2016 Update of the Italian Pediatric Society Guidelines for Management of Fever in Children

Saiga antelope horn suppresses febrile seizures in rats by regulating neurotransmitters and the arachidonic acid pathway

BACKGROUND

Saiga antelope horn (SAH) is a traditional Chinese medicine for treating febrile seizure (FS) with precise efficacy, but its mechanism of action and functional substances are still unclear. Given the need for further research on SAH, our group conducted studies to elucidate its mechanisms and active substances.

METHODS

An FS rat pup model was constructed through intraperitoneal injection of LPS and hyperthermia induction. Behavioural indicators of seizures, hippocampal histopathological alterations, serum levels of inflammatory cytokines and hippocampal levels of neurotransmitters were observed and measured to investigate the effects of SAH on FS model rats. Hippocampal metabolomics and network pharmacology analyses were conducted to reveal the differential metabolites, key peptides and pathways involved in the suppression of FS by SAH.

RESULTS

SAH suppressed FS, decreased the inflammatory response and regulated the Glu-GABA balance. Metabolomic analysis revealed 13 biomarkers of FS, of which SAH improved the levels of 8 differential metabolites. Combined with network pharmacology, a "biomarker-core target-key peptide" network was constructed. The peptides of SAH, such as YGQL and LTGGF, could exert therapeutic effects via the arachidonic acid pathway. Molecular docking and ELISA results indicated that functional peptides of SAH could bind to PTGS2 target, inhibiting the generation of AA and its metabolites in hippocampal samples.

CONCLUSION

In summary, the functional peptides contained in SAH are the main material basis for the treatment of FS, potentially acting through neurotransmitter regulation and the arachidonic acid pathway.

Biomarkers for Serious Bacterial Infections in Febrile Children

Febrile infections in children are a common cause of presentation to the emergency department (ED). While viral infections are usually self-limiting, sometimes bacterial illnesses may lead to sepsis and severe complications. Inflammatory biomarkers such as C reactive protein (CRP) and procalcitonin are usually the first blood exams performed in the ED to differentiate bacterial and viral infections; nowadays, a better understanding of immunochemical pathways has led to the discovery of new and more specific biomarkers that could play a role in the emergency setting. The aim of this narrative review is to provide the most recent evidence on biomarkers and predictor models, combining them for serious bacterial infection (SBI) diagnosis in febrile children. Literature analysis shows that inflammatory response is a complex mechanism in which many biochemical and immunological factors contribute to the host response in SBI. CRP and procalcitonin still represent the most used biomarkers in the pediatric ED for the diagnosis of SBI. Their sensibility and sensitivity increase when combined, and for this reason, it is reasonable to take them both into consideration in the evaluation of febrile children. The potential of machine learning tools, which represent a real novelty in medical practice, in conjunction with routine clinical and biological information, may improve the accuracy of diagnosis and target therapeutic options in SBI. However, studies on this matter are not yet validated in younger populations, making their relevance in pediatric precision medicine still uncertain. More data from further research are needed to improve clinical practice and decision making using these new technologies.

Childhood fever and medical students: A multicentre, educational intervention

AIM

Misconceptions and non-evidence-based practices toward childhood fever are reported worldwide. Medical students might be ideal candidates to introduce long-lasting changes in clinical practice. However, no study has gauged the effectiveness of an educational intervention to improve fever management in this population. We conducted an educational, interventional study on childhood fever among final-year medical students.

METHODS

We conducted a prospective, multicentre interventional study employing a pre/post-test design. Participants from three Italian Universities filled in a questionnaire just before the intervention (T0), immediately after (T1) and 6 months later (T2) in 2022. The intervention was a two-hour lecture focused on the pathophysiology of fever, recommendations for its treatment and risks associated with improper management.

RESULTS

188 final-year medical students (median age of 26 years, 67% females) were enrolled. Relevant improvements in the criterion for treating fever and conceptions about the beneficial effects of fever were observed at T1 and T2. Similar data were found for the reduction of physical methods advice to decrease body temperature and concerns for brain damage from fever.

CONCLUSION

This study shows for the first time that an educational intervention is effective in changing students' conceptions and attitudes toward fever both in the short and medium term.

Pain Management in Children Admitted to the Emergency Room: A Narrative Review

Pain is a biopsychosocial experience characterized by sensory, physiological, cognitive, affective, and behavioral components. Both acute and chronic pain can have short and long-term negative effects. Unfortunately, pain treatment is often inadequate. Guidelines and recommendations for a rational approach to pediatric pain frequently differ, and this may be one of the most important reasons for the poor attention frequently paid to pain treatment in children. This narrative review discusses the present knowledge in this regard. A literature review conducted on papers produced over the last 8 years showed that although in recent years, compared to the past, much progress has been made in the treatment of pain in the context of the pediatric emergency room, there is still a lot to do. There is a need to create guidelines that outline standardized and easy-to-follow pathways for pain recognition and management, which are also flexible enough to take into account differences in different contexts both in terms of drug availability and education of staff as well as of the different complexities of patients. It is essential to guarantee an approach to pain that is as uniform as possible among the pediatric population that limits, as much as possible, the inequalities related to ethnicity and language barriers.

Aetiology of Acute Undifferentiated Fever Among Children Under the Age of Five in Vietnam: A Prospective Study

BACKGROUND

To investigate the aetiology of acute undifferentiated fever (AUF) among children under the age of five in Vietnam.

METHODS

This prospective study was conducted in the Thai Binh paediatric hospital, between July 2020 and July 2021 among children with AUF at admission. Real-time PCR testing 18 microbial pathogens were done on blood samples.

RESULTS

286 children were included, with median age of 16 months. 64.7% were male. 53.9% were positive for at least one pathogen by PCR. Enterovirus, human herpesvirus 6, adenovirus, and varicella zoster virus PCR were positive for 31.1, 12.6, 1.4, and 1.0% patients, respectively. Other pathogens tested negative by PCR. During the hospital stay, based on clinical criteria 47.2% children secondarily presented with signs of respiratory tract infections, 18.9% had hand, foot and mouth disease, 4.6% had chickenpox. 4.2% presented signs of central nervous system infections, 1.0% had dengue (antigenic test) and 1.0% had signs of gastrointestinal infection. Finally, 23.1% patients presented a fever with or without a rash and no other symptoms and ultimately received a diagnosis of AUF.

CONCLUSION

Real-time PCR of blood is useful for detecting pathogens and diagnosing infectious causes of AUF. Further prospective studies with blood and urine culture testing and PCR investigation of not only blood but also cerebrospinal fluid, throat, and skin samples according to symptoms would be of interest to confirm the predominance of viral infections in children with AUF and to guide therapeutic options.

