And fever in a child - symptoms and treatment. A child’s body temperature is a manifestation of complex processes in the body that keep indicators within certain limits. The main center for temperature control is in the brain, from where it “sends instructions” through nerve fibers and various hormones. The latter, in turn, keep two opposing processes in balance - heat production and heat transfer.
Features of thermoregulation in children
Firstly, in infants, such a mechanism for increasing heat production as muscle tremors - chills. Additional heat is produced only through the breakdown of fatty tissue.
Secondly, sweat glands in children they do not function sufficiently, so heat transfer through the evaporation of sweat is not as effective as in adults. The main “weapon” of heat transfer in children is evaporation from the mucous membrane of the upper respiratory tract and oral cavity. This is related to certain tactics for treating children with elevated temperatures, which I will discuss later.
Thirdly, in a child under 7 years of age, only one type of nervous system is developed - the sympathetic one. This system controls body temperature by constricting blood vessels in the skin and preventing heat from escaping through them. Prolonged and severe narrowing of blood vessels can lead to serious complications.
What is considered normal body temperature in a child?
Temperature indicators do not and cannot have a clear number. The values change with age, during the day, during physical and emotional stress, after eating, etc. I can list this list for quite a long time. But parents still need to focus on something in order to find out if their child has a disease.
Some reference limits have been established depending on age:
- - from 0 to 6 months - 36.4 - 36.8 ⁰ C;
- from 6 months to 5 years - 36.1 - 37.7 ⁰ C;
- from 5 to 7 years and older - 36.1 - 37.0 ⁰ C.
If the temperature is below normal, then you should be wary. Hypothermia may be a symptom of serious diseases - infections, tumors, decreased immunity, endocrine pathology, etc. You should contact a specialist for diagnosis if a low temperature is observed for a long time.
Excess normal values speaks of the emergence hyperthermia.
Hyperthermia and its variants
An increase in body temperature does not always occur according to one scenario. It all depends on the reason that caused it. According to this, there are three types of hyperthermia.
1. Overheating
In this case, the environment is exposed to hot air. With high humidity and lack of wind, the situation becomes even worse. The child cannot give off heat, i.e. There is no heat transfer, and heat production remains unchanged. Overheating can lead to the development.
2. Fever
The occurrence of fever is provoked by special substances - pyrogens. They always accompany an inflammatory reaction. Increasing the temperature of the internal environment of the body is necessary to combat inflammation, but also has Negative consequences. A wide range of factors trigger the formation and impact of pyrogens on the body:
This number of provoking mechanisms indicates the greatest prevalence of this type of hyperthermia compared to the other two.
3. Fever-like conditions
The occurrence of elevated temperature in some cases occurs without exposure to pyrogens. The reason for these increases is not fully understood, but such conditions still occur:
— hyperthermia of a psychogenic nature (occurs with emotional overexcitation, stress and some mental illnesses);
- drug hyperthermia (caffeine, adrenaline, ephedrine, novocainamide, etc.);
- increased temperature with thyrotoxicosis, pheochromocytoma (with a tumor of the adrenal glands, hyperthermia is promoted by both released pyrogens and produced hormones).
Classification of fever
Since this is the most common type of hyperthermia that any parent encounters, I will tell you more about the types of fever.
Fever is divided according to duration into:
- — ephemeral (up to 3 days);
— acute (up to 2 weeks);
— subacute (up to 40–45 days);
— chronic (more than 1.5 months).
The levels of temperature increase also have their own names:
- — subfebrile (no more than 38 ⁰С);
— moderate (up to 39.5 ⁰С);
— high (39.6 – 40.9 ⁰С);
- hyperpyretic (above 41 ⁰С).
There is a fairly comprehensive classification that characterizes certain models of temperature changes during the day, but I see no point in talking about it, since in modern times it has lost its relevance. Let me just say that the first place in frequency is occupied by laxative fever. With this option, the morning temperature is approximately 1 ⁰C lower than the evening temperature.
Stages of fever
The considered variant of hyperthermia is a typical reaction of the body and manifests itself in the same way for any reason. I also want to note that an increase in temperature affects all organs and tissues. This influence can have both positive and negative intentions.
1. Stage of temperature increase.
At the first stage, a large amount occurs in the body chemical reactions, increasing heat generation and reducing heat transfer. In many experiments it was found that during fever, in contrast to overheating, a violation of heat transfer prevails. As I said earlier, heat transfer in children is largely due to the evaporation of moisture from the mucous membranes of the oropharynx. With high levels of hyperthermia, the skin turns pale, the child’s arms and legs become cold, and chills appear (except for infants). The child strives to wrap himself up and curl up. The duration of temperature rise depends on the cause of the disease. For example, with the flu, an increase to the maximum value occurs within a few hours.
2. Stable stage high temperature.
At this stage, the body takes control of thermoregulation mechanisms without reducing the temperature to normal. The blood vessels of the skin dilate, the extremities turn pink and become warm or even hot, and the chills disappear.
3. Temperature reduction stage.
When the disease begins to recede, heat transfer takes over and normalizes the temperature; in children over 1 year of age, sudden sweating occurs. The return to the original numbers can occur gradually ( the best option), and suddenly, for a couple of hours. Such a drop in temperature is called critical, and it is very dangerous, as it can cause a sharp decrease, including loss of consciousness.
Hyperthermia itself manifests itself with such symptoms, but fever, including the entire body in the process, has a more extensive clinical picture.
Symptoms of fever
With subfibrility, hyperthermia has a weak effect on organ systems, so most of the signs I list below are characteristic of higher rates.
- 1. Hallucinations and delusions.
2. Loss of consciousness.
3. Cramps.
4. .
5. Myalgia and myasthenia (muscular).
6. Tachycardia and other rhythm disturbances (in children under one year of age, an increase in temperature for every half degree is accompanied by an increase in pulse by 10 beats; after 1 year, the pulse increases by 8-10 beats per 1 degree of hyperthermia).
7. Promotion blood pressure during the period of rising temperature.
8. Increased urination during the first stage of fever.
9. Respiratory rate in different periods varies - decreases with rising temperature and increases during the second stage.
10. Dry mouth. Reducing the secretion of saliva, which has bactericidal properties, creates an optimal environment for the emergence and proliferation of microorganisms, which leads to the appearance unpleasant odor from the mouth and the appearance of plaque on the tongue.
11. Increased thirst.
12. Decreased appetite.
13. .
14. and increased gas formation.
Naturally, one child does not exhibit all the signs at once, but informed parents will be able to understand that certain symptoms are a logical manifestation of the febrile syndrome. And to understand the cause of hyperthermia, not always, but often additional signs of the disease can help.
Fever and additional symptoms
1. Diarrhea with fever.
A clear sign of acute intestinal infection is diarrhea accompanied by hyperthermia. Intestinal infections can be specific, such as dysentery, salmonellosis, or more general. Food poisoning is one of the most common types of poisoning and intestinal dysfunction in children. The disease occurs when eating foods that contain large amounts of toxins produced by bacteria. In addition to diarrhea, the child may experience nausea and vomiting.
2. Hyperthermia and conjunctivitis.
If the cause of the fever is a viral infection of the upper respiratory tract, then by simple transfer of viral particles, infection of the mucous membrane of the eye can occur. Red eyes and watery eyes when the temperature rises indicate conjunctivitis.
3. Fever and cough.
Cough syndrome is associated with irritation of the mucous membrane of the respiratory tract due to laryngitis, tracheitis or. These diseases can be of bacterial, viral or even fungal etiology. For children, ordinary ones are more typical. Any infection causes an inflammatory response in the body and an increase in temperature. A choking cough is a sign bronchial asthma. With exacerbation of bronchial asthma, a rise in temperature to subfebrile levels is also possible.
4. Fever and runny nose.
Like a cough, it accompanies any seasonal viral infection in which hyperthermia is present. may cause a slight increase in temperature during its exacerbation. If this occurs, then I note that fever often occurs with this option.
5. Vomiting with fever.
I have already mentioned that at high temperatures, vomiting is possible as one of the symptoms of fever. Also, I already said that food poisoning may be accompanied by dyspeptic syndrome, including vomiting. Poisoning is possible not only with food, but also with medicines, household poisons, salts of heavy metals, and chemical fumes. Infection of the lining of the brain, for example, meningitis, exacerbation of cholecystitis, gastritis, peptic ulcer stomach, appendicitis, also manifests itself with vomiting and fever.
6. Hyperthermia and rash.
There are many types of rash depending on the cause. Skin rashes can occur with a number of infections -, typhoid fever, etc. These diseases are naturally accompanied by an increase in temperature. Chickenpox is the most common infection in children, causing itchy, fluid-filled blisters. The temperature during chickenpox can be either low-grade or moderate in the first days of the illness. An allergic rash can also cause fever.
7. Increase in temperature during teething and vaccinations.
Usually, parents first encounter a fever in their child after the next one (a hyperthermic reaction to the DTP vaccine often occurs) and during. This hyperthermia usually lasts 1-2 days.
8. Hyperthermia with chest pain.
The chest contains important organs—including the lungs. Inflammatory diseases (myocarditis, pleurisy, pneumonia) may be accompanied by pain. If you do not clarify the presence, then the resulting fever may not be immediately justified.
9. Cachexia and chronic fever.
Cachexia is severe exhaustion of the body, a significant decrease in adipose tissue and the development of severe muscle weakness. This type of exhaustion is often caused by malignant neoplasms. And the decay and metabolic products of the tumor are internal pyrogens, causing a persistent, long-term increase in temperature.
Treatment of fever
The great minds of medicine have developed a form of cure for many diseases - “cold, hunger and peace.” This formula is also suitable for the treatment of hyperthermic syndrome. Before you grab it, I advise you to ensure everything the necessary conditions so that the processes of heat production and heat transfer work more efficiently and strive to normalize the state.
1. Cold.
The child's room should be well ventilated and humidified. You should not put a lot of clothes on your baby if he is not cold and does not have chills, much less turn on the heater.
2. Hunger.
The child spends all his energy fighting the disease. On the one hand, he needs high-calorie food, on the other hand, it will be difficult for him to digest heavy fatty foods, and appetite is usually reduced. That's why the best option consumption of chicken broth is considered.
