So you are away travelling and your child develops a fever. They seem otherwise OK and are still running around like crazy. But you are concerned that they might be getting sick. Should you give them a dose of paracetamol?

Fever is one of the most common symptoms of illness in children. And it is one of the most frequent reasons for children to present to our hospitals and medical centres (some estimate it to account for 1/3 of paediatric presentations to healthcare providers).
Fever is classified as a body temperature above 38 C.
Here is a quick bullet-point summary on the management of paediatric fever with Paracetamol (Also known as Acetaminophen in the USA).

Benefits of Fever:

1. Fever has beneficial effects in fighting infection.
   It retards the growth and reproduction of both viruses and bacteria.
   It also enhances neutrophil and T-lymphocyte production (the bodies immune response to fight infection).
2. Fever may also help the body to recover more quickly from viral infections.

So, if your child is well and happy there is really no need to treat the fever.

Problems with Fever:

1. Childs discomfort.
2. Increased insensible water loss (dehydration).

Therefore the primary goal for administering paracetamol should be to improve the level of comfort of the child rather than to bring down the temperature.

Myths about Fever:

• Fever does not increase the risk of adverse outcomes such as brain damage.
  There will be no increase in adverse outcomes even with fevers above 40 C.
• Height of the temperature does not correlate with the severity of illness.
  The caveat to this is that fevers of 38 or more in infants < 3 months old.
  A temperature higher than 38 C in an infant less than 3 months old requires immediate medical assessment.
• There is no evidence that antipyretic treatment (giving Panadol or other medication to reduce the temperature) decreases the recurrence of febrile seizures.
• Tepid sponging is not recommended.
  However over-wrapped children should have excess clothing removed when febrile.

Paracetamol:

• Recommended dose 10 to 15 mg/kg every 4 to 6 hrs orally up to a maximum of 4 doses each 24hrs.
• Onset of antipyretic effect is 30–60 minutes.
  Approximately 80% of children will experience drop in temperature at that time.
• Some suggest an initial loading dose of 20–30 mg/kg. But there is no consistent evidence to support improved antipyretic efficacy with this regime.
• There is no substantial difference in effectiveness between paracetamol and ibuprofen in a generally healthy child with fever.
• There is some evidence that combining paracetamol and ibuprofen may be more effective than a single agent alone.
  However, there is no evidence that combination therapy results in overall improvement of clinical outcomes.
• Combination treatment with alternating paracetamol and ibuprofen are not recommended as it presents an increased risk of dosage errors.

Paracetamol Dose:  10 to 15 mg/kg every 4 to 6 hrs orally up to a maximum of 4 doses each 24hrs. If unsure of correct amount follow instructions on the packaging.

Important tips:

• Correct dosage of paracetamol should be based on childs weight.
  Accurate measuring devices should be used.
• Paracetamol should always be stored in a safe child proof area.
• The goal is to focus on improving the comfort/well-being of your child.
  To maintain good level of hydration and to observe for signs of serious illness.
  There is no need to wake your child overnight to administer paracetamol.

When to seek prompt medical assessment:

Remember fever is a symptom and there is something causing this response. It is important to monitor for further underlying symptoms rather than focusing just on the fever. Other symptoms that would indicate need for medical assessment include:

• a stiff neck or light is hurting their eyes
• vomiting and refusing to drink much
• a rash
• more sleepy than usual
• problems with breathing
• pain that doesn’t get better with pain relief medication.
• have a fever above 40°C, but show no other symptoms
• have had any fever for more than two days
• seem be getting more unwell
• have had a febrile convulsion.

Bottom line, if you are concerned that your child is not improving or your gut feeling is that something more serious may be wrong, seek medical assessment.

A useful information sheet is available here.

REFERENCE:

1. Fever and Antipyretic Use in Children [Internet]. Available from: http://pediatrics.aappublications.org/content/127/3/580.full
2. FOAM4GP Map – Paediatric Fever Phobia | FOAM4GP [Internet]. Available from: http://foam4gp.com/2013/11/08/foam4gp-map-paediatric-fever-phobia/
3. NSW Health, New South Wales, Department of Health. Infants and children: acute management of fever. North Sydney, NSW: NSW Dept. of Health; 2010.
4. JAMA Network | JAMA Pediatrics | Antipyretic Agents for Preventing Recurrences of Febrile Seizures:  Randomized Controlled Trial [Internet]. Available from: http://archpedi.jamanetwork.com/article.aspx?articleid=382103
5. Kids Health Info : Fever in children [Internet].Available from: http://www.rch.org.au/kidsinfo/fact_sheets/Fever_in_children/
6. NICE fever guidelines for kids [Internet]. Available from: http://lifeinthefastlane.com/nice-fever-guidelines-for-kids/