Approach to fever in children among final-year nursing students: a multicenter survey

BACKGROUND

Unfounded concerns regarding fever are increasingly observed among nurses worldwide. However, no study has so far explored the preferred approach towards pediatric fever among nursing students. Therefore, we aimed to investigate the attitude towards pediatric fever among final-year nursing students.

METHODS

Between February and June 2022, final-year nursing students of 5 Italian university hospitals were asked to answer an online survey on their approach to fever in children. Both quantitative and qualitative methods were utilized. Multiple regression models were employed to explore the existence of moderators on fever conceptions.

RESULTS

The survey was filled in by 121 nursing students (response rate 50%). Although most students (98%) do not consider discomfort to treat fever in children, only a minority would administer a second dose of the same antipyretic in nonresponsive cases (5.8%) or would alternate antipyretic drugs (13%). Most students would use physical methods to decrease fever (84%) and do not think that fever has mainly beneficial effects in children (72%). The own know-how adequacy on fever was inversely associated (OR 0.33, 95% CI 0.13-0.81) with the beliefs that high fever might lead to brain damage. No further predictive variable was significantly associated with the concern that fever might be associated with brain damage, the advice of physical methods use, and the assumption that fever has mostly positive effects.

DISCUSSION

This study shows for the first time that misconceptions and inappropriate attitudes towards fever in children are common among final-year nursing students. Nursing students could potentially be ideal candidates for improving fever management within clinical practice and amongst caregivers.

Perception, knowledge and attitude towards childhood fever: A survey among final-year medical students

AIMS

Undue concerns about the consequences of fever and its inappropriate management have been documented worldwide among physicians. However, no data exist on medical students. We investigated the perception, knowledge and attitude towards childhood fever among final-year medical students.

METHODS

Between June and September 2021, final-year medical students of six Italian universities were invited to complete an online survey on their conceptions and attitude towards pharmacological and non-pharmacological management of childhood fever. History of relevant personal or second-hand experience with childhood fever was also addressed. Both quantitative and qualitative approaches were used.

RESULTS

Of 1095 (69%) final-year medical students, 756 completed the survey. Many students believe that high fever might cause brain damage, would recommend physical methods and alternate two drugs for fever. Most students do not think that fever has mainly beneficial effects. In Northern Italy, students are less likely to believe that fever might lead to brain damage (OR 0.55, 95% CI 0.33-0.94), and in Southern Italy students are more likely to advise physical methods (OR 1.77, 95% CI 1.22-2.57) and less likely to believe that fever has mainly beneficial effects (OR 0.55, 95% CI 0.39-0.77). History of a relevant personal episode of fever during childhood was not associated with these outcomes.

CONCLUSIONS

Misconceptions about fever are common among final-year medical students in Italy. Cultural factors rather than individually learned traits might underlie these beliefs. Medical students are a promising target for educational interventions to improve childhood fever management.

A Comparative Study of Forehead Temperature and Core Body Temperature under Varying Ambient Temperature Conditions

When the ambient temperature, in which a person is situated, fluctuates, the body's surface temperature will alter proportionally. However, the body's core temperature will remain relatively steady. Consequently, using body surface temperature to characterize the core body temperature of the human body in varied situations is still highly inaccurate. This research aims to investigate and establish the link between human body surface temperature and core body temperature in a variety of ambient conditions, as well as the associated conversion curves.

METHODS

Plan an experiment to measure temperature over a thousand times in order to get the corresponding data for human forehead, axillary, and oral temperatures at varying ambient temperatures (14-32 °C). Utilize the axillary and oral temperatures as the core body temperature standards or the control group to investigate the new approach's accuracy, sensitivity, and specificity for detecting fever/non-fever conditions and the forehead temperature as the experimental group. Analyze the statistical connection, data correlation, and agreement between the forehead temperature and the core body temperature.

RESULTS

A total of 1080 tests measuring body temperature were conducted on healthy adults. The average axillary temperature was (36.7 ± 0.41) °C, the average oral temperature was (36.7 ± 0.33) °C, and the average forehead temperature was (36.2 ± 0.30) °C as a result of the shift in ambient temperature. The forehead temperature was 0.5 °C lower than the average of the axillary and oral temperatures. The Pearson correlation coefficient between axillary and oral temperatures was 0.41 (95% CI, 0.28-0.52), between axillary and forehead temperatures was 0.07 (95% CI, -0.07-0.22), and between oral and forehead temperatures was 0.26 (95% CI, 0.11-0.39). The mean differences between the axillary temperature and the oral temperature, the oral temperature and the forehead temperature, and the axillary temperature and the forehead temperature were -0.08 °C, 0.49 °C, and 0.42 °C, respectively, according to a Bland-Altman analysis. Finally, the regression analysis revealed that there was a linear association between the axillary temperature and the forehead temperature, as well as the oral temperature and the forehead temperature due to the change in ambient temperature.

CONCLUSION

The changes in ambient temperature have a substantial impact on the temperature of the forehead. There are significant differences between the forehead and axillary temperatures, as well as the forehead and oral temperatures, when the ambient temperature is low. As the ambient temperature rises, the forehead temperature tends to progressively converge with the axillary and oral temperatures. In clinical or daily applications, it is not advised to utilize the forehead temperature derived from an uncorrected infrared thermometer as the foundation for a body temperature screening in public venues such as hospital outpatient clinics, shopping malls, airports, and train stations.

Clinical Accuracy of Non-Contact Forehead Infrared Thermometer Measurement in Children: An Observational Study

We evaluated the clinical reliability and utility of temperature measurements using no-contact forehead infrared thermometers (NCFITs) by comparing their temperature measurements with those obtained using infrared tympanic thermometers (IRTTs) in children. In this observational, prospective, and cross-sectional study, we enrolled 255 children (aged 1 month to 18 years) from the pediatric surgery ward at a tertiary medical center in Korea. The mean age of the children was 9.05 ± 5.39 years, and 54.9% were boys. The incidence rate of fever, defined as an IRTT reading of ≥38.0 °C, was 15.7%. The ICC coefficient for the assessment of agreement between temperatures recorded by the NCFIT and IRTT was 0.87, and the κ-coefficient was 0.83. The bias and 95% limits of agreement were 0.15 °C (−0.43 to 0.73). For an accurate diagnosis of fever (≥38 °C), the false-negative rate was much lower, but the false-positive rate was higher, especially in 6-year-old children. Therefore, NCFITs can be used to screen children for fever. However, a secondary check is required using another thermometer when the child’s temperature is >38 °C. NCFITs are proposed for screening but not for measuring the temperature. For the latter, an accurate and reliable thermometer shall be used.

