Antipyretic use in children: more than just temperature.

One of the most remarkable facts about the treatment of febrile illness in children is that, despite its ubiquity and the plethora of guidelines, recommendations, and other publications, the exaggerated fear of fever (sometimes referred to as “fever phobia”) remains common around the world, and has remained so for many years. The result of this fear is that parents and professionals worry unduly about fever, and many over-treat febrile children. Some of these interventions at least reduce fever, such as antipyretic drugs; others don’t even achieve this, such as physical cooling. Another manifestation of this fear is the over-use or combination of antipyretic drugs, which is the focus of the study by Pereira et al. From a historical context, the fear of fever makes sense, as in the past, and even today in many parts of the world, infectious diseases are a cause not just of morbidity, but also of significant mortality, and even in countries with highly developed health systems children continue to die from undiagnosed serious infections. The important issue for caregivers and professionals alike is to separate the symptom of fever, which is a normal physiological response that poses no danger, from the underlying condition, which in a relatively small number of cases may be a serious illness. The question of what role fever plays in the recovery from illness is complex. Fever results from the release and conversion of arachadonic acid from cellular lipid membranes into prostaglandin E 2 , through the action of the cyclooxygenase enzymes COX-1 and COX-2. The former, which is constitutively expressed, is thought to be primarily responsible for maintaining homeostasis. The latter, which is induced by a range of cytokines including IL-1 and TNF-a, is mainly responsible for fever and inflammation, a syndrome sometimes referred to as “acute phase response”. It is possible to construct both evolutionary and immunological arguments for the benefit of fever, based on its ubiquity throughout the animal kingdom and the important role of cytokines in the immune response. However, clinical studies have proved to be more difficult to conduct; even when performed, the results were not conclusive, and it is impossible to separate the possible beneficial effect of fever from the other parts of the acute phase response. One study that demonstrated a reduced antibody response to some vaccine antigens in children given prophylactic paracetamol has led many countries to advise against the routine prophylactic use of antipyretics, but such evidence is rare. Although the benefits of fever are hard to define, what is known is that the symptom and the underlying illness are separate issues, and their clear separation may make the fear of fever itself easier to manage. We can be unequivocal: fever will not harm an otherwise well child, and the highly exaggerated concerns regarding brain damage and death as a result of fever are not warranted. However, as this and other studies show, we are some length from achieving this. One manifestation of this phobia is the co-administration or