Case scenario 1

A new mother comes into the pharmacy with a 4-month-old who she believes has started teething. This is the first time she has considered giving her child medicine. 

Case scenario 2

A mother comes into the pharmacy with her 18-month-old after having the child immunised by a GP. She is aware of possible adverse effects and has come pre-emptively to stock up on children’s medicine.

Introduction

Pain and fever in young children can be highly distressing for parents, particularly for new parents.1,2 Parents receive a lot of conflicting information about appropriate management of pain and fever, and are often unclear on when and what treatment should be administered.3–5 In particular, the fear that fever could be harmful to their child can lead to parents treating high temperatures with an antipyretic, even when treatment may not be necessary.5 Inappropriate dosing of medicine in young children is a key issue that needs to be addressed imminently, since most paediatric doses are individually based on the child’s weight and age.6 

Pharmacists are in an ideal position to provide education to parents about the appropriate use of children’s medicines. This article will focus on the appropriate management of two common conditions that occur during childhood: fever, both in general and due to immunisations, and teething pain. 

Learning objectives

After successful completion of this CPD activity, pharmacists should be able to:

  • Explain when fever occurs
  • Describe the signs and symptoms of teething
  • Discuss common misconceptions about fever and teething
  • Describe the appropriate use of pharmacological therapies for managing fever and teething symptoms.

Competency standards (2016) addressed: 1.1, 1.5, 2.1, 2.3, 3.1, 3.2, 3.5

 

This article is produced in partnership with Reckitt Benckiser.

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS. 

Test your knowledge on this CPD topic prior to completion to monitor your learning experience:

Fever and immunisation

Fever is defined as a body temperature above 38 °C.7,8 It is a common occurrence in young children, with approximately 60% of children experiencing a fever by the age of five.9 

Any abnormal elevation of body temperature should be evaluated as a potential symptom of an underlying condition.4 In addition to a high temperature, fever may be accompanied by malaise, irritability, sleepiness, nausea/vomiting, shivering and pain.10 The most common cause of fever in children is infections, including respiratory tract infections (RTIs).7 Colds are one of the most common acute RTI presentations among young children in Australian general practice, affecting infants and children more often than adults.11,12 Cold symptoms are also more prolonged in young children compared to adults.11 However, the likelihood of serious infections in children is quite low and is estimated to be <1% in primary care settings.4

Fever can also occur as an adverse effect of some childhood immunisations.4 Post-vaccination fever is not a pathological response, but rather an indication of the immune response to the vaccine.13 It is usually mild in nature and self-limiting over a few days.13 From birth to 4 years of age, most children in Australia will receive around 15 vaccines.14 Depending on which vaccine the child receives, the onset of fever can vary (see Table 1).7,15–23

Table 1 – Probability of fever with National Immunisation Program-recommended vaccines for children <5 years old

Disease

Likelihood and onset of fever as an ADVERSE effect

Diphtheria, tetanus, pertussis
  • Fever is uncommon15,16
  • Tends to occur after the fourth and fifth doses24

Pneumococcal disease
  • Occurs in about 37% of young children and about 5% have fever >39 °C17
  • More common after the dose at 12 months of age than after the primary doses17

Measles, mumps, rubella
  • Fever may develop 7–10 days after vaccination and last for 2–3 days18
  • Up to 15% of children may develop a high fever (>39.4 °C)18

Meningococcal disease
  • Meningococcal groups A, C, W and Y (MenACWY) – mild systemic reactions in one-fifth of recipients19 
  • Meningococcal group B (MenB) – a quarter of infants may develop a fever ≥38 °C, while 4–8% may have a fever ≥39 °C19

Haemophilus influenzae type b
  • Up to 2% of infants may develop a fever20
  • Onset is usually within 3–4 hours of vaccination and tends to resolve within 24 hours20

Varicella (chickenpox)
  • Fever >39 °C may develop in 15% of children21
  • Onset is usually 5–12 days after vaccination21

Hepatitis A
  • Systemic adverse events such as fever are much less common than local adverse events22

Influenza
  • 1–10% of people develop a fever23
  • Onset may be a few hours after vaccination and may last for 1–2 days23

Fever phobia

Despite the self-limiting nature of most causes of fever, it can be a worrisome occurrence for parents and caregivers.1,9 They may hold misconceptions about the long-term effects fever can have on their child’s health, which can result in the inappropriate use of medicines and overuse of health resources, such as emergency departments.1,9 A study evaluating fever literacy among parents and caregivers highlighted large gaps in knowledge and attitudes (see Figure 1).1 It is imperative to educate parents and caregivers about what fever is as well as appropriate management strategies. 

