamol has the least side effects. But it is not that this drug is absolutely safe. It has the potential to cause liver toxicity. Another question raised in this review is whether it is necessary to bring down fever at all. The review stated that fever might actually have some beneficial effects of enhancing host resistance to infection and that bringing down the fever could increase mortality in severe infections, prolong viral shedding and impair antibody response to viral infection. The second study by Huang and Greenes (2004) can be categorized in the Level 3-1 of the JB hierarchy. The study was done to determine the prevalence of recent antipyretic use among febrile infants at a pediatric emergency department and to test the hypothesis that recent antipyretic use is associated with lower measured temperatures in the emergency department. The authors concluded that recent antipyretic use is associated with higher measured temperatures in the emergency department and those treated with a therapeutic dose 1 to 5 hours prior to arrival experience more defervescence from their T max than untreated subjects. Conclusion From the above literature review, the following can be deducted for evidence based practice regarding uncomplicated fever: 1. It is not important to bring down fever in children with uncomplicated fever. However, one might consider doing it for concerns of discomfort and parental anxiety. Anti pyretic use is not reported to bring down the incidence of febrile convulsions. 2. If one has decided upon bringing down the fever, then paracetamol use or tepid sponging might be considered. Others drugs shall not be recommended in view of potential side effects. Cold sponging, fanning and decreased clothing have minimal effects. In temperate climates, sponging is not beneficial. In non-temperate climates, a combination of sponging and paracetamol may be considered (JBI 2001). However sponging can cause shivering and discomfort. 3. It is not advisable to give 4th hourly paracetamol as a regime because it has its own side effects as discussed above. The best would be to observe the child and give paracetamol only if needed (child discomfort, parental anxiety, fear of convulsion). Hence in children with uncomplicated fever, based on the scenario given, the following questions may be asked: 1. Is it necessary to treat this type of fever? 2. If so, what methods should be used to treat? 3. If paracetamol is used, what is the dosage schedule? These questions can be answered as follows in PICO format: Question One Is it necessary to treat this type of fever? Type of Question Intervention Ideal Study Type Randomised controlled trial or systematic review PICO Format P Bringing down temperature in children with uncomplicated fever I Methods to bringing down fever (anti-pyretics and environmental methods) C Placebo O Subsidence of fever without treatment and no complications arising Answer It is not required to bring down temperature in these children unless you want to do it to improve comfort of the child or decrease parental anxiety Question One What methods should be used to treat fever? Type of Question Phenomena Ideal Study Type Qualitative or systematic review PICO Format P Bringing down temperature in children with uncomplicated fever I anti-pyretics C Environmental methods O Subsidence of fever with treatment and no complications arising Answer Fever can be brought down with antipyretic or environmental methods. Of these paracetamol and tepid sponging are the most effective with least side effects. Most of the studies report that paracetamol is more effective than sponging especially in temperate climates. A combination of both may also be used. Question One If paracetamol is used, what is the dosage schedule? Type of Question Intervention Ideal Study Type Systematic review PICO Format P Bringing down temperature in children with uncomplicated fever with paracetamol I paracetamol C O Subsidence of fever with treatment and no complications arising Answer Since it is not required to bring down temperature in these children unless you want to do it to improve comfort of the child or decrease parental anxiety and paracetamol itself is known to have side effects, one might consider giving only if necessary with the dosage being 10- 15 mg/kg/dose (max.60mg/kgday) Based on the above literature review, findings and answers to questions in PICO format, I would like to forward the following policy draft to the director of nursing. Safe Practice MANAGEMENT OF UNCOMPLICATED FEVER IN CHILDREN Objectives: To manage uncomplicated fever in children safely. Procedure: All children with uncomplicated fever do not require bringing down temperature. However, it might be necessary to bring down the temperature to allay discomfort and parental anxiety. Outcome standard: The method used to bring down fever should not be a threat to toxicity or other complications Evaluation method: Audit Continuous – any complications arising due to treatment are reported immediately. Evidence based practice Recommendations: 1. In all children admitted with fever, clinical acumen must be used to determine whether the child has complicated or uncomplicated fever. 2. It is not necessary to bring down temperature in all children with uncomplicated fever. Fever must be reduced only if the child is uncomfortable or there is parental anxiety or the child has history of seizures. Hence it is important to assess these factors to decide upon fever management. 3. Paracetamol is the best method to bring down fever due to convenience and less discomfort. However tepid sponging may be considered in tropical climates. A combination of the two also may be used. 4. Though, of all the drugs used to bring down fever, paracetamol has the least side effects with similar efficacy, it has the potential to accumulate and cause hepatic toxicity. Hence instead of giving 4th hourly a routine practice, the nurse must observe the child and give only when required. 5. The recommended dose of paracetamol is 10-15mg/kg/dose (maximum- 60 mg/kg/day). 6. Along with these, good hydration also should be maintained. Alert: If by mistake excessive dose has been given or the child looks toxic or sick inform the concerned pediatrician. References Barclay, L.,2007. Best Management of Fever from an Unidentifiable Source in Young Children. Available from: http://www.medscape.com/viewarticle/558964 [Cited 25 august 2007] Huang, S.Y, & Bavid, S.G., 2004. Effect of Recent Antipyretic Use on Measured Fever in the Pediatric Emergency Department. Arch Pediatr Adolesc Med., 158, pp.972-976. Impicciatore, P., Pandolfini, C.,  Casella, N., & Bonati, M., 1997. Reliability of health information for the public on the world wide web: systematic survey of advice on managing fever in children at home. Information in practice. Available from: 314http://www.bmj.com/archive/7098ip1.htm [Cited 25 august 2007] JBI, 2001. Management of the Child with Fever, Best Practice, 5 (5), Blackwell Science-Asia, Australia. Kwok, M.Y., & Vazquez, H., 2006. Fever in toddler. eMedicine MD. Available from: http://www.emedicine.com/ped/topic3009.htm [Cited 25 august 2007] Luszczak, M., 2001. Evaluation and Management of Infants and young children with Fever. American family Physician, 64(7). Available from: http://www.aafp.org/afp/20011001/1219.html [Cited 25 august 2007] Meremikwu, M., & Oyo-Ita, A., 2002. Paracetamol for treating fever in children (Cochrane Review). The Cochrane Library, Issue 4, Oxford Update Software. Shann, F., 1995. Paracetamol use in children. Australian Prescriber 18, pp. 33-5. Available from: http://www.australianprescriber.com/magazine/18/2/33/5/ [Cited 25 August 2007] Tejani, N.R., 2006. Pediatrics, Febrile Seizures. Emedicine. Available from: http://www.emedicine.com/EMERG/topic376.htm [Cited 25 August 2007] Watts, R., Roberton, J., & Thomas, G., 2003. Nursing management of fever in children: A systematic review. International Journal of nursing practice, 9(1), pp. S1-S8. Read More