3. Peace.
Bed rest was not invented in vain. The body mobilizes all its forces and, if they are not enough, the disease will not recede quickly. The question of walking often comes up here. The answer is You can walk with a child with a fever if:
- - low-grade fever;
— it’s warm outside, but not hot (20-25 degrees);
- walking will consist, for example, of sitting on a bench and reading a book, i.e. no active games.
I would like to add a drinking regime to these rules. Since fever is accompanied by strong evaporation of fluid from the mucous membranes, sweating and increased urination, the child can very quickly lose water reserves in the body, which will lead to serious problems associated with dehydration. The best way to replenish fluid reserves is with special rehydration solutions, which are sold at pharmacies. If you cannot give the child something to drink, and the skin has become dry and the amount of urine produced has sharply decreased, this is a reason to call an ambulance and administer intravenous fluid.
Drug treatment
There are recommendations that advise starting only if the hyperthermia numbers exceed 38 ⁰C. This is quite reasonable, because increasing the temperature of the internal environment of the body is necessary to combat the cause that caused the disease. However, high temperatures can cause more harm than good. But I want to note that this option does not always work for children. The baby can react differently to fever, and if the child feels very unwell with low-grade fever, then you should not wait for the temperature to rise further, but start treatment.
From medicines Currently, two antipyretic drugs are widely used:
- — (there are forms and dosages used from birth);
— Nurofen for children (can be used from 3 months).
A few words about folk methods
Most often I hear advice that when the temperature rises, you need to rub the child with alcohol or vinegar. So, I urge you to never do this! Yes, such exposure lowers the temperature, but it can cause great harm to the child.
If you cannot reduce your temperature with medications, then I advise you to check whether all the conditions I described are met. When the cause of persistent hyperthermia is still unclear, you should consult a doctor.
Fever is a protective-adaptive reaction of the body that occurs in response to exposure to pathogenic stimuli and is characterized by a restructuring of thermoregulation processes, leading to an increase in body temperature and stimulating the natural reactivity of the body. The biological significance of fever is the activation of immunological defense. An increase in body temperature leads to increased phagocytosis, increased synthesis of interferons, activation and differentiation of lymphocytes and stimulation of antibody genesis. Fever body prevents the proliferation of viruses, cocci and other microorganisms.
Fever is fundamentally different from the increase in body temperature observed when the body overheats, which occurs due to various reasons: with a significant increase in ambient temperature, active muscular work, etc. In case of overheating, the thermoregulation center is set to normalize the temperature, while in case of fever, the thermoregulation center purposefully rearranges the “set point” to a more high level body temperature.
Since fever is a nonspecific protective-adaptive reaction of the body, the reasons that cause it are very diverse. The most common fever occurs when infectious diseases, among which acute respiratory diseases of the upper and lower respiratory tract dominate. Fever of infectious origin develops in response to exposure to viruses, bacteria and their decay products. buy levitra An increase in body temperature of a non-infectious nature can be of various origins: central (hemorrhage, tumor, trauma, cerebral edema), psychogenic (neurosis, mental disorders, emotional stress), reflex (pain syndrome with urolithiasis), endocrine (hyperthyroidism, pheochromacytoma) , resorptive (bruise, necrosis, aseptic inflammation, hemolysis); it may also occur in response to the introduction of certain medicines(ephedrine, xanthine derivatives, antibiotics, etc.).
Feverish process acute diseases usually occurs in three stages. In the first of them, the temperature rises due to a significant predominance of heat production over heat transfer. At the second stage, heat transfer increases; further temperature changes do not occur for some time (days, hours). On the third stage, after the cessation of the action of pyrogens, the “set point” of the thermoregulation center drops to normal level. Heat transfer increases due to the expansion of skin vessels, profuse sweating, and frequent breathing. The decrease in temperature can be gradual (lytic) or rapid (critical). If a critical decrease in temperature, accompanied by a sharp dilation of blood vessels, is combined with intoxication, then a life-threatening collapse may occur for the child.
With the same level of hyperthermia, fever in children can occur differently. It is advisable to distinguish between “white” and “pink” fever in children.
If heat transfer corresponds to heat production, this indicates an adequate course of fever and is clinically manifested by the child’s relatively normal state of health, pink or moderately hyperemic skin color, moist and warm to the touch (“pink fever”). The absence of sweating in a child with pink skin and fever should raise suspicion of severe dehydration due to diarrhea, vomiting, and tachypnea.
In the case of “white” fever with increased heat production, heat transfer is inadequate due to impaired peripheral circulation; the course of such fever is prognostically unfavorable. Leading pathogenetic link“white” fever is excessive hypercatecholaminemia, which leads to the appearance of clinical signs of centralization of the blood circulation. Clinically, severe chills, pallor of the skin, acrocyanosis, cold feet and palms, tachycardia, increased systolic blood pressure, and an increase in the difference between the axillary and rectal temperature (up to 1°C and above) are noted.
When a child has a fever, the doctor decides the main questions:
- when to lower the temperature;
- why lower the temperature;
- how to reduce the temperature;
- how to reduce.
When to lower the temperature
The national program for the treatment of acute respiratory infections in children prescribes the use of antipyretics:
1. Previously healthy children:
- at body temperature above 39.0°C and/or
- for muscle aches and/or
- for headaches.
2. Children with a history of febrile seizures:
- at body temperature above 38.0-38.5°C.
3. Children in the first 3 months of life:
- at body temperature above 38.0°C.
Early administration of antipyretics is also indicated for children:
with hereditary metabolic abnormalities,
with a history of seizures
· in the presence of signs of circulatory failure, stage II or more;
· at respiratory failure II Art. and more;
· dehydration;
· prolonged fever;
thymomegaly stage 2 and more;
“white” hyperthermia.
At the same time, it is necessary to take into account the arguments against the mandatory prescription of antipyretics for any rise in temperature:
· fever can serve as the only diagnostic and prognostic indicator of the disease;
· antipyretic therapy “shades out” clinical picture diseases, providing a sense of false security;
· febrile reaction - protective, enhances the immune response, etc.;
· antipyretic therapy carries with it a certain risk, including side effects of the drugs.
How and with what to reduce the temperature
You can start with non-drug methods temperature reduction. The administration of additional fluids is necessary for any febrile child to prevent dehydration, which easily occurs in children due to increased breathing and increased sweating and leading to thickening of the blood. In children older than one year, additional fluid is given in the form of berry and fruit drinks, decoctions, and juices. Dietary restrictions are determined by the nature of the disease and premorbid background.
Physical cooling methods increase heat transfer from the surface of the body. Typically, wiping with a sponge moistened with water or 40-50% alcohol is used, blowing on the body for 5 minutes, every half hour (4-5 times).
They are not used if the child has signs of microcirculation disorders (white-type fever).
Physical methods of external cooling are especially effective for neurogenic fever in children.
The rate of temperature decrease is 1-1.5º C in 30-60 minutes.
The duration of use of antipyretics is no more than 3 days, analgesics - up to 5 days.
In children at risk, drug therapy with antipyretics should be started. Although many drugs have antipyretic effects, only four commercially available ones are optimal for the treatment of fever in children: paracetamol, ibuprofen, naprosyn and acetylsalicylic acid (aspirin). The fifth drug, ketoprofen, is being prepared for introduction into pediatric practice. Knowledge of the pharmacology of drugs, the balance between benefits and risks ensures their optimal use.
Paracetamol
Paracetamol (acetominophen, Tylenol) inhibits the “cerebral” synthesis of prostaglandins to a greater extent than the “peripheral” one and therefore it does not have (or has a minimal degree of) an antiplatelet effect (i.e., it does not impair platelet function), does not cause or increases bleeding. The minimal peripheral effect of paracetamol creates another important advantage over other NSAIDs: paracetamol does not reduce diuresis, which is the case in febrile children early age with a tendency to cerebral edema, toxicosis, convulsions - a very important advantage. It has antipyretic and analgesic effects, but lacks anti-inflammatory effects.
The usual antipyretic and analgesic dose of paracetamol is 10-15 mg/kg, it can be prescribed 3-4 times a day.
The daily dose of paracetamol should not exceed 60 mg/kg.
The toxicity of paracetamol in children occurs when its concentration in the blood is above 150 mcg/ml. Liver disease, intake of hepatic oxidase activators, and in adults, alcohol, increase the toxicity of paracetamol. The toxic effects of paracetamol are due to its hepatotoxicity:
· in the first hours accompanied by nausea, vomiting, pallor, sweating;
· from the end of the 1st, beginning of the 2nd day there are no clinical symptoms, but an increase in transaminases begins;
· from the 3rd day, jaundice, coagulopathy, encephalopathy, increased transaminases and bilirubin, tremor, hypoglycemia, acute renal failure, and myocardial damage develop.
With long-term use, cases of nephrotoxicity (tubular necrosis), cardiotoxicity (heart attacks, ischemia), and pancreatitis have been described.
If, due to an overdose or cumulation, damage to the liver, kidneys occurs and the child develops nausea, vomiting, diarrhea, oliguria, hematuria, jaundice, hypoglycemia, he should immediately be given acetylcysteine (ACC) orally at a dose of 140 mg/kg and then 70 mg each /kg every 4 hours (total 17 doses).
Tips for rational use paracetamol for parents:
. reduce temperature only when indicated;
. do not re-introduce an antipyretic in order to prevent a new rise in temperature; it should be given only after the child’s body temperature has returned to its previous level;
. use the recommended single dosage of paracetamol (10-15 mg/kg), in no way exceed the daily dose (60 mg/kg);
. do not give paracetamol without consulting a doctor for more than 3 days due to the risk of a bacterial infection and being late in prescribing an antibacterial agent;
. If hyperthermia develops with spasm of skin vessels (cold, pale hands and feet, marbling of the skin), after administering an antipyretic, you should vigorously rub the child’s skin until it turns red and immediately call a doctor.
Ibuprofen (brufen, nurofen)
The usual single dose of 5 mg/kg body weight can be increased in case of severe fever to 10 mg/kg.
Ibuprofen is one of the best true NSAIDs (i.e., drugs that have antipyretic, analgesic and anti-inflammatory effects) in terms of tolerability.