Recommended management of fever in children

Parents and caregivers often perceive fever itself as a disease rather than a symptom, which can create a sense of urgency to reduce the temperature.9 However, in most cases, it is not necessary to treat a child’s fever.7 For children older than 3 months who have a temperature less than 38.9 °C and are acting normally, no treatment for fever is necessary.7 If the child is experiencing discomfort, the following strategies are recommended to help make the child more comfortable. 

Increase fluids to reduce the risk of dehydration. Fluids can be in the form of milk (cow’s or breast), formula or water. Children may refuse to eat, but this should generally not be an issue as long as they are hydrated.7,10

Encourage rest as fever can make children feel tired and achy.7,10

Recommend ibuprofen or paracetamol as first-line pharmaco-therapy if fever is making the child distressed or they have other symptoms, such as a sore throat.10 A key difference between the two medicines is that paracetamol can be given from 1 month of age, while ibuprofen can be given from 3 months.25,26 Paracetamol also has a shorter dosing interval (4-6 hours) than ibuprofen (6-8 hours),25,26 with ibuprofen shown to provide up to 8 hours’ fever relief.27 Fever-reducing medications should only be given as needed and discontinued once bothersome symptoms have resolved.7 For signs and symptoms in a child with fever that require referral to a GP, see Box 1.

Figure 1 – Parent and caregiver knowledge and attitudes in a fever literacy study1

Source: Wallenstein MB et al.1

Teething pain

The process of tooth eruption, which involves teeth moving from their developmental position within the alveolar bone until they emerge in the oral cavity, begins at around 6 months of age.2,29,30 Some infants may begin teething as early as 4 months, while others as late as 10 months.30 Regardless, many infants will experience pain during the process, which can make it a distressing time for parents and caregivers.3 This pain is likely a result of increased levels of inflammatory mediators in the gingival crevicular fluid and the tissues surrounding the erupting tooth, which stimulate nociceptive receptors.3,29

Many parents do not know how to identify the signs of tooth eruption and may attribute systemic symptoms (fever, diarrhoea, vomiting and skin rash) to teething.2,3,31 Despite popular belief, teething does not cause fever or other systemic symptoms (see Box 2).4 The symptoms of teething tend to be mild (see Figure 2); however, unrelated systemic symptoms may be seen due to the length of time that tooth eruption takes to complete (2.5 years).28,31,32 During this period, infants undergo other developmental changes that predispose them to a variety of infections.31,32 Pharmacists can help educate parents about the teething process and what to expect during this time, to avoid delays in diagnosis and management of more serious issues.31 

Box 1 – Alerting features of fever

Parents and caregivers should consult a GP if their child10,28:

  • Is <3 months old and has fever above 38 °C
  • Is immunocompromised and has fever above 38 °C
  • Has a stiff neck or light is hurting their eyes
  • Is vomiting, refusing to drink much, or has reduced urine output
  • Has a rash – emergency care must be sought if non-blanching rash is detected (rash will not disappear when pressed)
  • Has a bulging fontanelle (possible infection) or sunken fontanelle (dehydration)
  • Feels more sleepy than usual, is listless or not responding to their parent’s or carer’s voice
  • Has problems breathing
  • Experiences pain that does not get better with pain-relief medication
  • Has had fever for more than 2 days and there is no obvious cause
  • Seems to be getting more unwell
  • Has a febrile seizure.