The Effect of Cold-Water Hydrotherapy According to Sebastian Kneipp for Immune Stimulation: A Nonrandomized, Controlled, Explorative, Mixed-Methods Clinical Study

Highlights Home-based hydrotherapy leads to fewer missed kindergarten-days in total. In the application group, more fever days could be registered. Hydrotherapy, according to the hormesis principle by Sebastian Kneipp, aims to reduce infections of the lower respiratory tract. Parents participation motivated by increase in applicable health knowledge for their children. Objectives: This study investigates the effect of cold-water hydrotherapy stimulation according to the hormesis principle by Sebastian Kneipp on the number of missing kindergarten-days, fever days, and respiratory tract infections in children aged 3-6 years. Study design: A nonrandomized, controlled, explorative, mixed-methods clinical study. Intervention: The hydrotherapeutic intervention treated children aged 3-6 years with Kneipp arm affusions over 6 weeks. The control group received no intervention. Number of missed kindergarten-days, fever days, and respiratory tract infections were assessed by means of a digital diary. Through a self-developed structured questionnaire, sociodemographic data of both groups were compared and reason for participation in the study was recorded and qualitatively evaluated. Results: Twenty children participants and their parents in the intervention group and 18 in the control group were evaluated. The intervention was conducted at home by the parents. Statistical analysis revealed no significant differences between the groups but still showed intermediate effect sizes (indicating an underpowered study). These effect sizes point to a potentially lower proportion of children in the application group versus the control group with missed kindergarten-days in total (d = 0.67), days missed due to fever (d = 0.29), and infections of the lower respiratory tract (d = 0.60). In a future study, these parameters will thus serve as promising factors for evaluation. Parent's stated reasons for participation interest were to improve health, increase their own health knowledge, and because of their interest in alternative therapies and to support research. Conclusions: Cold-water hydrotherapy stimulation, according to the hormesis principle by Sebastian Kneipp, did reduce the number of days absent in kindergarten in total in the intervention group and lower respiratory tract infections occurred less frequently. Parent' participation interest demonstrated a desire to increase health literacy and implement this with their own children. Due to the small sample size, the results should be interpreted cautiously. Clinical Trial Registration Number: German Register of Clinical Trials (DRKS): ID 00017562.

The impact of ibuprofen on valproic acid plasma concentration in pediatric patients

The combination of valproic acid (VPA) and ibuprofen is common in children with epilepsy. Three case reports investigated that ibuprofen might decrease plasma concentration of VPA, however, no cohort study was published to evaluate the interaction of ibuprofen on VPA plasma concentration in pediatric patients.Data from patients with measured VPA trough concentrations (C₀) were retrospectively collected in a Chinese teaching and tertiary Children's Hospital from January 2017 to June 2019. The samples measured within 6 weeks of the last ibuprofen administration were considered as ibuprofen combination samples. Patients with paired samples before and after ibuprofen administration were additionally analyzed. The effects of ibuprofen on the VPA trough concentration to dose (C₀/D) ratio were investigated. The proportion of samples with achieved target concentrations of VPA (50-100 mg/L) and the corresponding required dosage were compared. Moreover, subgroup analysis according to the interval between the last ibuprofen dosage and C₀ measurement was performed.A total of 616 samples from 434 patients, of whom 16 had paired samples, were included. VPA C₀/D decreased when ibuprofen was administered by 7.5% and 30.6% of the total samples and paired samples, respectively. The interaction was significant within 1 week of the last ibuprofen dose. No significant differences were observed in the proportion of target concentration achieved and VPA dose requirement when ibuprofen was combined.A moderate effect of ibuprofen on VPA C₀/D was observed within 1 week of ibuprofen administration; the target concentration and required doses of VPA were comparable.

Management of fever in infants and children in the emergency setting and during home discharge: recommendations from an Italian panel

In infants and children, fever is very common in the emergency setting. The overall aim of the present publication was to overview guidance and provide an algorithm for use in the emergency setting as well as recommendations to inform parents for home care. To obtain consensus, a core steering committee drafted a management algorithm and general consensus was obtained by remote voting among experts. A number of common messages are found in current guidelines: management of fever depends on age, antipyretics are indicated only for discomfort; paracetamol or ibuprofen can be recommended; physical methods for lowering temperature are discouraged. A consensus algorithm is presented in which infants <28 days are considered separately, while those >28 days and <90 days are divided into those ill or well appearing. All infants <28 days with fever ≥37.5 °C should undergo complete work-up for sepsis, strongly considered to receive empirical antibiotics ± acyclovir, and be hospitalized. All infants (between 28 and 90 days) ill appearing should undergo diagnostic work-up for sepsis, receive empirical antibiotics, and be hospitalized. In well appearing infants, diagnostic work-up should be carried out to decide admission to hospital and administration of antibiotics. Specific recommendations are also given for home discharge that can be used to inform parents about the actions to take during home care in the attempt to reinforce existing guidelines. At present, physical examination and laboratory tests, along with best clinical judgement and postdischarge guidance following a defined algorithm, are the foundation of management of febrile children.

Development of an observer-reported outcome measure to capture the signs and impact of fever distress symptoms in infants and young children

PURPOSE

This qualitative study aimed to construct an observer-reported outcome measure (ObsRO) to evaluate fever distress in young children.

METHODS

A literature review was conducted to identify fever-related concepts. Clinical experts were interviewed for feedback on these concepts. Parents of young children were interviewed to identify behaviours the child exhibited during a recent fever episode. Fever sign and behaviour concepts endorsed by ≥ 20% parents were used to create items for the draft ObsRO. Parents of young children who recently had fever completed the ObsRO and gave feedback during two successive rounds of cognitive interviews.

RESULTS

Twenty-five parents participated in the concept elicitation. Mean child age was 2.7 years (range: 0.6-5.8 years). Fever sign and behaviour concepts endorsed by ≥ 20% participants were high temperature (80%), skin hot to touch (32%), skin redness/flushing (32%), reduced appetite/drink (96%), needy/clingy/irritable (48-92%), less active/interactive (68-84%) and lethargic (64-88%). Eighteen items, four in the Fever Signs Module and 14 in the Fever Behaviours Module, were developed for the draft ObsRO. Chosen recall period was 24 h. Thirty participants (Round 1: n = 17; Round 2: n = 13), participated in cognitive interviews. Mean child age was 2.4 years (range 0.3-5.8). Round 1 feedback resulted in two Fever Signs items being combined. Three Fever Behaviour items were deleted, six revised and four unchanged. No changes were made following Round 2 feedback. Most participants understood all aspects of the ObsRO and found it user-friendly.

CONCLUSION

The ObsRO will undergo further development in validation studies testing measurement properties of each item.