The daily dose should not exceed 25-30 mg/kg. In acute overdose, the minimum toxic dose is approximately 100 mg/kg. Symptoms depend on the dose (nausea, abdominal pain, confusion, lethargy, headache, visual disturbances, metabolic acidosis). Rare side effects include gastropathy with nausea, vomiting, enteropathy with diarrhea or constipation, bleeding, oliguria, and tachycardia.
Aspirin (acetylsalicylic acid, ASA)
Antipyretic dose of aspirin 10 mg/kg. Maximum take 3 times a day (break between doses from 3 to 6 hours).
The toxic effects of salicylates are accompanied by a violation of the amino acid receptor (aspirin), metabolic acidosis and respiratory alkalosis:
· Metabolic acidosis due to inhibition of the Krebs cycle with accumulation of lactic acid and increased formation of ketone bodies due to lipolysis.
Respiratory alkalosis - result toxic effect salicylates on the central nervous system.
· Alkalosis is an early stage of aspirin poisoning, acidosis - in the later stages.
· Dehydration, hyperthermia, hyperventilation, hypo- or hypernatremia, and glycemia develop.
· When the central nervous system is affected, ringing in the ears, disorientation, hallucinations, irritability, lethargy, convulsions, coma, and rarely cerebral edema are noted.
· Stomach damage - gastritis, bleeding.
· Hemostasis disorders - impaired formation of prothrombin in the liver, thrombocytopathy, increased fibrinolysis, uncontrolled bleeding;
· In children with G-6 PD deficiency, hemolysis is possible.
· Pulmonary edema - in case of impaired secretion of ADH, acute renal failure.
· Bronchospasm due to inhibition of prostaglandins E.
Aspirin in children suffering from influenza, ARVI and chicken pox, it can cause Reye's syndrome. WHO experts do not recommend the use of ASA as an antipyretic in children under 12 years of age, which is reflected in the national Formulary (2000). By order of the Pharmaceutical Committee of the Russian Federation dated March 25, 1999, the use of ASA for acute respiratory infections is permitted from the age of 15.
Amidopyrine(pyramidon) in previous years was widely used in febrile children, but has now been abandoned due to a possible adverse effect on hematopoiesis (leukopenia, granulocytopenia, even agranulocytosis), as well as allergic and other complications (provoking convulsive syndrome).
Phenacetin was also excluded from the list of antipyretics due to their toxicity. The latter, unfortunately, is included in the Tsefekon suppositories, and amidopyrine is in Tsefekon-M. It is dangerous to use these suppositories when treating children.
Analgin(metamizole) is not recommended for widespread and frequent use due to its possible side effects- increased convulsive readiness, kidney damage, hypoplastic anemia, sudden death. Metamizole can cause fatal agranulocytosis, as well as anaphylactic shock. This was the reason for its ban or sharp restriction of use in many countries around the world. The widespread use of analgin as an antipyretic is not recommended by WHO in a special letter dated October 18, 1991. Analgin (tablets, suppositories) is prescribed 5-10 mg/kg/take 3-4 times a day; more often it is used as a parenteral antipyretic drug. 50-25% analgin solutions are used, 0.1-0.2 ml per year of life, no more than 3-4 times a day.
Monotherapy is usually sufficient to reduce fever.
At high temperatures, it is possible to introduce a lytic mixture.
In children with allergies it is possible to administer solutions of diprazine, diphenhydramine, tavegil (for young children 0.2 ml/year of life per administration; older children 0.1 ml/year of life per administration, with a frequency of administration no more than 3 times a day).
In children with white fever
, i.e., with pronounced clinical signs of centralized blood circulation with microcirculation disorders, the use of NSAIDs is either ineffective or not effective enough to reduce body temperature. Such children are prescribed drugs from the group of phenothiazines (pipolfen, diprazine, propazine) at a dose of 0.25 mg/kg (single dose), sometimes in combination with droperidol (0.05-0.1 ml of 0.1% solution per kg of body weight per administration) every 6-8 hours. These drugs reduce the excitability of the central nervous system, dilate peripheral vessels, thereby eliminating microcirculation disorders and increasing sweating. They are used intravenously or intramuscularly.
In case of persistent hyperthermia, it is advisable to intensify the above therapy. intravenous administration 0.25% novocaine solution 2 ml/kg.
For “white” hyperthermia, children are prescribed vasodilators. You can start with nicotinic acid 1 mg/kg per dose simultaneously with paracetamol. The ineffectiveness of twice-administered drugs may be an indication for intramuscular administration of pipolfen and droperidol in the doses mentioned above. As the first prescription for children with clinical signs of centralized blood circulation, a combination of drugs such as papaverine and dibazole can be used (for young children 0.2 ml/year of life per administration; older children 0.1 ml/year of life per administration, with an administration frequency of no more than 3-4 once a day).
Steroid hormones have a powerful antipyretic effect: prednisolone 1-2 mg/kg/day divided into 2-3 doses.
A particular problem for the doctor and the child’s parents is febrile seizures
, i.e. convulsions that occur in children aged 3 months. - 5 years associated with fever. Infections of the c.n.s. (meningitis, encephalitis), often occurring with high fever, and also when the occurrence of febrile convulsions is preceded by afebrile paroxysms, do not belong to this group. Febrile seizures are divided into simple and complex. Characteristic Features simple febrile seizures are: single episodes, short duration (no more than 15 minutes), generalized tonic-clonic, clonic or tonic seizures. As a rule, simple febrile seizures occur in normally developing children who do not have focal neurological disorders. Complex febrile seizures are characterized by the following features: duration more than 15 minutes, recurrence within 24 hours, focal nature (motor focal paroxysms, deviation eyeballs, gaze fixation, aura or change in mental status). After complex febrile seizures, transient neurological disorders in the form of paresis of the limbs often occur. It is also possible to develop febrile status epilepticus - recurring generalized tonic-clonic seizures that occur against the background of fever, lasting more than 30 minutes.
When a diagnosis of “febrile convulsions” is made, the doctor’s initial task is to provide emergency assistance the patient and conducting an explanatory conversation with parents on the possible nature of febrile seizures and measures for their prevention. The likelihood of developing repeated paroxysms of febrile seizures is quite high. Therefore, it is necessary to teach parents first aid techniques:
· do not panic, behave calmly;
· unbutton the collar and free from tight clothing;
· put the child on his back and turn his head to the side;
· do not try to unclench your jaws using any objects;
· to measure the temperature;
· carefully monitor the course of the attack;
· do not give any medications or liquids by mouth;
· stay near the child until the attack completely stops.
Although the attack is provoked by high temperature, physical methods of cooling should not be used too actively, in particular, cold baths, rubbing with alcohol, using fans, enemas, gastric lavage cold water and other similar procedures, because the discomfort they can cause in a child is a provocateur of convulsive syndrome. This is due to the fact that a strong decrease in temperature can cause metabolic disturbances in the body, which contribute to a second wave of temperature reaction in response to infection. Physical cooling of the head helps more.
The first-line drug of choice for the relief of febrile seizures is diazepam, prescribed parenterally (into a muscle or vein) at a dose of 0.5 mg/kg (0.1 ml/kg), or as a solution for rectal administration. Lorazepam (Ativan) is also used - 0.05-0.2 mg/kg, phenobarbital - 10-20 mg/kg. If the convulsions are not stopped, then you can repeat the indicated dose of diazepam (Seduxen, Relanium, Valium, Sibazon) after 10-15 minutes or inject a 20% solution of GHB at a dose of 100 mg/kg in saline solution into a vein slowly. In addition to anticonvulsants, prednisolone can be administered.
In most cases, by the time the doctor arrives, the convulsions have already ended, because they usually last from several seconds to several minutes. It is important to find out the genesis of the fever, prescribe antipyretics (paracetamol in combination with pipolfen and droperidol), exclude neuroinfection, and if there is any doubt in favor of meningitis, perform a lumbar puncture (in a hospital setting), hospitalize the patient in a specialized department. If seizures recur, hospitalization directly to the intensive care unit.
If the convulsive syndrome has already ended, then phenobarbital or diazepam (Valium) is usually prescribed orally for 8-10 days. The usual daily dose of phenobarbital is 4-5 mg/kg body weight, but we must remember that the anticonvulsant concentration of the drug at such doses occurs only towards the end of the course. Therefore, if the convulsive syndrome was sufficiently long-lasting (more than 10 minutes) or atypical, then on the first day of treatment it is necessary to give a loading dose of phenobarbital - 15-20 mg/kg, divided into 3 doses; further 3-5 mg/kg per day. With this prescription, by the beginning of the second day of treatment, an anticonvulsant concentration of phenobarbital appears in the blood. Diazepam is given either in suppositories or orally. A single dose of diazepam in suppositories is 0.2-0.45 mg/kg body weight, orally diazepam is prescribed at a dose of 0.5 mg/kg body weight.
Antiepileptic drugs such as diphenin (phenytoin) and carbamazepine (finlepsin) are ineffective for febrile seizures.
The possibility of recurrence of febrile seizures, as well as the risk of their transformation into afebrile seizures, determine the need for the prevention of febrile seizures. There are two schemes for the prevention of febrile seizures: long-term (3-5 years) anticonvulsant therapy and intermittent prophylaxis (during the period of probable risk of developing febrile seizures). Largest quantity Supporters now have intermittent prescription of anticonvulsants with antipyretics at the first signs of an infectious disease. In this case, diazepam is given orally or rectally. daily dose 0.6-0.8 mg/kg (for 3 oral doses per day) from the moment the first signs of a febrile illness appear until 2 days after complete recovery. Paracetamol is given only in the first days of illness.
The pediatrician must constantly conduct sanitary educational work with parents
on the correct use of over-the-counter antipyretics:
· a child with a fever should be uncovered and wiped with water at room temperature: this is often enough to reduce it;
· an antipyretic should be used only if the body temperature rises to the above values or if chills and/or trembling occur;
· a course of taking antipyretic drugs should be avoided - in addition to the danger of overdose, this may complicate the diagnosis of a bacterial infection, which requires timely antibacterial therapy. A repeat dose of the antipyretic should be given only after a new increase in body temperature to the above level;
· if the body temperature is above 38.0°C, persisting for 3 days, a bacterial disease is likely, which requires a second visit to the doctor;
· simultaneous prescription of an antibiotic and an antipyretic makes it difficult to assess the effectiveness of the antibiotic, since its main criterion is a decrease in body temperature; exceptions to this rule are convulsions or impaired heat transfer.
