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Management of fever in children: Summary of the Italian pediatric society guidelines
Clinical Therapeutics, 10/19/09

Chiappini E et al. – Use of physical methods of reducing fever is discouraged, except in the case of hyperthermia. Use of antipyretics—paracetamol (acetaminophen) or ibuprofen—is recommended only when fever is associated with discomfort. Combined or alternating use of antipyretics is discouraged. The dose of antipyretic should be based on the child's weight rather than age. Whenever possible, oral administration of paracetamol is preferable to rectal administration. Use of ibuprofen is not recommended in febrile children with chickenpox or dehydration. Use of ibuprofen or paracetamol is not contraindicated in febrile children with asthma. There is insufficient evidence to form any recommendations concerning fever in children with other chronic conditions, but caution is advised in cases of severe hepatic/renal failure or severe malnutrition. Newborns with fever should always be hospitalized because of the elevated risk of severe disease; paracetamol may be used, with the dose adjusted to gestational age. Use of paracetamol or ibuprofen is not effective in preventing febrile convulsion or the adverse effects of vaccines.

Exclusive Author Commentary
Elena Chiappini, 10/20/09

The barriers to the clinical application of literature evidence are numerous, including lack of awareness among health care professionals, inertia of previous practice and parents’ misconceptions(1). Thus, 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. References 1)El-Radhi AS. Why is the evidence not affecting the practice of fever management? Arch Dis Child 2008;93:918-20. 2)Pandolfini C, Impicciatore P, Provasi D, Rocchi F, Campi R, Bonati M; Italian Paediatric Off-label Collaborative Group. Off-label use of drugs in Italy: a prospective, observational and multicentre study. Acta Paediatr 2002;91:339-47. 3) Italian Drug Agency- Paracetamol – Reports of overdoses (AIFA 16/02/2007). Available at website : http//www.agenziafarmaco.it (accessed 30 october, 2008). 4) National Institute for Health and Clinical Excellence. NICE. Clinical Guideline. Feverish illness in children younger that 5 years. BMJ 2007;334:1165-7. 5) de Martino M, Principi N. Italian Guideline for the management of the sign/symptom fever in children (abs.) Minerva Pediatr 2008;60: 489-501.

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