Accuracy of the Axillary Temperature Screening Compared to Core Rectal Temperature in Infants

Purpose. To compare the sensitivity of axillary and rectal temperature in infants who presents to the emergency department with a recent history of fever. Methods. A single-center cross-sectional comparative study of 201 patients who presents with a recent history of fever. Infants Up to 12 months of age were included. Demographic characteristics such as age and gender, weight, mean axillary and rectal temperatures were documented. Fever is defined as rectal temperature >38°C as opposed to >37.4 in the axillary method. Results. The mean age was 6.1 ± 3.5 months. The mean (SD) rectal-axillary temperature difference was 0.8°C ± 0.7°C which was statistically significant ( P < .001). The sensitivity, specificity, positive predictive and negative predictive values of the axillary method for fever >37.4 were 79.34% (95% CI [73-84.9]), 14.3% (95% CI [0.36-57.9]), 96.2% (95% CI [95-97.2]), and 2.4% (95% CI [0.4-13.5]), respectively. Conclusion. The rectal method remains highly important for accurate and prompt diagnosis in infants.

The Effective Management of Fever in Pediatrics and Insights on Remote Management: Experts' Consensus Using a Delphi Approach

BACKGROUND

Even after the publication of the 2017 update of Italian guidelines on treatment of fever in pediatrics, some fundamental questions are still open and new ones emerged during the COVID-19 pandemic.

OBJECTIVE

To assess the level of consensus among Italian pediatricians on different topics related to treatment of fever in children by using the Delphi technique.

METHODS

A Delphi study was undertaken between June and September 2021, when two questionnaires were consecutively sent to a panel of experts to be answered anonymously. An invitation to participate was sent to 500 pediatricians distributed over the whole national territory and 80 (16%) of them accepted to participate on a voluntary basis. The questionnaires were structured into three specific topics: "therapeutic appropriateness and management of the febrile child," "management of the febrile child in the presence of other diseases," and "future perspectives in remote management." Each topic had six statements.

RESULTS

A first-round questionnaire was sent to 80 accepting pediatricians from different Italian regions. Of the 72 respondents (23% working in hospitals and 72% outside), 33% were from northern, 12% central, and 55% southern Italy or islands. A second-round questionnaire was sent to the same 80 pediatricians and 69 of them responded, without significant differences for workplaces or geographical distribution as compared with the first questionnaire. Overall, 75 participants answered at least one of the two questionnaires. All the statements on the topics of "therapeutic appropriateness and management of the febrile child" and "future perspectives in remote management" reached the predefined cut off for consensus (75% or more). Only one statement on "management of the febrile child in the presence of other diseases" did not achieve the consensus even after the second round.

CONCLUSIONS

Italian pediatricians agree on several aspects of treatment of febrile children and their expert opinions could support everyday decision process complementary to recommendations by regulatory agencies and guidelines.

Systematic review of methodology and reporting quality of global guidelines on fever in children

OBJECTIVE

This study aimed to evaluate the global clinical practice guidelines on fever in children. We also aimed to select a guideline with good methodology and reporting quality to provide scientific reference for diagnosis and treatment of fever in children.

METHODS

The Chinese and English databases Embase, PubMed, Cochrane library, China National Knowledge Infrastructure, Wanfang database, clinical guides, and the website of the Department of Public Health Administration were retrieved up to January 2020. The clinical practice guidelines on fever in children were included. The AGREE II instrument and Reporting Items for Practice Guidelines in Healthcare statement were used to evaluate the methodology and reporting quality of the guidelines.

RESULTS

Eight clinical guidelines for fever in children were included. Methodological quality assessment showed that the recommendation level of ISP, South Africa, National Institute for Health and Care Excellence, China, and American College of Emergency Physicians were grade B (recommended with modification), while that of American Academy of Pediatrics, New South Wales, and South Australia was grade C recommendation (not recommended). No grade A recommendation guideline was found. The reporting quality from higher to lower was National Institute for Health and Care Excellence, the Chinese guideline, American College of Emergency Physicians, ISP, South Africa, New South Wales, South Australia, and American Academy of Pediatrics. The guideline recommendations were similar in various countries, but they were slightly different in various aspects, including body temperature measurement and the timing of drug administration.

CONCLUSION

There are limitations in the methodology and reporting quality of all eight global guidelines on fever in children. For future development of these guidelines, attention should be paid to improving applicability of the guidelines in terms of methodology. Additionally, the principles and explanations for formation of recommendations should be described, as well as the limitations of the reporting guideline in detail in terms of the reporting quality. Treatments of fever in children are similar in different countries, but there are still differences that require further research.

Managing fever in children: developing guidelines that turn evidence into practice

The importance of evidence-based practice has been emphasised in nursing in recent years. However, the process by which research evidence is turned into clinical recommendations is not always clear. This is important because understanding and communicating the rationale for clinical decisions is a vital part of the role of the children's nurse. This article discusses the methods by which nurses can turn evidence into practice using a framework devised by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group. The article uses the treatment of fever in children as an example of how nurses can apply the GRADE framework to ensure that their practice is evidence-based.

Paracetamol and Ibuprofen in the Treatment of Fever and Acute Mild-Moderate Pain in Children: Italian Experts' Consensus Statements

Fever and pain are challenging symptoms in children and adolescents and are common reasons for consultations in primary care and hospital. Paracetamol and ibuprofen are currently the only recommended drugs for treating fever in Italy, but the therapeutic approaches are discrepant in the different settings. In Italy, paracetamol and ibuprofen are the most prescribed analgesics for acute mild–moderate pain in children; however, their use is often inappropriate in that fever is over-treated and pain is under-treated. An Italian board of experts analyzed the motivations for the misalignment between daily practice and guidelines of fever and acute mild–moderate pain management of the territory and hospitals. The expert opinion consensus process underscored the appropriate use of paracetamol and ibuprofen according to clinical scenarios, patients’ profiles, and the safety features of the drugs. Although patients’ profiles can indicate different benefits from paracetamol or ibuprofen, critical issues of fever and acute mild–moderate pain management persist in primary care and hospitals. These expert opinion consensus statements can be an across-the-board tool to harmonize the routine practice between the territory and hospitals, especially under special conditions (at-risk for dehydration, coagulation disorder patients, etc.). It can also promote educational activity about fever and acute mild–moderate pain management to enhance the milestones already achieved by Italian pediatricians.