T.M.Tvorogova
Fever continues to be one of the leading reasons for seeking emergency care. medical care in pediatric practice.
It has been noted that an increase in body temperature in children is not only one of the most common reasons for visiting a doctor, but also the main reason for the uncontrolled use of various medications. At the same time, various non-steroidal anti-inflammatory drugs (salicylates, pyrazolone and para-aminophenol derivatives) have traditionally been used as antipyretic drugs for many years. However, in the late 1970s, convincing evidence emerged that the use of derivatives salicylic acid with viral infections in children may be accompanied by the development of Reye's syndrome. Considering that Reye's syndrome is characterized by an extremely unfavorable prognosis (mortality rate - up to 80%, high risk of developing serious neurological and cognitive impairments in survivors), in the United States in the early 80s it was decided to introduce a ban on the use of salicylates in children for influenza and acute respiratory viral infections. and chickenpox. In addition, all over-the-counter medications that contained salicylates began to be labeled with a warning that their use in children with influenza and chickenpox could lead to the development of Reye's syndrome. All this contributed to a significant decrease in the incidence of Reye's syndrome in the United States. Thus, if before the restriction of the use of aspirin in children (in 1980), 555 cases were registered of this disease, then already in 1987 - only 36, and in 1997 - only 2 cases of Reye's syndrome. At the same time, data on serious side and undesirable effects of other antipyretics were accumulating. Thus, amidopyrine, often used by pediatricians in past decades, was also excluded from the range of drugs due to its high toxicity. Convincing evidence that analgin (dipirone, metamizole) can adversely affect the bone marrow, inhibiting hematopoiesis, up to the development of fatal agranulocytosis, has contributed to a sharp limitation of its use in medical practice in many countries of the world.
Serious analysis of results scientific research to study the comparative effectiveness and safety of various analgesics-antipyretics in children led to a significant reduction in antipyretic drugs approved for use in pediatric practice. Currently, only paracetamol and ibuprofen are officially recommended for use in children with fever as safe and effective antipyretic drugs. However, despite clear recommendations from the World Health Organization on the selection and use of antipyretics for fever in children, domestic pediatricians still often continue to use acetylsalicylic acid and analgin.
Development of fever
Before the active introduction into medical practice of antipyretic and antibacterial agents analysis of the characteristics of the course of the febrile reaction played an important diagnostic and prognostic value. At the same time, specific features of fever in many infectious diseases (typhoid fever, malaria, typhus, etc.) were identified. At the same time, S.P. Botkin, back in 1885, drew attention to the conventionality and abstractness of the average characteristics of fever. In addition, it is necessary to take into account the fact that the nature of the fever depends not only on the pathogenicity, pyrogenicity of the pathogen and the massiveness of its invasion or the severity of aseptic inflammation processes, but also on the individual age and constitutional characteristics of the patient’s reactivity and his background conditions.
Fever is usually assessed by the degree of increase in body temperature, the duration of the febrile period and the nature of the temperature curve:
Depending on the degree of temperature increase:
Depending on the duration of the febrile period:
It should be noted that currently, due to the widespread use of etiotropic (antibacterial) and symptomatic (antipyretic) drugs, early stages infectious disease, typical temperature curves are rarely seen in practice.
Clinical variants of fever and its biological significance
When analyzing the temperature reaction, it is very important not only to assess the magnitude of its rise, duration and fluctuations, but to compare this with the child’s condition and the clinical manifestations of the disease. This will not only greatly facilitate the diagnostic search, but will also allow you to choose the right tactics observation and treatment of the patient, which will ultimately determine the prognosis of the disease.
Particular attention should be paid to the clinical equivalents of the correspondence of heat transfer processes increased level heat production, because Depending on individual characteristics and background conditions, fever, even with the same level of hyperthermia, can occur differently in children.
Highlight "pink" and "pale" fever variants. If, with an increase in body temperature, heat transfer corresponds to heat production, then this indicates an adequate course of fever. Clinically this manifests itself "pink" fever. In this case, normal behavior and satisfactory well-being of the child are observed, the skin is pink or moderately hyperemic, moist and warm to the touch. This is a prognostically favorable variant of fever.
The absence of sweating in a child with pink skin and fever should raise suspicion of severe dehydration due to vomiting and diarrhea.
In the case when, with an increase in body temperature, heat transfer due to a significant impairment of peripheral circulation is inadequate to heat production, the fever acquires an inadequate course. The above is observed in another variant - "pale" fever. Clinically, a disturbance in the condition and well-being of the child, chills, pallor, marbling, dry skin, acrocyanosis, cold feet and palms, and tachycardia are noted. These clinical manifestations indicate a prognostically unfavorable course of fever and are a direct indication of the need for emergency care.
One of the clinical options for the unfavorable course of fever is hyperthermic syndrome. The symptoms of this pathological condition were first described in 1922. (L. Ombredanne, 1922).
In young children, the development of hyperthermic syndrome in the vast majority of cases is caused by infectious inflammation accompanied by toxicosis. The development of fever against the background of acute microcirculatory metabolic disorders underlying toxicosis (spasm followed by capillary dilatation, arteriovenous shunting, platelet and erythrocyte sludge, increasing metabolic acidosis, hypoxia and hypercapnia, transmineralization, etc.) leads to aggravation of the pathological process. Decompensation of thermoregulation occurs with a sharp increase in heat production, inadequately reduced heat transfer and lack of effect from antipyretic drugs.
Hyperthermic syndrome, in contrast to adequate (“favorable”, “pink”) fever, requires urgent use of a comprehensive emergency therapy.
As a rule, with hypertemic syndrome, there is an increase in temperature to high numbers (39-39.50 C and above). However, it should be remembered that the basis for distinguishing hypertemic syndrome into a separate variant of the temperature reaction is not the degree of increase in body temperature to specific numbers, but clinical features course of fever. This is due to the fact that, depending on the individual age and premorbid characteristics of children, concomitant diseases, the same level of hyperthermia can be observed in different variants of the course of fever. In this case, the determining factor during fever is not the degree of hyperthermia, but the adequacy of thermoregulation - the correspondence of heat transfer processes to the level of heat production.
Thus, Hypertemic syndrome should be considered a pathological variant of fever, in which there is a rapid and inadequate increase in body temperature, accompanied by impaired microcirculation, metabolic disorders and progressively increasing dysfunction of vital organs and systems.
In general, the biological significance of fever is to increase the body's natural reactivity. An increase in body temperature leads to an increase in the intensity of phagocytosis, an increase in the synthesis of interferon, an increase in the transformation of lymphocytes and stimulation of antibody genesis. Increased body temperature prevents the proliferation of many microorganisms (cocci, spirochetes, viruses).
However, fever, like any nonspecific protective-adaptive reaction, when compensatory mechanisms are depleted or in the hyperthermic variant, can cause the development of severe pathological conditions.
It should be noted that individual factors of aggravated premorbitis can have a significant impact on the development of adverse consequences of fever. Thus, in children with serious cardiovascular and respiratory systems fever can lead to the development of decompensation of these systems. In children with central nervous system pathologies (perinatal encephalopathy, hematocerebrospinal fluid syndrome, epilepsy, etc.), fever can trigger the development of an attack of convulsions. The age of the child is no less important for the development of pathological conditions during fever. The younger the child, the more dangerous a rapid and significant rise in temperature is for him due to the high risk of developing progressive metabolic disorders, cerebral edema, transmineralization and impairment of vital functions.
Differential diagnosis of pathological conditions accompanied by fever.
An increase in body temperature is a nonspecific symptom that occurs in numerous diseases and pathological conditions. When carrying out differential diagnosis, you need to pay attention to:
Fever in newborns and children of the first three months requires close medical supervision. Thus, if a fever occurs in a newborn baby during the first week of life, it is necessary to exclude the possibility of dehydration as a result of excessive weight loss, which is more common in children born with a large birth weight. In these cases, rehydration is indicated. In newborns and children in the first months of life, there may be an increase in temperature due to overheating and excessive excitement.
Similar situations often occur in premature infants and children born with signs of morphofunctional immaturity. At the same time, the air bath helps to quickly normalize body temperature.
Combination of fever with individual clinical symptoms and her possible reasons are given in table 1.
When compiling the table, we used many years of clinical observations and experience of the staff of the Department of Pediatrics of the Russian Medical Academy of Postgraduate Education, as well as literature data.
