According to Dr Schmitt, almost all parents believe that fever, defined as a rise in body temperature above the normal daily range and a natural physiological process, can cause extensive harm (eg brain damage, seizures) to their children despite extensive evidence to the contrary.¹ 

However, there are rare exception. For instance, in some patients, fever may be indicative of a serious illness such as an underlying neurological condition that affect the temperature control centre (eg hypothalamic lesion). Other red flags include infections like malaria, non-infective inflammatory conditions such as juvenile chronic arthritis, and cancer like acute leukaemia.^1,2,3  

Discomfort during febrile illness often stems from associated pain, warranting further investigation if warning signs persist, such as sudden or severe headache, neurological symptoms, or abnormal abdominal pain. Children with such symptoms require immediate attention.³  

It is therefore crucial to assess the distress level in children with fever and distinguish between those at high risk of serious illness needing specific treatment, hospitalisation, or specialist care, and those at low risk who can be managed at home.³  

Factors that influence core body temperature 

The human body's core temperature is influenced by multiple physiological factors, resulting in variations among individuals and even within the same person. These factors include the time of day, activity level, meals, and age.²  

In infants, core temperature can fluctuate from as low as 36°C during sleep to as high as 37.8°C during active periods, notably after feeding. Due to this variability, there is not a universally applicable upper limit for normal body temperature.^2,3 

While fever is commonly defined as a core temperature of ≥38°C, some researchers characterise fever in paediatric patients as a body temperature of ≥37.5°C.³ 

Antibiotic overprescription poses significant risks  

Antibiotics are frequently overprescribed, subjecting children to unnecessary treatment-related adverse effects and increasing the risk of antibiotic resistance and future health complications. Fever alone does not warrant antibiotic therapy. They should only be prescribed when necessary.³ 

Microbial sampling should guide antibiotic decisions where feasible. Empiric antibiotics for occult bacteraemia in infants over three months offer no significant advantage.³ 

Symptomatic relief recommended for non-severe cases 

In non-severe cases, symptomatic therapy can be initiated for 48 hours before considering antibiotics. Antipyretic pharmacotherapy, such as ibuprofen and paracetamol, aims to alleviate discomfort associated with fever, particularly pain-related symptoms like myalgia, headache, sore throat, and ear pain. Antipyretics may also enhance feeding activity, and reduce irritability, potentially limiting the risk of dehydration.³ 

When deciding on antipyretic therapy, it is essential to consider the overall clinical picture and individual patient needs. Various formulations are available, with suppositories being helpful when oral medication is not feasible.³ 

In South Africa, paediatric paracetamol-containing suppositories are indicated for infants form three- months to five-years. Suppositories are a viable alternative to the oral route for paediatric patients, as these dosage forms do not require swallowing and do not necessitate taste-masking.^4,5 

They are especially useful in paediatric patients who are nauseous or vomiting or in infants/children reluctant or unable to take oral medication if they are very poor, for example when they have fever. Furthermore, suppositories are easy and simple to use and can be administered in emergencies to unconscious patient.⁵  

An Italian study showed that while most paediatricians (73.1%) prefer oral formulations, more parents (>50%) preferred suppositories because they think that they are more practical than oral formulation. More than 70% of parents reported that they use suppositories for reasons other than vomiting.⁶ 

Oral vs paracetamol-containing suppositories: Which is best? 

Bastola et al compared the effectiveness of two different rectal doses of paracetamol (15mg/kg and 30mg/kg) to that of the standard oral dose of 15mg/kg. Participants (192 febrile children aged six months to six years) were randomised to the oral standard dose (Group A), rectal standard dose (Group B), and the high dose rectal paracetamol (Group C) groups. Temperature readings were recorded before and after paracetamol administration at 30, 60, 120, and 180 minutes using a digital thermometer.⁷ 

The mean temperatures before medication administration in Groups A, B, and C were 38.7°C, 38.8°C, and 38.6°C respectively. At 30 minutes post-administration, temperatures were 38.2°C, 38.2°C, and 38.1°C, while at 60 minutes, temperatures were 37.7°C, 37.6°C, and 37.6°C respectively for Groups A, B, and C. However, at 120 and 180 minutes, temperatures significantly decreased in those who received rectal paracetamol at 30mg/kg.⁷ 

More recently, Tantivit et al conducted a meta-analysis to compare the antipyretic effectiveness of oral versus paracetamol-containing suppositories in paediatric patients with fever, focusing on temperature reduction. The meta-analysis included five randomised studies involving a total of 362 participants.⁸  

The study concluded that both oral and paracetamol-containing suppositories are equally effective in reducing fever at one- and three-hours post-administration. Paracetamol-containing suppositories rectal acetaminophen remains a viable short-term alternative (<48 hours) for febrile children who cannot take oral medication due to specific circumstances such as vomiting or unconsciousness.⁸ 

Conclusion 

Fever is a common concern leading parents to seek emergency care, with "fever phobia" being prevalent due to misconceptions about fever and its management. While fever is a natural physiological response and not inherently harmful, it is important to assess and manage it appropriately, especially in children at high risk of serious illness. 

Suppositories provide a valuable alternative to oral medication for pediatric patients, particularly for those who are vomiting, unconscious, or otherwise unable to take oral medication. They are easy to administer and do not require swallowing or taste-masking. Despite a preference among paediatricians for oral formulations, many parents find suppositories more practical for various reasons. 

Studies comparing oral and paracetamol-containing suppositories have shown that both methods are equally effective in reducing fever. Suppositories can serve as a reliable short-term alternative (<48 hours) for managing fever in children when oral administration is not feasible. This highlights the importance of considering suppositories in clinical practice to ensure effective and accessible fever management for all pediatric patients. 

References 

1. Elkon-Tamir E, Rimon A, Scolnik D, Glatstein M. Fever Phobia as a Reason for Pediatric Emergency Department Visits: Does the Primary Care Physician Make a Difference? Rambam Maimonides Med J, 2017. 
2. Barbi E, Marzuillo P, Neri E, Naviglio S, Krauss BS. Fever in Children: Pearls and Pitfalls. Children (Basel), 2017. 
3. Green R, Webb D, Jeena PM, et al. Management of acute fever in children: Consensus recommendations for community and primary healthcare providers in sub-Saharan Africa. Afr J Emerg Med, 2021. 
4. Empaped. 2011. [Internet]. Available at: www.sahpra.org.za/wp-content/uploads/2020/08/Empaped_PIL_Takeda_MCC-Format17-October-2011.pdf  
5. Jannin V, Lemagnen G, Geuroult P, et al. Rectal route in the 21st Century to treat children. Advanced Drug Delivery Routes, 2014. 
6. Chiappini E, Parretti A, Becherucci P, et al. Parental and medical knowledge and management of fever in Italian pre-school children. BMC Pediatr, 2012.  
7. Bastola R, Shrestha SK, Bastola BS, Shrestha D, Sharma Y. Comparison of Oral Versus Normal and High-Dose Rectal Paracetamol in the Treatment of Fever in Children. Journal of Nepal Paediatric Society, 2018. 
8. Tantivit N, Thangjui S, Trongtorsak A. Antipyretic Effectiveness of Oral Acetaminophen Versus Rectal Acetaminophen in Pediatric Patients with Fever. Hospital Paediatrics, 2022.