Box 2 – Alerting features of teething

  • Systemic upsets (fever, vomiting, diarrhoea, etc) are usually unrelated to teething and could be a sign of an underlying issue.3,31
  • Infants should be referred to a doctor for further investigation.3,29

Managing teething pain

The first step for relieving the symptoms of teething should always be non-pharmacological strategies.34 Recommended interventions include:

  • Distracting the child with affection and attention may help to keep their mind off their discomfort.32,33,35
  • Hugs and cuddles will also help to comfort and reassure the child if they get distressed.32,33
  • Cooling the teething site using a chilled teething ring (or a frozen carrot or cucumber large enough not to be swallowed if the child is eating solids) may help to reduce inflammation by constricting dilated blood vessels and temporarily numbing the gingivae.3 
  • Applying pressure by massaging the gums with a clean figure or a chilled washcloth may also help to reduce pain by overwhelming the sensory receptors.32,33

Advise parents to avoid using amber necklaces and bracelets as they pose a choking hazard.33 In addition, applying sugar, honey or jam to the tip of a baby’s bottle or dipping a dummy in honey should be avoided. Honey has been shown to cause infant botulism and should not be introduced to an infant’s diet until they are older than12 months.36 Additionally, these practices do not provide pain relief and may lead to dental decay. Medicines should also not be added to the child’s food or bottle.33

If the child is still distressed, ibuprofen or paracetamol can be recommended for managing mild to moderate pain.37 Because of its anti-inflammatory action, ibuprofen is an effective pain relief choice for teething pain in babies over 3 months of age.35 Teething gels are also available in Australia, but the pain relief from these tends to be short-lived, as the gel is washed away by saliva.38 The Australian and New Zealand Society of Paediatric Dentistry does not endorse the use of topical lidocaine for teething due to the risk of toxicity.39 Accurate dosing can also be difficult with lidocaine gel, and excessive application can lead to severe adverse reactions, including seizures and respiratory depression.39 Application
in the oral cavity also increases the risk of ingestion and potential for aspiration, particularly with lidocaine-based preparations.39 

Figure 2 – Common signs and symptoms of teething

Sources: Memarpour et al29, Australian Dental Association33

Counselling on accurate dosing of ibuprofen or paracetamol

In Australia, the use of over-the-counter (OTC) medicines in young children is quite high, with over 98% of parents reporting purchasing at least one OTC medicine for their child of ≤24 months of age in the last year in a cross-sectional survey.40 The pharmacy was the most common place for purchasing children’s medicines, which provides pharmacists with an excellent platform to address incorrect use of medicines.40

Young children are particularly vulnerable to inappropriate medication use, as dosing tends to be individually calculated based on both age and weight.6 In 2015, concerns about OTC medicines accounted for a large proportion of calls to Australian Poisons Information Centres for children under 5 years of age.41 Inappropriate medicine use was also demonstrated in a study evaluating medication dosing behaviour of Australian caregivers when managing fever and cough/cold in children aged less than 5 years.5 Many caregivers measured incorrect doses and stated incorrect dosing intervals. Only 35% of dose measurements observed were accurate based on the child’s weight.5 Furthermore, in a study assessing paracetamol-associated paediatric liver failure cases in Australia and New Zealand, medication errors were found to be the leading cause.42 

Educating parents on correct administration techniques and addressing any misconceptions they have can go a long way towards ensuring appropriate use of OTC medicines in children. In particular, ensuring parents understand that OTC medicines are not devoid of safety issues if used inappropriately and a double dose can be harmful.5 Some parents may also be under the impression that ibuprofen must be taken with or after food to protect against potential gastrointestinal effects.43,44 Help them understand that food can delay the onset of action of ibuprofen and negatively affect its efficacy.43,44 Key counselling points for paracetamol and ibuprofen are listed in Box 3.

Box 3 – Key counselling points for paracetamol and ibuprofen

  • Overdosing can be toxic, while underdosing is subtherapeutic3,34
  • Use of a syringe allows for the most accurate dose measurement and helps make it easier to administer to babies5
  • Dose should be based on weight, not age alone25,26,35
  • Paracetamol should be administered up to every 6 hours when necessary, or up to every 8 hours for ibuprofen when necessary25,26
  • When given in an over-the-counter setting, neither paracetamol nor ibuprofen needs to be taken with food43,44
  • Do not use for more than a few days at a time. If symptoms persist, see your doctor34

Case scenario continued

This video is part of the article. To complete your CPD points, watch the video and learn from John Bell how pharmacists can manage the case scenario introduced at the start of this article. 