Table 1 Possible causes of fever in combination with individual clinical symptoms
| Symptom complex | Possible reasons |
| Fever accompanied by damage to the pharynx, pharynx, and oral cavity | Acute pharyngitis; acute tonsillitis, tonsillitis, acute adenoiditis, diphtheria, aphthous stomatitis, retropharyngeal abscess |
| Fever + damage to the pharynx, as a symptom complex of infectious and somatic diseases. | Viral infections: Infectious mononucleosis, flu, adenovirus infection, enterovirus herpangina, measles, foot and mouth disease. Microbial diseases: tularemia, listeriosis, pseudotuberculosis. Blood diseases: agranulocytosis-neutropenia, acute leukemia |
| Fever associated with cough | Influenza, parainfluenza, whooping cough, adenoviral infection, acute laryngitis. Bronchitis, pneumonia, pleurisy, lung abscess, tuberculosis |
| Fever + rash in combination with symptoms characteristic of these diseases | Childhood infections (measles, scarlet fever, etc.); typhus and paratyphoid; yersiniosis; toxoplasmosis (congenital, acquired) in acute phase; drug allergy; exudative erythema multiforme; diffuse diseases connective tissue(SLE, JRA, dermatomyositis); systemic vasculitis (Kawasaki disease, etc.) |
| Fever accompanied by hemorrhagic rashes | Acute leukemia; hemorrhagic fevers (Far Eastern, Crimean, etc.); acute form of histiocytosis X; infective endocarditis; meningococcal infection; Waterhouse-Friderickson syndrome; thrombocytopenic purpura; hypoplastic anemia; hemorrhagic vasculitis. |
| Fever + erythema nodosum | Erythema nodosum, as a disease; tuberculosis, sarcoidosis, Crohn's disease |
| Fever and local enlargement of peripheral lymph nodes as part of symptom complexes of these diseases | Lymphadenitis; erysipelas; retropharyngeal abscess; diphtheria of the throat; scarlet fever, tularemia; cat scratch disease; Kaposi's syndrome |
| Fever with generalized enlargement of lymph nodes | Lymphodenopathy due to viral infections: rubella, chicken pox, enterovirus infections, adenoviral infection, infectious mononucleosis; for bacterial infections: listeriosis, tuberculosis; for diseases caused by protozoa: leishmaniasis, toxoplasmosis; Kawasaki disease; malignant lymphomas (lymphogranulomatosis, non-Hodgkin lymphomas, lymphosarcoma). |
| Fever, abdominal pain | Foodborne illnesses, dysentery, yersiniosis; acute appendicitis; Crohn's disease, ulcerative colitis, gastrointestinal tumors; acute pancreatitis; pyelonephritis, urolithiasis disease; tuberculosis with damage to mesenteric nodes. |
| Fever + splenomegaly | Hemato-oncological diseases (acute leukemia, etc.); endocarditis, sepsis; SLE; tuberculosis, brucellosis, infectious mononucleosis, typhoid fever. |
| Fever + diarrhea in combination with symptoms observed with these diseases | Foodborne illnesses, dysentery, enterovirus infections (including rotavirus); pseudotuberculosis, foot and mouth disease; nonspecific ulcerative colitis, Crohn's disease; collagenosis (scleroderma, dermatomyositis); systemic vasculitis; |
| Fever associated with meningeal syndrome | Meningitis, encephalitis, poliomyelitis; flu; typhoid and typhus; Q fever. |
| Fever combined with jaundice | Hemolytic anemia. Hepatic jaundice: hepatitis, cholangitis. Leptospirosis. Neonatal sepsis; cytomegalovirus infection. Prehepatic jaundice: acute cholecystitis; |
| Fever headache | Influenza, meningitis, encephalitis, meningo-encephalitis, typhus and typhoid fever |
From the data presented in Table 1, it follows that the possible causes of fever are extremely diverse, therefore only a thorough history taking, analysis of clinical data in combination with an in-depth targeted examination will allow the attending physician to identify the specific cause of fever and diagnose the disease.
Antipyretic drugs in pediatric practice.
Antipyretic drugs (analgesics-antipyretics)
- are one of the most commonly used drugs in medical practice.
Drugs belonging to the group of non-steroidal anti-inflammatory drugs (NSAIDs) have an antipyretic effect.
The therapeutic possibilities of NSAIDs were discovered, as often happens, long before their mechanism of action was understood. Thus, in 1763, R.E. Stone made the first scientific report on the antipyretic effect of a drug obtained from willow bark. It was then found that the active principle of willow bark is salicin. Gradually, synthetic analogs of salicin (sodium salicylate and acetylsalicylic acid) completely replaced natural compounds in therapeutic practice.
Subsequently, salicylates, in addition to the antipyretic effect, had anti-inflammatory and analgesic activity. At the same time, other chemical compounds were synthesized, to varying degrees, with similar therapeutic effects (paracetamol, phenacetin, etc.).
Medicines characterized by anti-inflammatory, antipyretic and analgesic activity and not being analogues of glucocorticoids began to be classified as non-steroidal anti-inflammatory drugs.
The mechanism of action of NSAIDs, which consists in suppressing the synthesis of prostaglandins, was established only in the early 70s of our century.
Mechanism of action of antipyretic drugs
The antipyretic effect of analgesics-antipyretics is based on the mechanisms of inhibition of prostaglandin synthesis by reducing the activity of cyclooxygenase.
The source of prostaglandins is arachidonic acid, which is formed from phospholipids of the cell membrane. Under the action of cyclooxygenase (COX), arachidonic acid is converted into cyclic endoperoxides with the formation of prostaglandins, thromboxane and prostacyclin. In addition to COX, arachidonic acid is subjected to enzymatic action with the formation of leukotrienes.
IN normal conditions the activity of arachidonic acid metabolic processes is strictly regulated by the physiological needs of the body for prostaglandins, prostacyclin, thromboxane and leukotrienes. It is noted that the direction of the vector of enzymatic transformations of cyclic endoperoxides depends on the type of cells in which arachidonic acid metabolism occurs. Thus, thromboxanes are formed in platelets from most of the cyclic endoperoxides. While in the cells of the vascular endothelium, prostacyclin is formed predominantly.
In addition, it has been established that there are 2 COX isoenzymes. So, the first one - COX-1 functions in normal conditions, directing the metabolic processes of arachidonic acid to the formation of prostaglandins necessary for the physiological functions of the body. The second isoenzyme of cyclooxygenase - COX-2 - is formed only when inflammatory processes under the influence of cytokines.
As a result of blocking COX-2 with non-steroidal anti-inflammatory drugs, the formation of prostaglandins is reduced. Normalization of the concentration of prostaglandins at the site of injury leads to a decrease in the activity of the inflammatory process and the elimination of pain reception (peripheral effect). Blockade of cyclooxygenase by NSAIDs in the central nervous system is accompanied by a decrease in the concentration of prostaglandins in the cerebrospinal fluid, which leads to normalization of body temperature and an analgesic effect (central action).
Thus, by acting on cyclooxygenase and reducing the synthesis of prostaglandins, non-steroidal anti-inflammatory drugs have anti-inflammatory, analgesic and antipyretic effects.
In pediatric practice, various non-steroidal anti-inflammatory drugs (salicylates, pyrazolone and para-aminophenol derivatives) have traditionally been used as antipyretic drugs for many years. However, by the 70s of our century, a large amount of convincing data had accumulated on the high risk of developing side and undesirable effects when using many of them. It has been proven that the use of salicylic acid derivatives for viral infections in children may be accompanied by the development of Reye's syndrome. Reliable data were also obtained on the high toxicity of analgin and amidopyrine. All this has led to a significant reduction in the number of approved antipyretic drugs for use in pediatric practice. Thus, in many countries of the world, amidopyrine and analgin were excluded from national pharmacopeias and the use of acetylsalicylic acid in children without special indications was not recommended.
This approach was also supported by WHO experts, according to whose recommendations Acetylsalicylic acid should not be used as an analgesic-antipyretic in children under 12 years of age.
It has been proven that among all antipyretic drugs, only paracetamol and ibuprofen fully meet the criteria of high therapeutic efficacy and safety and can be recommended for use in pediatric practice.
table 2 Antipyretic drugs approved for use in children
Application in pediatric practice analgin (metamizole) as an antipyretic and analgesic is permissible only in certain cases:
So currently Only paracetamol and ibuprofen are officially recommended for use in children with fever as the safest and most effective antipyretic drugs. It should be noted that ibuprofen, unlike paracetamol, by blocking cyclooxygenase both in the central nervous system and at the site of inflammation, has not only an antipyretic, but also an anti-inflammatory effect, potentiating its antipyretic effect.
A study of the antipyretic activity of ibuprofen and paracetamol showed that when using comparable doses, ibuprofen exhibits greater antipyretic effectiveness. It has been established that the antipyretic effectiveness of ibuprofen in a single dose of 5 mg/kg is higher than that of paracetamol in a dose of 10 mg/kg.
We conducted a comparative study of the therapeutic (antipyretic) effectiveness and tolerability of ibuprofen ( Ibufen-suspension, PolPharma, Poland) and paracetamol (Calpol) for fever in 60 children aged 13-36 months suffering from acute respiratory infections.
An analysis of the dynamics of changes in body temperature in children with an initial fever of less than 38.50C (a risk group for the development of febrile seizures) showed that the antipyretic effect of the studied drugs began to develop within 30 minutes after their administration. It was noted that the rate of decrease in fever was more pronounced with Ibufen. A single dose of Ibufen was also accompanied by a more rapid normalization of body temperature compared to paracetamol. It was noted that if the use of Ibufen led to a decrease in body temperature to 370C by the end of 1 hour of observation, then in children from the comparison group the temperature curve reached the specified values only 1.5-2 hours after taking Calpol. After normalization of body temperature, the antipyretic effect from a single dose of Ibufen persisted for the next 3.5 hours, whereas when using Calpol it lasted 2.5 hours.
When studying the antipyretic effect of the compared drugs in children with an initial body temperature above 38.50C, it was found that a single dose of ibuprofen was accompanied by a more intense rate of reduction in fever compared to calpol. In children of the main group, normalization of body temperature was noted 2 hours after taking Ibufen, while in the comparison group children continued to have a low-grade and febrile fever. The antipyretic effect of Ibufen, after reducing fever, persisted throughout the entire observation period (4.5 hours). At the same time, in the majority of children receiving Calpol, the temperature not only did not decrease to normal levels, but also increased again starting from the 3rd hour of observation, which required repeated use of antipyretic drugs in the future.
The more pronounced and prolonged antipyretic effect of ibuprofen that we noted compared to comparable doses of paracetamol is consistent with the results of studies by different authors. The more pronounced and prolonged antipyretic effect of ibuprofen is associated with its anti-inflammatory effect, potentiating antipyretic activity. It is believed that this explains the more effective antipyretic and analgesic effect of ibuprofen compared to paracetamol, which does not have significant anti-inflammatory activity.
Ibufen was well tolerated, and no side effects or undesirable effects were recorded. At the same time, the use of calpol was accompanied by the appearance of allergic exanthema in 3 children, which was relieved by antihistamines.
Thus, our studies have shown high antipyretic efficacy and good tolerability of the drug - Ibufen suspensions (ibuprofen) - for relieving fever in children with acute respiratory infections.
Our results are fully consistent with literature data indicating the high effectiveness and good tolerability of ibuprofen. It was noted that short-term use of ibuprofen has the same low risk of developing undesirable effects as paracetamol, which is rightfully considered the least toxic among all analgesics-antipyretics.