Evaluating the interchangeability of infrared and digital devices with the traditional mercury thermometer in hospitalized pediatric patients: an observational study

Gradual replacement of the mercury thermometers with alternative devices is ongoing around the world in a bid to protect human health and the environment from the adverse effects of mercury. However, to reduce the risks of misdiagnosis, unnecessary treatments, and omission of care in pediatric populations, more evidence on the reliability of alternative thermometers is needed. The aim of this comparative observational study was to detect any differences in temperature measurements between the use of the axillary mercury thermometer and the alternative techniques. Temperature values in degree Celsius (°C) were measured in a group of Albanian children aged up to 14 years using mercury and digital axillary thermometers, as well as forehead and tympanic infrared thermometers. The digital axillary device, compared with the mercury one, showed no clinically significant difference in the mean values (− 0.04 ± 0.29 °C) and the narrowest 95% level of agreement (+ 0.53 °C to − 0.62 °C) in the paired comparisons. For cut-off point of 37.5 °C, the digital axillary thermometer showed the highest levels of sensitivity (72.5%) and specificity (99.1%) in detecting fever. This study indicates that the digital axillary thermometer may be the better option since it adequately balances accuracy, safety, and children’s comfort.

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

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.

The diagnostic accuracy of digital, infrared and mercury-in-glass thermometers in measuring body temperature: a systematic review and network meta-analysis

Not much is known about how accurate and reproducible different thermometers are at diagnosing patients with suspected fever. The study aims at evaluating which peripheral thermometers are more accurate and reproducible. We searched Medline, Embase, Scopus, WOS, CENTRAL, and Cinahl to perform: (1) diagnostic accuracy meta-analysis (MA) using rectal mercury-in-glass or digital thermometry as reference, and bivariate models for pooling; (2) network MA to estimate differences in mean temperature between devices; (3) Bland-Altman method to estimate 95% coefficient of reproducibility. PROSPERO registration: CRD42020174996. We included 46 studies enrolling more than 12,000 patients. Using 38 °C (100.4 ℉) as cut-off temperature, temporal infrared thermometry had a sensitivity of 0.76 (95% confidence interval, 0.65, 0.84; low certainty) and specificity of 0.96 (0.92, 0.98; moderate certainty); tympanic infrared thermometry had a sensitivity of 0.77 (0.60,  0.88; low certainty) and specificity of 0.98 (0.95, 0.99; moderate certainty). For all the other index devices, it was not possible to pool the estimates. Compared to the rectal mercury-in-glass thermometer, mean temperature differences were not statistically different from zero for temporal or tympanic infrared thermometry; the median coefficient of reproducibility ranged between 0.53 °C [0.95 ℉] for infrared temporal and 1.2 °C [2.16 ℉] for axillary digital thermometry. Several peripheral thermometers proved specific, but not sensitive for diagnosing fever with rectal thermometry as a reference standard, meaning that finding a temperature below 38 °C does not rule out fever. Fixed differences between temperatures together with random error means facing differences between measurements in the order of 2 °C [4.5 ℉]. This study informs practitioners of the limitations associated with different thermometers; peripheral ones are specific but not sensitive.

Assessment of Saudi Parents' Beliefs and Behaviors towards Management of Child Fever in Saudi Arabia-A Cross-Sectional Study

OBJECTIVE

Fever alone can lead to rare serious complications in children, such as febrile seizures. The aim of this study is to assess the knowledge, beliefs, and behavior of parents toward fever and its management.

METHODS

A cross-sectional study using an online questionnaire was applied over a period of 3 months, from January to March 2018, to parents who were living in Saudi Arabia. The inclusion criteria were a parent who is a resident of Saudi Arabia, with at least one child aged 6 years or less, while incomplete questionnaires, having a child aged more than 6 years, or parents who were not living in Saudi Arabia were excluded.

RESULTS

A total of 656 parents completed the questionnaire. More than two-thirds of the subjects were female, the majority of whom were aged between 25-33 years old. The best-reported place to measure the temperature of children was the armpit (46%), followed by the ear (28%) and the mouth (10.7%). More than half of the parents considered their children feverish at a temperature of 38 °C. The majority of parents (79.7%) reported that the most serious side effects of fever were seizure, brain damage (39.3%), coma (29.9%), dehydration (29.7%), and death (25%). The most common method used to measure a child's temperature was an electronic thermometer (62.3%). The most common antipyretic was paracetamol (84.5%).

CONCLUSIONS

Our study demonstrates the good knowledge of parents in identifying a feverish temperature using the recommended route and tools for measuring body temperature.

Effect of prophylactic administration of antipyretics on the immune response to pneumococcal conjugate vaccines in children: a systematic review

Background

Prophylactic administration of antipyretics at the time of immunization seems to decrease some side effects, however reduced immune responses have been reported in some studies. This systematic review aimed to investigate the effect of prophylactic use of antipyretics on the immune response following administration of pneumococcal conjugate vaccines (PCVs).

Methods

A systematic review of randomized controlled trials and observational studies concerning the immune response to PCVs after antipyretic administration was performed up to November 2020 in the electronic databases of Pubmed and Scopus.

Results

Of the 3956 citations retrieved, a total of 5 randomized control trials including 2775 children were included in the review. Included studies were referred to PCV10 (3 studies), PCV7 and PCV13 (one study each). The prophylactic administration of paracetamol decreased the immune response to certain pneumococcal serotypes in all included studies. The effect was more evident following primary vaccination and with immediate administration of paracetamol. Despite the reductions in antibody geometric mean concentrations, a robust memory response was observed following the booster dose. Besides, antibody titers remained above protective levels in 88–100% of participants. The use of ibuprofen, that was evaluated in two studies, did not seem to affect the immunogenicity of PCVs .

Conclusion

Although the reviewed studies had significant heterogeneity in design, paracetamol administration seems to affect the immune response for certain serotypes. The clinical significance of reduced immunogenicity especially before booster dose needs further investigation.

Prescribing patterns, indications and adverse events of ibuprofen in children: results from a national survey among Italian pediatricians

Background

Despite ibuprofen widely recognized safety profile, an increase of suspected adverse events has been reported in the last decade in parallel with its growing over-the-counter use. The aims of this study were to assess the therapeutic approach to the feverish child and to evaluate the main indications and the most frequent adverse events related to ibuprofen administration in children.

Methods

A specific questionnaire-form regarding the management of ibuprofen therapy in children was distributed among a sample of pediatricians all over the Italian territory between September and October 2020. An electronic data collection through a specifically designed web-based platform was performed among the participating pediatricians.