Video references

  1. Xu T, Neto ACA, Moles RJ. In J Pharm Pract 2012;20(5):307–319.
  2. Hietbrink E, Bakshi R, Moles RJ. Int J Pharm Pract 2014;22(3):205–215.
  3. Wallenstein MB, Schroeder AR, Hole MK et al. Clin Pediatr 2013;52(3):254–259.
  4. Massignan C, Cardoso M, Porporatti AL et al. Pediatrics 2016;137(3):e20153501.
  5. Barbi E, Marzuilo P, Neri E et al. Children (Basel) 2017;4(9):81.
  6. Ahn SH, Zhiang J, Kim H et al. JMIR Mhealth Uhealth 2019;7(4):e12223.
  7. Das RR, Panigrahi I, Niak SS. PLoS One 2014;9(9):e106629.
  8. The Royal Children’s Hospital Melbourne. Acute pain management. Available from: www.rch.org.au/clinicalguide/guideline_index/Acute_pain_management/ (accessed 20 December 2021).
  9. Australian Government Department of Health and Ageing. OTC medicine monograph: ibuprofen for oral use. Version 1.0, September 2013.
  10. Australian Government Department of Health and Ageing. OTC medicine monograph: paracetamol for oral use. Version 1.0, September 2013.
  11. Kanabar DJ. Inflammopharmacology 2017;25(1):1–9.
  12. Rainsford KD, Bjarnason I. J Pharm Pharmacol 2012;64(4):465–469.
  13. Rajanayagam J, Bishop JR, Lewindon PJ et al. Arch Dis Child 2015;100(1):77–80.
  14. Tsang AKL. Int Dent SA 2010;12(5):48–61.
  15. Memarpour M, Soltanimehr E, Eskandarian T. BMC Oral Health 2015;15:88.
  16. Australian Dental Association. Terrible teething – soothing your teething tot. Available from: www.ada.org.au/getattachment/Your-Dental-Health/Resources-for-Professionals/Resources-for-Children-0-11/Terrible-teething-soothing-your-teething-tot/Terrible-teething,-soothing-your-teething-tot.pdf.aspx (accessed 20 December 2021).
  17. Owais AI, Zawaideh F, Al-Batayneh OB. Int J Dent Hyg 2010;8(1):28–34.
  18. Meer Z, Meer A. Int J Dent Clin 2011;3(2):75–77.
  19. Therapeutic Guidelines. Pain and analgesia. eTG December 2020 edition.
  20. The Royal Children’s Hospital Melbourne. Kids Health Information: Pain relief for children – paracetamol and ibuprofen. Available from: www.rch.org.au/kidsinfo/fact_sheets/Pain_relief_for_children_-_Paracetamol_and_Ibuprofen/ (accessed 20 December 2021).
  21. The Royal Children’s Hospital Melbourne. Kids Health Information: Fever in children. Available from: www.rch.org.au/kidsinfo/fact_sheets/Fever_in_children/ (accessed 20 December 2021).
  22. Ward MA. Patient education: Fever in children (beyond the basics). Available from: www.uptodate.com/contents/fever-in-children-beyond-the-basics (accessed December 2021).

Conclusion

Along with correct medication administration techniques, it is important for pharmacists to improve parents’ and caregivers’ general understanding of the pain or fever that a child presents with. Knowledge of what to expect during these circumstances, as outlined throughout this article, can help parents and caregivers identify when analgesics or antipyretics should be used, as well as when they need to seek further help from a healthcare professional.