In cases where clinical and anamnestic data indicate the need for antipyretic therapy, it is necessary to follow the recommendations of WHO specialists, prescribing the most effective and safest medications - ibuprofen and paracetamol. It is believed that ibuprofen can be used as initial therapy in cases where the use of paracetamol is contraindicated or ineffective (FDA, 1992).
Recommended single doses: paracetamol - 10-15 mg/kg body weight, ibuprofen - 5-10 mg/kg . When using children's forms of drugs (suspensions, syrups), it is necessary to use only the measuring spoons included with the packages. This is due to the fact that when using homemade teaspoons, the volume of which is 1-2 ml less, the actual dose of the drug received by the child is significantly reduced. Repeated use of antipyretic drugs is possible no earlier than 4-5 hours after the first dose.
Paracetamol is contraindicated
for severe diseases of the liver, kidneys, hematopoietic organs, as well as for deficiency of glucose-6-dehydrogenase.
Simultaneous use of paracetamol with babriturates, anticonvulsants and rifampicin increases the risk of developing hepatotoxic effects.
Ibuprofen is contraindicated
with exacerbation of gastric ulcer and duodenal ulcer, aspirin triad, severe disorders of the liver, kidneys, hematopoietic organs, as well as diseases optic nerve.
It should be noted that ibuprofen increases the toxicity of digoxin. With simultaneous use of ibuprofen with potassium-sparing diuretics, hyperkalemia may develop. While the simultaneous use of ibuprofen with other diuretics and antihypertensive drugs weakens their effect.
Only in cases where oral or rectal administration of first-line antipyretic drugs (paracetamol, ibuprofen) is impossible or impractical, parenteral administration of metamizole (analgin) is indicated. In this case, single doses of metamizole (analgin) should not exceed 5 mg/kg (0.02 ml of 25% analgin solution per 1 kg of body weight) in infants and 50-75 mg/year (0.1-0.15 ml 50% analgin solution per year of life) in children older than one year . It should be noted that the emergence of convincing evidence of the adverse effects of metamizole (analgin) on the bone marrow (up to the development of fatal agranulocytosis in the most severe cases!) contributed to a sharp limitation of its use.
When identifying “pale” fever, it is advisable to combine the use of antipyretic drugs with vasodilators (papaverine, dibazol, papazole) and physical cooling methods. In this case, single doses of the drugs of choice are standard (paracetamol - 10-15 mg/kg, ibuprofen - 5-10 mg/kg). Among the vasodilator drugs, papaverine is most often used in a single dose of 5-20 mg, depending on age.
In case of persistent fever, accompanied by a violation of the condition and signs of toxicosis, as well as with hyperthermic syndrome, a combination of antipyretics, vasodilators and antihistamines. For intramuscular administration, a combination of these drugs in one syringe is permissible. These drugs are used in the following single dosages.
50% analgin solution:
2.5% solution of diprazine (pipolfen):
2% papaverine hydrochloride solution:
Children with hyperthermic syndrome, as well as with intractable “pale fever” should be hospitalized after emergency care.
It should be especially noted that course use of antipyretics is unacceptable without a serious search for the causes of fever. At the same time, the danger of diagnostic errors increases ("missing" symptoms of serious infectious and inflammatory diseases such as pneumonia, meningitis, pyelonephritis, appendicitis, etc.). In cases where a child receives antibacterial therapy, regular use of antipyretics is also unacceptable, because may contribute to unjustified delay in deciding whether to replace the antibiotic. This is explained by the fact that one of the earliest and most objective criteria for the therapeutic effectiveness of antimicrobial agents is a decrease in body temperature.
It must be emphasized that “non-inflammatory fevers” are not controlled by antipyretics and, therefore, should not be prescribed. This becomes understandable, because with “non-inflammatory fever” there are no points of application (“targets”) for analgesics-antipyretics, because cyclooxygenase and prostaglandins do not play a significant role in the genesis of these hyperthermia.
Thus, to summarize the above, rational therapeutic tactics for fever in children are as follows:
- In children, only safe antipyretic drugs should be used.
- The drugs of choice for fever in children are paracetamol and ibuprofen.
- Prescribing analgin is possible only in case of intolerance to the drugs of choice or if parenteral administration of an antipyretic drug is necessary.
- The prescription of antipyretics for low-grade fever is indicated only for children at risk.
- The prescription of antipyretic drugs in healthy children with a favorable temperature reaction is indicated for fever >390 C.
- For “pale” fever, a combination of analgesic-antipyretic + vasodilator drug (if indicated, antihistamine) is indicated.
- Rational use of antipyretics will minimize the risk of developing their side and undesirable effects.
- The course use of analgesics-antipyretics for antipyretic purposes is unacceptable.
- The use of antipyretic drugs is contraindicated for “non-inflammatory fevers” (central, neurohumoral, reflex, metabolic, medicinal, etc.)
Literature
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Signs that distinguish the first and second stages of fever are often used to distinguish clinical variants of fever - “pale” and “pink”. This division of the syndrome is a feature of the domestic pediatric school.
Pediatricians under clinical option "pink" Fever is understood as “an increase in body temperature in children combined with clinical signs of the second stage of fever.”
Clinically, this is manifested by the child’s normal behavior and well-being, pink or moderately hyperemic skin color, moist and warm to the touch (“ pink fever»).
This course of fever is considered prognostic favorable.
Another clinical option is " pale" fever is understood as “a significant increase in body temperature, combined with clinical signs of the first stage of fever during long lasting! time (several hours)".
Clinically, there is a disturbance in the condition and well-being of the child, persistent chills, pale skin, acrocyanosis, cold feet and palms (“ pale fever»).
These clinical manifestations indicate pathological course fever, prognostic unfavorable and are a direct indication for emergency care.
Signs of limited heat transfer in combination with significant increase body temperatures that persist for a long time (more than an hour), Dont Have physiological expediency and can be precursors of febrile seizures in young children.
One of the clinical variants of the unfavorable course of fever is hyperthermic syndrome.
Hyperthermic syndrome is considered as a pathological variant of fever, in which there is a rapid and inadequate increase in body temperature, accompanied by impaired microcirculation, metabolic disorders and progressively increasing dysfunction of vital organs and systems.
Hyperthermic syndrome, in contrast to adequate (“favorable”, “pink”) fever, requires the urgent use of complex emergency therapy.
Causes of prolonged fever
The diagnosis of “fever of unknown origin” is made if a rise in body temperature above 38 ° C persists for more than 2-3 weeks, and the cause of the fever remains unclear even after generally accepted (routine) studies. Typically, the cause of an increase in body temperature is a serious illness, often curable. A thorough examination of the patient is necessary, preferably in a hospital, to identify the cause of the fever.
The basis of long-term fever of unknown origin in 70% is the “big three”:
Infections - 35%,
Malignant tumors - 20%,
Systemic connective tissue diseases - 15%.
Another 15-20% are due to other diseases, and in approximately 10-15% of cases the cause of fever of unknown origin remains unknown.
The following common conditions should be ruled out before further testing:
Pneumonia (based on x-rays of organs) chest and auscultation). Chest x-ray may also reveal pulmonary tuberculosis, sarcoidosis, alveolitis, pulmonary infarction, or lymphoma;
Urinary tract infection (urinalysis, bacteriological examination); urine analysis may suggest hemorrhagic fever with renal syndrome or kidney tumor;
Sinusitis (ultrasound or x-ray of the skull).
Overheating in children
The human body, being warm-blooded, strictly controls body temperature, avoiding significant metabolic shifts. But in emergency conditions, in an attempt to get through a painful or traumatic period faster, the human body artificially raises body temperature and speeds up metabolism. This process is called fever and reflects a general acceleration of vital activity.
Fever should be distinguished from another case of increased body temperature - overheating. Overheating or hyperthermia is the result of decompensation of warm-blooded mechanisms with persistent insufficiency of heat transfer in relation to heat production, which leads to a pathological increase in temperature. Hyperthermia may be exogenous(when the body is exposed to physical and chemical factors that impede heat transfer or activate heat production), as well as endogenous caused by direct damage to the hypothalamus and mitochondrial disorders.
Hyperthermia is formed without the primary influence of any signals on immune system, although during its development the same inflammatory mediators are formed and act as during fever. Having begun as exogenous, any overheating in the decompensation phase acquires a mixed character due to the addition of an endogenous component. When compensatory mechanisms fail, warming up the body accelerates the metabolic production of endogenous heat. Overheating cannot last long, as it leads to irreversible disturbances in water-electrolyte homeostasis and intense protein denaturation. Denaturation of clotting factors and red blood cell proteins leads to hemorrhagic syndrome and hemolysis. At a temperature of 42.2°C, the functioning of neurons is disrupted (necrobiosis develops). The extreme degree of decompensated overheating is called heatstroke . A temperature of 43.3°C with overheating is considered lethal.
It has been established that in adults the mechanism of temperature rise during fever involves mainly limiting heat transfer. In infants, the most significant role is played by increased non-shivering thermogenesis in brown fat. Brown fat is located in Bisha's lumps, interscapular region, in the mediastinum, along the aorta and large vessels, along the spine and sympathetic trunk, in the abdominal cavity, behind the sternum, around the kidneys and adrenal glands, it is quickly depleted by the end of the neonatal period. Fever is a more energy-intensive process for a child than for an adult, so young children quickly lose weight when they have a fever. Intensive lipolysis increases the risk of ketoacidosis and aggravates the clinical manifestations of fever.
Differential diagnosis infectious fever and non-infectious hyperthermia
The program for the initial examination of sick children with fever is built depending on its genesis: infectious or non-infectious.
TO mandatory methods investigations of a patient with fever include:
Thermometry in 3–5 areas of the body;
Clinical blood test;
General urine analysis;
Determination of diuresis.
Additional studies of a child with fever are carried out depending on the identified symptom complex in the process of differential diagnosis.
Differential diagnosis of fever is sometimes difficult. First of all, it is necessary to determine the nature of the fever - “inflammatory” or “non-inflammatory”.