Results

One-hundred-eighty-one pediatricians completed the survey. In case of fever, 177 (98%) participants prescribe paracetamol, while only 4 (2%) preferred ibuprofen as first choice. One-hundred-twenty-eight pediatricians (71%) administer paracetamol alone, while 53 (29.2%) use the combined/alternating treatment with ibuprofen. Ibuprofen is mostly administered for musculoskeletal pain (30%), upper respiratory tract infection (20%), headache (15%) and post-surgical pain (9%). Sixty-three (35%) out of 181 participating pediatricians reported 191 adverse events during ibuprofen administration. The most common were gastrointestinal (GI), with GI bleeding being reported in 30/191 cases (15.7%), epigastric pain in 29/191 (15.1%), non-specified abdominal pain in 22/191 (11.1%) and nausea/vomiting in 21/191 (11%). Severe adverse events including kidney damage (3.1%), complicated infections (0.5%), pneumonia associated empyema (0.5%), soft tissue infection (0.5%) and disseminated intravascular coagulation (0.5%) were also reported. The adverse events led to a hospitalization in 12% of children. In 53/191 cases (28%) the adverse events were related to a wrong dosage or prolonged therapy or errors in frequency of administration.

Conclusions

This survey demonstrate a sufficient awareness of Italian pediatricians regarding ibuprofen-prescribing patterns with the only possible concern related to the relatively high percentage of pediatricians performing a combining/alternating use of paracetamol and ibuprofen. The reported adverse events were mild in most of the cases and often related to errors in dosage, frequency and treatment duration, emphasizing the need for a major caution of both practitioners and patients in their use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13052-021-01047-y.

Use of antipyretics for preventing febrile seizure recurrence in children: a systematic review and meta-analysis

The efficacy of antipyretics for preventing febrile seizure recurrence has been reported by a recent study, and the results might overturn previous evidence. We systematically reviewed the efficacy of antipyretics in the prevention of febrile seizure recurrence in children focused on the timing of its administration. We searched the Medline, Embase, and Cochrane Central Register of Controlled Trials databases for randomized and quasi-randomized trials and prospective non-randomized studies of aged up to 60 months, diagnosed with febrile seizure, who were treated with antipyretics. Data were extracted from eight studies. Only one study reported that antipyretics prevented the recurrence of febrile seizures within the same fever episode (9.1% in the acetaminophen group vs. 23.5% in the control group, p < 0.01). Four studies found no evidence for the efficacy of antipyretics in preventing febrile seizure recurrence in distant fever episodes (odds ratio, 0.92; 95% confidence interval, 0.57-1.48, for two randomized controlled studies).Conclusion: This review provides very limited support for the use of antipyretics in preventing febrile seizure recurrence within the same fever episode and no evidence for its use in distant fever episodes. New studies are required to evaluate this topic further and determine whether the effectiveness of antipyretics is based on intervention timing. What is Known: • Reviews of prophylactic drug management among febrile seizure children found that antipyretics had no significant benefits. • Recent data suggest that antipyretics are effective in preventing febrile seizures. What is New: • Weak evidence suggests a possible role in preventing febrile seizure recurrence within the same fever episode. • There is clearly no role for antipyretic prophylaxis in preventing febrile seizures during distant fever episodes.

Serious infectious events and ibuprofen administration in pediatrics: a narrative review in the era of COVID-19 pandemic

Purpose of review

Despite its recognized efficacy and tolerability profile, during the last decade a rise of adverse events following ibuprofen administration in children has been reported, including a possible role in worsening the clinical course of infections. Our aim was to critically evaluate the safety of ibuprofen during the course of pediatric infectious disease in order to promote its appropriate use in children.

Recent findings

Ibuprofen is associated with severe necrotizing soft tissue infections (NSTI) during chickenpox course. Pre-hospital use of ibuprofen seems to increase the risk of complicated pneumonia in children. Conflicting data have been published in septic children, while ibuprofen in the setting of Cystic Fibrosis (CF) exacerbations is safe and efficacious. No data is yet available for ibuprofen use during COVID-19 course.

Summary

Ibuprofen should not be recommended for chickenpox management. Due to possible higher risks of complicated pneumonia, we suggest caution on its use in children with respiratory symptoms. While it remains unclear whether ibuprofen may have harmful effects during systemic bacterial infection, its administration is recommended in CF course. Despite the lack of data, it is seems cautious to prefer the use of paracetamol during COVID-19 acute respiratory distress syndrome in children.

Diagnosis and management of community-acquired pneumonia in children: South African Thoracic Society guidelines

BACKGROUND

Pneumonia remains a major cause of morbidity and mortality amongst South African children. More comprehensive immunisation regimens, strengthening of HIV programmes, improvement in socioeconomic conditions and new preventive strategies have impacted on the epidemiology of pneumonia. Furthermore, sensitive diagnostic tests and better sampling methods in young children improve aetiological diagnosis.

OBJECTIVES

To produce revised guidelines for pneumonia in South African children under 5 years of age.

METHODS

The Paediatric Assembly of the South African Thoracic Society and the National Institute for Communicable Diseases established seven expert subgroups to revise existing South African guidelines focusing on: (i) epidemiology; (ii) aetiology; (iii) diagnosis; (iv) antibiotic management and supportive therapy; (v) management in intensive care; (vi) prevention; and (vii) considerations in HIV-infected or HIVexposed, uninfected (HEU) children. Each subgroup reviewed the published evidence in their area; in the absence of evidence, expert opinion was accepted. Evidence was graded using the British Thoracic Society (BTS) grading system. Sections were synthesized into an overall guideline which underwent peer review and revision.

RECOMMENDATIONS

Recommendations include a diagnostic approach, investigations, management and preventive strategies. Specific recommendations for HIV infected and HEU children are provided.

VALIDATION

The guideline is based on available published evidence supplemented by the consensus opinion of SA paediatric experts. Recommendations are consistent with those in published international guidelines.

[Benefits and risks of ibuprofen in children with fever: Overview of the literature with a view to producing a written information tool for parents]

Drug information, as it appears in package leaflet, lacks relevant encrypted data for the patient. The aim of our research was to propose a written model of drug information inspired from the concept of the "Drug Facts Box", about ibuprofen in children with fever. To this end, we carried out a systematic review of systematic literature reviews ("overview") to look for data on the benefits and risks of ibuprofen compared to placebo, paracetamol or a treatment alternating or combining paracetamol and ibuprofen in children with fever aged 0-18 years. 9 systematic reviews were included from the Pubmed/Medline, Embase and Cochrane databases. 1 clinical practice guideline and 2 documents published by the French Haute Autorité de santé (HAS) and the French Agence nationale de sécurité du médicament et des produits de santé (ANSM) were also included. Paracetamol and ibuprofen have a comparable efficacy and safety profile in children with fever. A low increased risk of adverse reactions to ibuprofen is to be feared in specifics clinical situations (chicken pox, pneumonia, angina). Treatments alternating or combining paracetamol and ibuprofen can further lower the temperature compared to paracetamol or ibuprofen alone, but there is no evidence of improved child comfort. The limited data available on the adverse effects of these treatment regimens suggests that they should not be routinely recommended. There is little evidence of the comfort of the febrile child even though it is the primary objective of antipyretic treatment.

