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Re: Is the evidence regarding fever management up to date?

We read with interest El-Radhi’s article on the management of fever and whilst we agree that fever is a very common complaint a more recent paper by Armon et al showed that the most common medical presenting complaint to a UK paediatric emergency department was breathing difficulties (31%). Febrile illness was the second most common of medical ED attendances (20%) with similar figures demonstrated in other contemporary studies1.

The optimal antipyretic strategy remains controversial with a swell of recent papers examining this problem. The recent PITCH study 2 found that using paracetamol and ibuprofen in combination maximised the time children were without fever, thereby complicating the issue further.

Modern paediatricians are undoubtedly aware of the risk of febrile convulsions and also that fever is uncomfortable and unpleasant to the child. The author states that ‘the majority of paediatricians in Massachusetts believe that fever could be dangerous to a child with seizures, death and brain damage being the most common complications.’ This statement implies that these are currently held beliefs. The article quoted was in fact published in 1985. We question it’s relevance to current beliefs held by paediatricians working in the UK. The author states that the media and pharmaceutical companies contribute to the myths and parental fears by the use of emotive slogans and headlines. An internet search revealed advertising taglines such as “helping make kids better day or night” and “nothing reduces fever faster or for longer.” Similarly recent newspaper headlines 3,4 do not seem emotive and the articles accompanying these headlines are, in our opinion, balanced, up to date and well referenced.

When presented with outdated evidence and unreferenced assertions perhaps we begin to see how myths arise in the first place.

References 1 Armon K, Stephenson T, Gabriel V, MacFaul R, Eccleston P, Werneke U, Smith S Audit: Determining the common medical problems presenting to the emergency department. Arch Dis Child 2001;84:390-392

2 Hay AD, Costelloe C, Redmond NM, Montgomery AA, Fletcher M, Hollinghurst S, Peters TJ. Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial. BMJ 2008;337:a1302

3. Vine S. I’m sticking with the Pink Peril. The Times. Sept 19 2008, London.

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Re: Efforts to reduce the gap between research and practice: the Italian experience

Efforts to reduce the gap between research and practice: the Italian experience

Elena Chiappini (1), Filippo Festini (1), Riccardo Longhi(2), Franscesca Bonsignori (1), Maurizio de Martino (1)

(1)Department of Paediatrics, University of Florence, Italy (2)Department of Paediatrics, Sant’Anna Hospital, Como, Italy

Key words: fever, antipyretics, guidelines

Corresponding author: Prof. Maurizio de Martino, Department of Paediatrics, University of Florence, Viale Pieraccini, 24, I-50132 Florence, Italy. E-mail: maurizio.demartino@unifi.it

Editor,

In his article, El-Radhi underlines the barriers to the clinical application of literature evidence, including lack of awareness among health care professionals, inertia of previous practice and parents’ misconceptions(1). Targeted physician and parental education programs are advocated.

We would like to report the recent Italian experience. Fever-phobia is widespread in Italy and prescription practices often do not follow scientific evidence (2). In a recent survey, paracetamol was the off-label drug most often used in children, being frequently administered at higher dosages than those indicated in the product licences (2). Worryingly, antipyretic overdoses have been reported with increased frequency in Italy (3). The NICE guideline for the management of the febrile child (4) is not completely applicable in other countries, since the structure of the health care system varies among European countries.

For these reasons, a targeted national guideline has been developed by the Italian Society of Paediatrics (SIP) and has been divulgated among Italian primary care and hospital paediatricians (5). The document focuses on the management of the sign/symptom fever in children. Detailed information regarding methods to measure the body temperature (by parents in a domiciliary setting, and by health care professionals in ambulatory or hospital settings) is provided. Use of antipyretics for a substantial proportion of febrile children with minimal or no symptoms and alternated use of antipyretics are discouraged. Paediatricians are also alerted that several concomitant conditions may be associated with increased risk of paracetamol and/or ibuprofen toxicity. Written advices for the parents, recommendations for the management of fever in the newborn and child with an underlying chronic disease and algorithms for the management of the child with suspected antipyretic toxicity are provided.

Quality care is depending on the best evidence. The Italian guideline for the management of the sign/symptom fever aims to reduce the gap between research and clinical practice in our country.