To the signs "inflammatory" fevers include: - connection between the onset of the disease and infection (catarrhal symptoms from the upper respiratory tract, the presence of symptoms of an infectious disease, a burdened epidemiological history);
Inflammatory changes in the blood (leukocytosis, increased ESR, increased levels of fibrinogen, C-reactive protein, dysproteinemia);
Presence of symptoms of intoxication;
Poor health;
Tachycardia and tachypnea;
Relief of fever with the use of antipyretics;
Positive effect when prescribing antimicrobial agents.
At "non-inflammatory" In cases of fever, febrility is usually well tolerated, and there is no increase in heart rate adequate to the increase in temperature. There is no effect from the use of antipyretic and antibacterial drugs. Temperature response central genesis may spontaneously normalize as the impaired functions of the central nervous system are compensated.
MINISTRY OF HEALTH AND SOCIAL DEVELOPMENT OF THE RF
Department of Pediatrics
Educational and methodological manual
for students of pediatric faculties, interns, residents and pediatricians.
FEVER AND HYPERTHERMIA IN CHILDREN
The human body, being homeothermic, strictly controls body temperature, avoiding significant metabolic shifts. But in emergency conditions, in an attempt to get through a painful or traumatic period faster, the human body artificially raises body temperature and speeds up metabolism. This process is called fever and reflects the general acceleration of life activity.
Fever should be distinguished from another case of increased body temperature - overheating . Overheating or hyperthermia is the result of decompensation of homeothermic mechanisms with persistent insufficiency of heat transfer in relation to heat production, which leads to a pathological increase in temperature. Hyperthermia May be exogenous(when the body is exposed to physical and chemical factors that impede heat transfer or activate heat production), as well as endogenous caused by direct damage to the hypothalamus and mitochondrial disorders.
Hyperthermia develops without the initial impact of any signals on the immune system, although during its development the same inflammatory mediators are formed and act as during fever. Beginning as exogenous, any overheating in the decompensation phase acquires a mixed character due to the addition of an endogenous component, since when compensatory mechanisms fail, body heating accelerates the metabolic production of endogenous heat. Overheating cannot last long, as it leads to irreversible disturbances in water-electrolyte homeostasis and intense protein denaturation. Denaturation of coagulation factors and red blood cell proteins leads to hemorrhagic syndrome and hemolysis. At a temperature of 42.2 o C, the functioning of neurons is disrupted (necrobiosis develops). The extreme degree of decompensated overheating is called heat stroke. A temperature of 43.3 o C with overheating is considered lethal.
In the pathogenesis of hyperthermia, in addition to increasing temperature, the following are important: dehydration and salt imbalance; circulatory disorders; hypoxia. None of these disorders are observed during normergic fever (in the absence of accompanying pathological processes).
Fever, unlike hyperthermia, can last quite a long time, causing minimal and reversible damage to homeostasis, since its mechanisms are economical and based on a temporary shift in the equilibrium of heat production and heat transfer with its subsequent restoration to a new level.
Fever is an etiologically nonspecific and pathogenetically unified process, the triggering signals for which are pyrogens (exogenous - components of infectious pathogens, endogenous - cytokines of the body itself). The essence of fever is the response of the thermoregulatory apparatus of a homeothermic organism, which is characterized by a temporary shift in the set point of temperature homeostasis to a higher level while maintaining the mechanisms of thermoregulation. The thermoregulation system ensures that the temperature of the thermal core (brain, chest and abdominal cavity, pelvis) is maintained at a constant level, while the temperature of the thermal shell of the body (skin, mucous membranes, subcutaneous fat, superficial muscles) depends on the temperature of the core.
Measuring body surface temperature, first put on a systematic basis by the 19th century German physician K. Wunderlich, has become the most popular clinical and laboratory test. Normal indicators temperatures at any point on the surface of the body vary. Axillary temperature in healthy adults is in the range of 36.4–37.2 o C, oral – 37.2–37.7 o C, rectal and vaginal – 36.6–37.9 o C. In children, axillary temperature is depends largely on the condition of the skin and the tone of the vessels of the subcutaneous tissue, which is determined by various background conditions. The daily rhythm of body temperature has a minimum between 5 and 6 a.m. and a maximum exactly 12 hours later. The circadian rhythm persists during fever, but disappears during overheating.
Temperature homeostasis is based on the dynamic equilibrium of the rate of heat production and the rate of heat transfer. Heat production varies depending on muscle work and the intensity of metabolism in the organs of the thermal core. Heat transfer is the sum of heat losses through the thermal shell in several ways: convection, conduction, evaporative and radiation heat transfer.
The central body temperature control system is the most effective of all regulatory systems based on the feedback principle. Thermoregulatory centers are located in the hypothalamus. The preoptic area of the anterior hypothalamus contains thermosensitive serotonergic neurons (thermosensors) that respond to the temperature of the blood washing them. Most of them are excited by heat, some by cold. Cold neurons are present, in addition to the hypothalamus, in the septum and reticular formation of the midbrain. In the posterior hypothalamus, near the mammillary bodies, there are noradrenergic neurons that receive information from peripheral thermosensors about the temperature of the skin and some internal organs. At the periphery in the skin there are mainly cold receptors. Peripheral intraorgan thermoreceptors are also mainly cold. The centers of the anterior hypothalamus, sensitive to blood temperature, control the effector mechanisms of heat transfer; the centers of the posterior hypothalamus, which receive peripheral thermosensory information, control heat production. In the preoptic part of the anterior hypothalamus there are clusters of cholinergic neurons - generators of the standard comparison signal for thermosensors. Above them is the vascular organ of the end plate, in the area of which the blood-brain barrier is highly permeable. It is through this window that cytokines and other regulators can interfere with temperature control and influence the position of the “set point” of temperature homeostasis - the temperature of the hypothalamus itself (approximately 37.1 o C), at which heat production and heat loss in the body are balanced.
Effector influences on heat production are carried out by the hypothalamus through the control of contractile thermogenesis (muscle tremors and other forms of muscle activity) and non-contractile thermogenesis (intensification of metabolism due to the sympathoadrenal reaction and hyperfunction of the thyroid gland).
The etiology of fever is associated with the action of pyrogens. Exogenous pyrogens stimulate the production of endogenous pyrogens (IL-1, IL-6, TNF, interferons, etc.) in macrophage and other mesenchymal cells, which trigger the production of prostaglandins in the reference neurons of the preoptic region of the anterior hypothalamus. The main mediators of the action of pyrogens are prostaglandins E-1 and E-2, c-AMP and protein transmitters. Prostaglandins cause the neurons of the reference center to lose calcium, causing them to increase the set point of temperature homeostasis. In this case, normal temperature is perceived by the hypothalamus as low. Sympathetic centers are activated, limiting heat transfer and stimulating contractile and non-contractile thermogenesis.
It has been established that in adults the mechanism of temperature rise during fever involves mainly limiting heat transfer. In infants, the most significant role is played by the enhancement of non-shivering thermogenesis in brown fat (located in Bichat's lumps, interscapular region, in the mediastinum, along the aorta and large vessels, along the spine and sympathetic trunk, in the abdominal cavity, behind the sternum, around the kidneys and adrenal glands; quickly depleted towards the end of the neonatal period) and other organs under catecholamine influence. Warming the spinal oscillator area with warm blood flowing from adjacent brown fat prevents tremors. Fever is a more energy-intensive process for a child than for an adult, so young children quickly lose weight when they have a fever. Intensive lipolysis increases the risk of ketoacidosis and aggravates the clinical manifestations of fever.
The following periods are distinguished in the development of febrile conditions:
Statum incrementi(first stage of fever) with a typical course and moderate severity lasts no more than 3-4 hours from the start of metabolic processes.
Statum fastigii(stage of standing temperature, acmatic phase) - means that the new set point has been reached. At the height of this stage, thermoregulation is carried out by mechanisms similar to the norm. Heat production and heat transfer are balanced, the patient is neither hot nor cold; skin vessels are dilated, skin temperature has increased, chills and trembling have disappeared; breathing is rapid; diuresis is reduced. According to the temperature height during this phase, fever is subfebrile (up to 38 o C), weak (up to 38.5 o C), moderate (up to 39 o C), high (up to 41 o C), hyperpyretic (above 41 o C) . The duration of the acmatic phase can vary from several hours to several weeks.
Statum decrementi(stage of extinction, temperature drop) occurs when exogenous pyrogens are exhausted, endogenous production ceases and under the influence of natural or iatrogenic antipyretics. At this stage, heat transfer sharply increases, since the set point shifts downward, and the skin temperature and blood temperature are perceived by the hypothalamus as increased. Stimulates intense sweating, perspiration and diuresis. The drop in temperature can be gradual, lytic (over several days) and rapid, critical (in 1-2 hours), while a sharp expansion of skin blood vessels can be complicated by collapse.
The classic 3-phase cycle is characteristic of untreated fever and is now rarely observed.
Metabolic changes during fever are characterized by significant activation of oxidative processes and all the characteristic hormonal and metabolic features of the acute phase response.
Aseptic fevers develop in immunopathological non-infectious processes, allergic reactions, injuries, cancer, since in all these conditions there is non-microbial stimulation of the release of endogenous pyrogens. Food fever (fever and leukocytosis after eating) is associated with its nonspecific dynamic effect, which is reduced to the total effect of a number of hormones of the enteric system (vasoactive intestinal polypeptide and neurotensin). The concepts of “salt fever”, “stress fever”, “muscle fever” are associated with various forms of endogenous overheating, recognizing the inappropriateness of using the term “fever” in these cases. Transient hyperthermia of newborns is considered a unique form of stress-salt fever. The genesis of this transitional phenomenon (a rise in temperature to 38.5-39.5 o C on days 3-5 of life) is associated with several factors, including hyperosmolar dehydration and birth stress.
Fever is a genetically determined stereotype that has great protective potential. Numerous experiments have proven the strengthening of anti-infective immunity during fever, an increase in the body's antihypoxic resistance due to the stress accompanying fever. Acceleration of phagocytosis and formation of immunoglobulins; the synthesis of interferons and interleukins, which stimulate the cytotoxic and other protective functions of macrophages, lymphocytes and granulocytes, activate the oxidative neutralization of toxins.
