Symptomatic fever management in children: A systematic review of national and international guidelines

Abstract

Introduction Divergent attitudes towards fever have led to a high level of inconsistency in approaches to its management. In an attempt to overcome this, clinical practice guidelines (CPGs) for the symptomatic management of fever in children have been produced by several healthcare organizations. To date, a comprehensive assessment of the evidence level of the recommendations made in these CPGs has not been carried out. Methods Searches were conducted on Pubmed, google scholar, pediatric society websites and guideline databases to locate CPGs from each country (with date coverage from January 1995 to September 2020). Rather than assessing overall guideline quality, the level of evidence for each recommendation was evaluated according to criteria of the Oxford Centre for Evidence-Based Medicine (OCEBM). A GRADE assessment was undertaken to assess the body of evidence related to a single question: the threshold for initiating antipyresis. Methods and results are reported according to the PRISMA statement. Results 74 guidelines were retrieved. Recommendations for antipyretic threshold, type and dose; ambient temperature; dress/covering; activity; fluids; nutrition; proctoclysis; external applications; complementary/herbal recommendations; media; and age-related treatment differences all varied widely. OCEBM evidence levels for most recommendations were low (Level 3–4) or indeterminable. The GRADE assessment revealed a very low level of evidence for a threshold for antipyresis. Conclusion There is no recommendation on which all guidelines agree, and many are inconsistent with the evidence–this is true even for recent guidelines. The threshold question is of fundamental importance and has not yet been answered. Guidelines for the most frequent intervention (antipyresis) remain problematic.

Effectiveness of warm compresses in reducing the temperature of febrile children: A pilot randomized clinical trial

“…There are different understandings regarding the management of fever, especially in relation to non-pharmacological measures, with conceptual disparity related to the effectiveness of different methods, which are used both at home, by parents, and in the hospital service (2,11) . In the context of health care, nurses play a unique role in the care of febrile children and often make use of non-pharmacological measures based on individual convictions and clinical experience, with no scientific evidence (2,12) .…”

“…It was expected that the IG would have a greater decrease in temperature, compared to the CG, if the intervention was relevant. Another point is that the child in the IG was undressed during the 15 minutes of intervention, and as shown in the literature, the removal of excess clothing is also a relevant non-pharmacological measure (11,12) ; however, in the end, the CG showed a greater mean reduction in temperature, and it can be inferred that the intervention of warm compresses was not effective in helping to lower the temperature of febrile children compared to the CG, corroborating the aforementioned studies (14,15) and confirming the null hypothesis.…”

“…Fever clinical management is diverse. The use of pharmacological methods, represented by antipyretics, is the first choice (9)(10)(11) , but non-pharmacological methods such as baths, sponging, compresses, ice packs, refrigerated blankets, fluid intake, removal of clothes, and room ventilation are also widely used (12) , both among parents and health professionals (2,3,6,13) .…”

“…Based on pre-existing literature which portrays that the use of cold (12,19) and hot (20) water is not effective in reducing fever, but with differences regarding the use of warm water (11,19) , this study considered the warm compress an object of research. When observing that the literature portrays possible adverse effects of the use of warm water (12) , the null hypothesis was supported that the administration of antipyretic alone is as effective in reducing the mean body temperature of febrile children as the reduction in temperature that occurred with children who received antipyretic associated with the intervention with warm compresses.…”

Warming up for a better fever: a randomized pilot study in pediatric oncology

“…The usual treatment of fever is in most settings antipyresis from the very first moment, pharmacologically as well as by physical cooling [ 19 ]. Many hospitals advocate the regular use of the antipyretics paracetamol (acetaminophen), metamizol, and ibuprofen for body temperatures above a defined level (≥ 38.5 °C), although in clinical guidelines to date there is no uniform threshold for the administration of antipyretics [ 20 ]. In critically ill children with fever, a permissive temperature threshold was associated with a modest increase in the mean maximum temperature, while length of stay, duration of organ support, and mortality were similar between the groups and without serious adverse events [ 21 ].…”