Evaluating the Interchangeability of Forehead, Tympanic, and Axillary Thermometers in Italian Paediatric Clinical Settings: Results of a Multicentre Observational Study

PURPOSE

This study was conducted to investigate the interchangeability of infrared forehead, digital axillary, and infrared tympanic thermometers while identifying the most reliable non-invasive body temperature measurement method in paediatric settings.

DESIGN AND METHODS

A multicentre observational study was conducted enrolling all children less than or equal to 14 years of age requiring a temperature measurement and after obtaining their parent's informed consent. Socio-demographic characteristics and temperature values in Celsius (°C) were simultaneously collected using forehead, axillary, and tympanic thermometers.

RESULTS

A total of 433 children were enrolled, 57.5% were male and the mean age was 5.3 ± 3.9 years. The average value of tympanic temperature (37.05 °C) was higher than forehead (36.87 °C) and axillary (36.8 °C). The mean difference between axillary and forehead temperatures (-0.06 °C) was not statistically significant (p = 0.158). Comparing the measurements of each type of thermometer with the overall average of the three measurements recorded as the virtual gold standard, Bland Altman analysis highlighted tympanic with narrower 95% limits of agreement (+0.96 °C to -0.68 °C). The tympanic thermometer also had the highest percentage (81.6%) of differences falling within the maximum clinically acceptable difference (±0.5 °C).

CONCLUSIONS

Differences between paired measurements of the three investigated devices demonstrated the devices are not interchangeable. Measurements using the tympanic thermometer more closely resembled the reference temperature indicating its preferential use in paediatric clinical practice.

PRACTICE IMPLICATIONS

To safely and consistently measure body temperature, nurses should not assume peripheral thermometers are interchangeable. It is essential to clinically validate all temperature values with clinical observations.

Understanding Discomfort in Order to Appropriately Treat Fever

Although national and international guidelines on the management of childhood and adolescent fever are available, some inadequate practices persist, both from parents and healthcare professionals. The main goal of bringing children’s temperature back to normal can lead to the choice of inappropriate drugs or non-necessary combination/alternation of antipyretic treatments. This behavior has been described in the last 35 years with the concept of fever-phobia, caused also by the dissemination of unscientific information and social media. It is therefore increasingly important that pediatricians continue to provide adequate information to parents in order to assess the onset of signs of a possible condition of the child’s discomfort rather than focusing only on temperature. In fact, there is no clear and unambiguous definition of discomfort in literature. Clarifying the extent of the feverish child’s discomfort and the tools that could be used to evaluate it would therefore help recommend that antipyretic treatment is appropriate only if fever is associated with discomfort.

Performance of axillary and rectal temperature measurement in private pediatric practice

To better understand the role and reliability of axillary temperature measurements in clinical real life, axillary and rectal measurements in infants presenting in a private pediatric practice because of fever were compared. Prospectively, 169 infants (81 girls), median 9 (interquartile range 6-13) months of age, were examined at room temperature (20-24 °C). Two left and two right axillary, as well as two rectal measurements were taken with a digital thermometer and subsequently averaged. The median and interquartile range for axillary and rectal measurements were 36.9 (36.3-37.6) °C and 38.2 (37.4-38.9) °C, respectively (p < 0.0001). The limits of agreement in the Bland-Altman plots were 0.32 to 1.98 °C, with a mean bias of 1.15 °C. Axillary thermometers showed a good sensitivity for detecting rectal temperature > 38 °C (95%) but limited specificity (75%), with an area-under-the-curve of 0.95.Conclusions: Axillary readings are always lower than rectal ones, the limits of agreement are quite wide. Axillary readings can be used for screening but critical measurements should be confirmed by more reliable methods. What is Known • In infants and toddlers, temperature has been traditionally taken rectally. • Axillary measurements are better accepted and are recommended in current guidelines. What is New • Axillary temperature was always lower than rectal temperature. • The limits of agreement of axillary thermometers are wide. • Axillary thermometers have a good sensitivity but limited specificity and are therefore adequate for fever screening.

Beliefs, Practices and Health Care Seeking Behavior of Parents Regarding Fever in Children

Background and objectives: Fever in children is one of the most common reasons for seeking medical attention. Parents often have misconceptions about the effects to fever, which leads to inappropriate use of medication and nonurgent visits to emergency departments (ED). The aim of this study was to clarify the beliefs on the effects and management of fever and to identify healthcare seeking patterns among parents of febrile children in Latvia. Materials and Methods: Parents and legal guardians of children attending ED with febrile illness were included in the study. Participants were recruited in Children’s Clinical University Hospital (CCUH) in Riga, and in six regional hospitals in Latvia. Data on beliefs about fever, administration of antipyretics, healthcare-seeking behavior, and experience in communication with health care workers were collected via questionnaire. Results: In total, 355 participants were enrolled: 199 in CCUH and 156 in regional hospitals; 59.2% of participants considered fever itself as indicative of serious illness and 92.8% believed it could raise the child’s body temperature up to a dangerous level. Antipyretics were usually administered at median temperature of 38.0 °C, and the median temperature believed to be dangerous was 39.7 °C; 56.7% of parents usually contacted a doctor within the first 24 h of the illness. Parents who believed that lower temperatures are dangerous to a child were more likely to contact a doctor earlier and out-of-hours; 60.1% of participants had contacted their family doctor prior their visit to ED. Parental evaluation of satisfaction with the information and reassurance provided by the doctors at the hospital was higher than of that provided by their family doctor; 68.2% of participants felt safer when their febrile children were treated at the hospital. Conclusions: Fever itself was regarded as indicative of serious illness and potentially dangerous to the child’s life. These misconceptions lead to inappropriate administration of antipyretics and early-seeking of medical attention, even out-of-hours. Hospital environment was viewed as safer and more reassuring when dealing with febrile illness in children. More emphasis must be placed on parental education on proper management of fever, especially in primary care

A Survey About Fever Knowledge, Attitudes, and Practices Among Parents

A 21-question survey was conducted among parents attending 4 pediatric outpatient practices to assess their knowledge, perceptions, and attitudes about fever. One hundred and ninety-seven surveys were included. Most commonly the participating parent was the mother. Parents used mainly axillary thermometers to measure child's temperature and mentioned integers for their definition of fever, 100°F being the most frequent answer. Most parents would treat all fevers and would use alternating antipyretics. Parents had a generally negative perception of fever: only one third thought fever may have some benefit, and more than half thought there must be some risk. A positive perception of fever was associated with parental educational level but not with information by the pediatrician. There is much confusion about fever among our parents, a negative perception is prevalent, and parents seem to receive-or recall-little information from the pediatrician.