However, these adaptive mechanisms can lead to the development of a number of complications - ketoacidosis, seizures, arrhythmias, collapse, decreased mental activity; embryopathies (with fever in pregnant women).
A pathological variant of fever is hyperthermic syndrome, in which an increase in temperature is accompanied by significant disturbances in microcirculation, metabolic disorders and increasing multiple organ failure.
Fever can be dangerous in children with acute respiratory syndrome viral infection in the following cases:
in the presence of severe pulmonary or cardiovascular disease, severe pneumonia, mental impairment, the course of which may worsen with fever,
at very high temperatures (more than 41 o C),
in children under 5 years of age, especially from 6 months to 3 years, when there is a risk of developing febrile convulsions, as well as in children of the first 2 months of life, who suffer fever more severely than older children.
Fever is distinguished by duration, degree of increase in body temperature and type of temperature curve:
I. Duration:
acute (up to two weeks),
subacute (up to six weeks),
chronic (over six weeks);
II. By degree of temperature increase:
subfebrile (up to 38 o C),
moderate (up to 39 o C),
high (up to 41 o C),
hyperthermic (over 41 o C),
III. By type of temperature curve:
constant (daily temperature fluctuations up to 1 o C),
laxative (daily fluctuations up to 2 o C),
irregular or atypical (diurnal fluctuations are different and irregular),
debilitating, which is a combination of laxative and irregular fever with daily variations of more than 2-3 o C,
intermittent (short periods of high temperature combined with periods of apyrexia),
recurrent (alternating febrile attacks from 2 to 7 days with periods of apyrexia).
Questions about the benefits and harms of fever and the amount of necessary antipyretic therapy are resolved in each specific case individually, taking into account constitutional characteristics, premorbid background and the nature of the underlying disease.
The drop in temperature is not a simple consequence of the exhaustion of the pyrogen resource, but has the character of an active reaction controlled natural antipyretics .
Some hormones are natural antipyretics, such as arginine vasopressin, adrenocorticotropin, α-melanocyte-stimulating hormone, corticoliberin and glucocorticoids themselves. Many aspects of the acute phase response are inhibited by somatostatin and endogenous opioid and barbiturate receptor agonists (endorphins, enkephalins).
In febrile conditions, the ideal should be the selection of means of assistance that, while minimizing the unfavorable symptoms of fever or hyperthermia, do not disrupt the course of physiological processes.
Before starting any therapeutic measures, it is necessary, if possible, to determine the main constitutional characteristics of the child’s body. The older the child, the more difficult it is to identify his constitutional type, the fewer clinical and social criteria “fit” into a certain constitutional “portrait”. However, the genetically programmed reactions of the body to changing conditions of the external and internal environment are determined precisely by constitutional features (Table 1).
Table 1
Basic constitutional features in childhood
|
Clinical signs |
Basic constitutional types |
||
|
Neuro-arthritic |
Lymphatic-hypoplastic |
Allergic (atopic, exudative-catarrhal) |
|
|
Body type |
Asthenic, normosthenic |
Hypersthenic |
Various options |
|
Temperament (according to Hippocrates) |
Choleric, sanguine |
Phlegmatic person |
Sanguine, melancholic |
|
The course of the early neonatal period |
Severe transient hyperthermia on days 3-5, large weight loss on days 3-5 |
Severe transient hypothermia in the 1st hour, hypoglycemia on days 1-2, prolonged jaundice |
Toxic erythema, skin peeling, exudative manifestations |
|
Initial autonomic tone |
Sympathicotonia/eutonia |
Vagotonia |
Eutonia/vagotonia |
|
Autonomic reactivity |
Sympathicotonic, hypersympathicotonic |
Sympathico-tonic, sympathicoasthenic |
Sympathetic-asthenic, asympathicotonic |
|
Feature of temperature reaction |
Hyperthermia during inflammatory processes |
Low-grade fever |
Labile symptom, most often low-grade fever |
|
Skin |
Dry, hot, dark |
Wet, cool, pale |
Depending on the clinical manifestations, often – dyschromia |
|
Hair color |
Light, red |
||
|
Pupils |
Relatively wide |
Relatively narrow |
Labile trait |
|
Heartbeat |
More often tachycardia |
More often bradycardia |
Labile trait |
|
Upper respiratory tract |
Dry mucous membranes |
Hypertrophy of lymphoid tissue |
Labile trait |
|
Gastrointestinal tract |
Frequent regurgitation, vomiting, atonic constipation |
Spasmodic/atonic constipation |
Constipation/diarrhea |
Taking into account the constitutional characteristics, it becomes clear why in children with a neuro-arthritic type of constitution the fever is usually “pink”, in patients with the lymphatic-hypoplastic type it is “pale”, and in children with the exudative-catarrhal type it largely depends on initial condition of the skin. That is why the set of measures that balance the mechanisms of heat production - heat transfer, in the first case, should include physical methods of cooling and sedatives; in the second - peripheral antispasmodics and ganglion blockers (no-spa, papaverine, pipolfen, benzohexonium), and in severe cases - short-course glucocorticoids; in the third - antihistamines. In some cases, when symptoms of impaired coagulation homeostasis or an increase in multiple organ failure appear, controlled infusion and syndromic therapy is indicated.
Antipyretics (antipyretics) are among the most commonly used drugs in medical practice. These include non-steroidal anti-inflammatory drugs (NSAIDs: aspirin, analgin, diclofenac, indomethacin, ibuprofen, butadione, nimesulide, mefenamic acid) and paracetamol. The mechanism of their action is associated with inhibition of prostaglandin synthesis in peripheral tissues and the central nervous system (the central effect is most pronounced in paracetamol). Under normal conditions, the activity of arachidonic acid metabolic processes is strictly determined by the physiological needs of the body for prostaglandins, prostacyclin, thromboxane, leukotrienes and is supported by a certain level of cyclooxygenase (COX-1).
During inflammation, there is a sharp increase in the intensity of arachidonic acid metabolic processes, which leads to localized synthesis of prostaglandins and leukotrienes under the action of cyclooxygenase (COX-2) at the sites of injury. At the same time, there is an increased release of bradykinin, histamine, oxygen free radicals, and nitric oxide from phagocytes, which leads to increased sensitivity of pain receptors. Blockade of cyclooxygenase by NSAIDs is accompanied by inhibition of the synthesis of prostaglandin and biogenic amines (including in the cerebrospinal fluid), causing, on the one hand, a decrease in temperature, and on the other, an imbalance in the processes of heat production and heat transfer. Therefore, the tactics of actively reducing temperature with the use of NSAIDs should be considered justified in case of hyperthermia (overheating) and fever that has developed in newborns and children in the first 2 months of life, as well as with a burdened premorbid background: a history of febrile convulsions, severe neurological, pulmonary or cardiovascular diseases, significant genetically determined metabolic disorders, high febrile fever - above 39.1 o C.
According to the recommendations of the World Health Organization on the selection and use of antipyretics for fever in children (WHO, 1993), currently only paracetamol and ibuprofen officially recommended for use in children with fever as antipyretic drugs. The use of acetylsalicylic acid as an analgesic-antipyretic in children under 15 years of age is unacceptable due to the high risk of complications. It has been proven that the use of salicylic acid derivatives in children against the background of an acute respiratory infection provokes the development of Reye's syndrome - toxic encephalopathy and fatty degeneration of internal organs, mainly the liver and brain.
Serious complications that develop while taking NSAIDs include gastrointestinal bleeding, bronchospasm, hematological changes (impaired platelet aggregation, hypo- and agranulocytosis as a result of inhibition of bone marrow hematopoiesis), hypoglycemia, acute renal failure, anaphylaxis. That is why analgin (metamizole) is approved for use in pediatric practice only in cases of individual intolerance to the drugs of choice (paracetamol, ibuprofen) and the need for parenteral administration of an antipyretic under the supervision of a physician in the first 4 hours after administration of the drug.
Paracetamol is the drug of choice for hyperthermia and febrile conditions with moderate inflammatory changes in peripheral organs and tissues. By blocking COX in the central nervous system and affecting the centers of pain and thermoregulation, paracetamol in a single dose of 10-15 mg/kg reduces temperature without causing side effects characteristic of NSAIDs. However, paracetamol is contraindicated in cases of hypersensitivity to paracetamol and in the case of a genetic absence of glucose-6-phosphate dehydrogenase. In patients with impaired renal function and chronic liver diseases, there is a delay in the elimination of the drug and its metabolites. Combined use Liv.52 and paracetamol minimizes the toxic effect of the latter even when using high doses of the drug. Wherein Liv.52 does not change the intestinal absorption of paracetamol and does not affect its antipyretic effect.
It must be taken into account that in inflamed tissues, cellular peroxidases neutralize the effect of paracetamol on COX, which explains the almost complete absence of the anti-inflammatory effect of the drug and the weak antipyretic effect when using paracetamol in clinical cases, accompanied by severe inflammatory manifestations in the central nervous system and peripheral organs. In these situations, the drug of choice is considered ibuprofen .
Antipyretic effectiveness ibuprofen at a single dose of 5 mg/kg is higher than that of paracetamol at a dose of 10 mg/kg. Ibuprofen also exhibits a double analgesic effect (central and peripheral). With all the positive qualities ibuprofen Side effects may also occur. By suppressing the activity of COX-1 and inhibiting the synthesis of prostaglandin E2, which protects the gastric mucosa, it can cause gastrointestinal bleeding; by reducing the level of formation of prostacyclins and thromboxanes, it disrupts the regulation of hemostasis and microcirculation.
An antipyretic agent different from the above, also belonging to the NSAID group, is nimesulide (Nimulid), which selectively inhibits COX-2 and, along with numerous positive analgesic-antipyretic properties, has virtually no inhibitory effect on COX-1 and does not cause side effects associated with a decrease in the synthesis of prostaglandins in healthy tissues. Nimesulide blocks the release of histamine, showing a significant positive effect in allergic diseases accompanied by fever. The antipyretic and anti-inflammatory ability of nimesulide is more pronounced compared to indomethacin, ibuprofen, aspirin, paracetamol, comparable to diclofenac. The drug is used in children from 3 months of age at a dose of 5 mg/kg/day in 2-3 doses.