Key points

  • Fever, both due to infection or immunisation, and teething pain are commonly experienced by infants and toddlers under 5 years of age.3,7
  • Non-pharmacological strategies should be recommended to parents and caregivers as first-line treatments for fever and teething in a healthy infant.7,10,35
  • Analgesics/antipyretics may be considered to help reduce distress associated with pain or fever in children; paracetamol and ibuprofen are both appropriate first-choice pharmacotherapies.35 
  • For teething pain, consider that ibuprofen is indicated for pain with an inflammatory component while paracetamol has negligible anti-inflammatory effects.35,45 Topical lidocaine is not recommended.39 
  • Young children are particularly vulnerable to inappropriate medicine dosing, which is common among Australian parents and caregivers.5,6 It is imperative for pharmacists to provide adequate counselling about appropriate use of medicines
    to manage pain and fever, particularly with regard to correct dosing. 

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Article references

  1. Wallenstein MB, Schroeder AR, Hole MK et al. Clin Pediatr 2013;52(3):254–259.
  2. Massignan C, Cardoso M, Porporatti AL et al. Pediatrics 2016;137(3):e20153501.
  3. Tsang AKL. Int Dent SA 2010;12(5):48–61.
  4. Barbi E, Marzuilo P, Neri E et al. Children (Basel) 2017;4(9):81.
  5. Hietbrink E, Bakshi R, Moles RJ. Int J Pharm Pract 2014;22(3):205–215.
  6. Xu T, Neto ACA, Moles RJ. In J Pharm Pract 2012;20(5):307–319.
  7. Ward MA. Patient education: Fever in children (beyond the basics). Available from: www.uptodate.com/contents/fever-in-children-beyond-the-basics (accessed December 2021).
  8. The Royal Children’s Hospital Melbourne. Clinical Practice Guidelines: Febrile child. Available from: www.rch.org.au/clinicalguide/guideline_index/Febrile_child/ (accessed 20 December 2021).
  9. Urbane NU, Likopa Z, Gardovska D et al. Medicina (Kaunas) 2019;55(7):398.
  10. The Royal Children’s Hospital Melbourne. Kids Health Information: Fever in children. Available from: www.rch.org.au/kidsinfo/fact_sheets/Fever_in_children/ (accessed 20 December 2021).
  11. Pappas DE. Patient education: The common cold in children (beyond the basics). Available from: www.uptodate.com/contents/the-common-cold-in-children-beyond-the-basics?topicRef=1177&source=see_link (accessed December 2021).
  12. Biezen R, Pollack AJ, Harrison C et al. Med J Aust 2015;202(5):262–266.
  13. Ahn SH, Zhiang J, Kim H et al. JMIR Mhealth Uhealth 2019;7(4):e12223.
  14. Australian Government Department of Health. National Immunisation Program schedule for all people. Available from: www.health.gov.au/resources/publications/national-immunisation-program-schedule-for-all-people (accessed 20 December 2021).
  15. Australian Government Department of Health. Australian Immunisation Handbook: Diphtheria. Available from: https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/diphtheria (accessed 20 December 2021).
  16. Australian Government Department of Health. Australian Immunisation Handbook: Pertussis (whooping cough). Available from: https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/pertussis-whooping-cough (accessed 20 December 2021).
  17. Australian Government Department of Health. Australian Immunisation Handbook: Pneumococcal disease. Available from: https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/pneumococcal-disease (accessed 20 December 2021).
  18. Australian Government Department of Health. Australian Immunisation Handbook: Measles. Available from: https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/measles (accessed 20 December 2021).
  19. Australian Government Department of Health. Australian Immunisation Handbook: Meningococcal disease. Available from: https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/meningococcal-disease (accessed 20 December 2021).
  20. Australian Government Department of Health. Australian Immunisation Handbook: Haemophilus influenzae type b (Hib). Available from: https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/haemophilus-influenzae-type-b-hib (accessed 20 December 2021).
  21. Australian Government Department of Health. Australian Immunisation Handbook: Varicella (chickenpox). Available from: https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/varicella-chickenpox (accessed 20 December 2021).