Ibuprofen in the treatment of children's inflammatory pain: a clinical and pharmacological overview

Unlike fever, which is often over-treated especially in children, pain is underestimated and under-treated in pediatric age. The pharmacological agents approved for treating pain in these patients are few, also considering the recent limitation for codeine in children younger than 12 years. Paracetamol and the nonsteroidal anti-inflammatory drug (NSAID) ibuprofen are the most used at this purpose. The aim of this overview was to analyze the therapeutic appropriateness of ibuprofen in children based on its pharmacological properties. This work is a critical review of the pediatric literature over the last 20 years on efficacy and adverse events associated with the use of ibuprofen as analgesic in the pediatric population. Ibuprofen resulted effective in several pain conditions in children such as musculoskeletal pain, ear pain and acute otitis media, toothache and the inflammatory disease of the oral cavity and pharynx. The drug is a reasonable and efficacious alternative in postoperative pain, including tonsillectomy and adenoidectomy. It remains the treatment of choice for pain in chronic inflammatory diseases such as arthritis. Side effects and adverse events associated with ibuprofen are mild. It has the lowest gastrointestinal (GI) toxicity among NSAIDs, although some cases of GI toxicity may occur. Its renal effects are minimal, but dehydration plays an important role in triggering renal damage, so ibuprofen should not be given to patients with vomiting and diarrhea. Ibuprofen showed a good safety profile and provided evidence of effectiveness for mild-moderate pain of different origin in children. In case of fever or pain, the choice about the drug to be used should fall on ibuprofen in a clinical context where there is an inflammatory pathogenesis.

Prescribing Controversies: An Updated Review and Meta-Analysis on Combined/Alternating Use of Ibuprofen and Paracetamol in Febrile Children

Background: Ibuprofen and paracetamol are the only antipyretics recommended in febrile children. According to international guidelines the choice of the drug should rely on the child's individual characteristics, while a controversial issue regards the combined or alternate use of the two drugs. Objective: To compare the efficacy and safety of combined or alternating use of ibuprofen and paracetamol in children. Methods: A systematic review of literature was performed on Medline and Embase databases. The included studies were randomized controlled trials analyzing the efficacy of combined or alternating therapy with antipyretics in febrile children vs. monotherapy. A meta-analysis was performed to measure the effect of treatment on child's temperature and discomfort. Adverse effects were analyzed as secondary outcome. Results: Nine studies were included, involving 2,026 children. Mean temperature was lower in the combined therapy group at 1 h (mean difference: -0.29°C; 95%CI: -0.45 to -0.13) after the initial administration of therapy. No statistical difference was found in mean temperature at 4 and 6 h from baseline. A significant difference was found in the proportion of children reaching apyrexia at 4 and 6 h with the combined treatment (RR: 0.18, 95%CI: 0.06 to 0.53, and 0.10, 95%CI: 0.01-0.71, respectively) and at 6 h with alternating treatment (RR: 0.30, 95% CI: 0.15-0.57), compared to children treated with monotherapy. The child's discomfort score was slightly lower with alternating therapy vs. monotherapy. The pooled mean difference in the number of medication doses per child used during the first 24 h was not significantly different among groups. Discussion: Combined or alternating therapy resulted more effective than monotherapy in reducing body temperature. However, the benefit appeared modest and probably not clinically relevant. The effect on child discomfort and number of doses of medication was modest as well. According to our findings, evidences are not robust enough to encourage combined or alternating paracetamol and ibuprofen instead of monotherapy to treat febrile children, reinforcing the current recommendation of most of the international guidelines.

Knowledge, attitudes and misconceptions of Italian healthcare professionals regarding fever management in children

BACKGROUND

Fever phobia is still a major issue in paediatrics. We report knowledge of a sample of Italian paediatricians performed six years after the release of the Italian guidelines for the management of fever in children (IFG).

METHODS

A questionnaire, developed following the IFG recommendations and previously administered to 300 paediatricians in 2012, was proposed to all the paediatricians attending the 2015 National Congress of Practice Paediatrics, held in Florence, Italy. Changes in answers over time were analyzed.

RESULTS

70.2% (562/800) paediatricians returned the questionnaire. The recommended site and device for body temperature measurement in children > 1 year was correctly chosen by 89.3% of participants (vs. 80.7% of 2012 participants; P < 0.001), but with children aged less than 1 year the correct answer was selected only by the 50.3% (vs. 39.3% of 2012 participants: P < 0.001). Use of physical methods was still incorrectly recommended by 51.6% of paediatricians (vs. 63.6% in 2012; P < 0.001). Use of antipyretics according to discomfort was adopted only by 38.2% of participants, while 12.2% of them recommended alternate use of antipyretics. These proportions were substantially stable since 2012 (45 and 11% respectively), rectal administration of antipyretics only in case of vomiting was correctly recommended by 86.8% of paediatricians vs. 74.7% in 2012 (P < 0.001).

CONCLUSION

Improvements in some pediatricians' misconceptions were observed over time. However, some incorrect habits persist. Further studies are needed to better understand the "weak points" of the communication between Scientific Societies and paediatricians in order to impact everyday clinical practice.

Advances in paediatrics in 2016: current practices and challenges in allergy, autoimmune diseases, cardiology, endocrinology, gastroenterology, infectious diseases, neonatology, nephrology, neurology, nutrition, pulmonology

This review reports main progresses in various pediatric issues published in Italian Journal of Pediatrics and in international journals in 2016. New insights in clinical features or complications of several disorders may be useful for our better understanding. They comprise severe asthma, changing features of lupus erythematosus from birth to adolescence, celiac disease, functional gastrointestinal disorders, Moebius syndrome, recurrent pneumonia. Risk factors for congenital heart defects, Kawasaki disease have been widely investigated. New diagnostic tools are available for ascertaining brucellosis, celiac disease and viral infections. The usefulness of aCGH as first-tier test is confirmed in patients with neurodevelopmental disorders. Novel information have been provided on the safety of milk for infants. Recent advances in the treatment of common disorders, including neonatal respiratory distress syndrome, hypo-glycemia in newborns, atopic dermatitis, constipation, cyclic vomiting syndrome, nephrotic syndrome, diabetes mellitus, regurgitation, short stature, secretions in children with cerebral palsy have been reported. Antipyretics treatment has been updated by national guidelines and studies have excluded side effects (e.g. asthma risk during acetaminophen therapy). Vaccinations are a painful event and several options are reported to prevent this pain. Adverse effects due to metabolic abnormalities are reported for second generation antipsychotic drugs.