  22. Australian Government Department of Health. Australian Immunisation Handbook: Hepatitis A. Available from: https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/hepatitis-a (accessed 20 December 2021).
  23. Australian Government Department of Health. Australian Immunisation Handbook: Influenza (flu). Available from: https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/influenza-flu (accessed 20 December 2021).
  24. Ward MA. Patient education: Vaccines for infants and children age 0 to 6 years (beyond the basics). Available from: www.uptodate.com/contents/vaccines-for-infants-and-children-age-0-to-6-years-beyond-the-basics?source=related_link (accessed December 2021).
  25. Australian Government Department of Health and Ageing. OTC medicine monograph: ibuprofen for oral use. Version 1.0, September 2013.
  26. Australian Government Department of Health and Ageing. OTC medicine monograph: paracetamol for oral use. Version 1.0, September 2013.
  27. Autret-Leca E, Gibb IA, Goulder MA. Curr Med Res Opin. 2007;23(9):2205–11.
  28. Corrales YA, Starr M. Aust Fam Physician. 2010;39(5):270–5.
  29. Memarpour M, Soltanimehr E, Eskandarian T. BMC Oral Health 2015;15:88.
  30. Australian Dental Association. Teething chart – when the teeth come marching in. Available from: www.ada.org.au/getattachment/Your-Dental-Health/Resources-for-Professionals/Resources-for-Children-0-11/When-the-teeth-come-marching-in-teething-chart/When-the-teeth-come-marching-in,-teething-chart.pdf.aspx (accessed 20 December 2021).
  31. Owais AI, Zawaideh F, Al-Batayneh OB. Int J Dent Hyg 2010;8(1):28–34.
  32. Meer Z, Meer A. Int J Dent Clin 2011;3(2):75–77.
  33. Australian Dental Association. Terrible teething – soothing your teething tot. Available from: www.ada.org.au/getattachment/Your-Dental-Health/Resources-for-Professionals/Resources-for-Children-0-11/Terrible-teething-soothing-your-teething-tot/Terrible-teething,-soothing-your-teething-tot.pdf.aspx (accessed 20 December 2021).
  34. The Royal Children’s Hospital Melbourne. Kids Health Information: Pain relief for children – paracetamol and ibuprofen. Available from: www.rch.org.au/kidsinfo/fact_sheets/Pain_relief_for_children_-_Paracetamol_and_Ibuprofen/ (accessed 20 December 2021).
  35. Therapeutic Guidelines. Pain and analgesia. eTG December 2020 edition.
  36. Centers for Disease Control and Prevention. Botulism: Prevention. Available from: www.cdc.gov/botulism/prevention.html (accessed 24 January 2022).
  37. The Royal Children’s Hospital Melbourne. Acute pain management. Available from: www.rch.org.au/clinicalguide/guideline_index/Acute_pain_management/ (accessed 20 December 2021).
  38. Australian Dental Association. Babies and toddlers 0–3 years. Available from: www.teeth.org.au/babies-and-toddlers (accessed 22 December 2021).
  39. Teoh L, Moses GM. J Paediatr Child Health 2020;56(4):502–505.
  40. Trajanovska M, Manias E, Cranswick N et al. J Paediatr Child Health 2010;46:5–9.
  41. Huynh A, Cairns R, Brown JA et al. Med J Aust 2018;209(2):74–79.
  42. Rajanayagam J, Bishop JR, Lewindon PJ et al. Arch Dis Child 2015;100(1):77–80.
  43. Kanabar DJ. Inflammopharmacology 2017;25(1):1–9.
  44. Rainsford KD, Bjarnason I. J Pharm Pharmacol 2012;64(4):465–469.
  45. Australian Medicines Handbook. Paracetamol. July 2020.

Author: DR CAT PANWAR BSc(Hons), PhD has over 13 years of experience in health communications across a wide range of therapeutic areas. She has represented strategically and scientifically renowned healthcare agencies across the globe. Conflict of interest: Dr Panwar is a paid consultant for Reckitt Benckiser.

Video speaker: JOHN BELL AM BPharm, FPS, FRPharmS, FACPP, MSHP, FFIP, FCPA is a practitioner/teacher at the Graduate School of Health, University of Technology Sydney, and has a community pharmacy practice. Conflict of interest: Mr Bell has been a member of advisory boards for, or provided advice to: Astellas, Astra Zeneca, Bayer, GSK, Mylan, Novartis, Nutricia, Pfizer, Procter & Gamble and Reckitt Benckiser. He is currently a member of the international multidisciplinary Global Pain Faculty.

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