Saturday, September 23, 2017

美国儿科学会:儿童发热与退热药物的应用

国人对于儿童发热及退热药物的应用存在很多误区,这里引用美国儿科学会(American Academy of Pediatrics)的《儿童发热与退热药物应用》(Fever and Antipyretic Use in Children)中的部分内容,供大家参考。

Fever in a child is one of the most common clinical symptoms managed by pediatricians and other health care providers and a frequent cause of parental concern. Many parents administer antipyretics even when there is minimal or no fever, because they are concerned that the child must maintain a “normal” temperature. Fever, however, is not the primary illness but is a physiologic mechanism that has beneficial effects in fighting infection. There is no evidence that fever itself worsens the course of an illness or that it causes long-term neurologic complications. Thus, the primary goal of treating the febrile child should be to improve the child’s overall comfort rather than focus on the normalization of body temperature.

译文:儿童发热是儿科医生及医护人员常遇见的临床症状之一,同时也是引发家长焦虑的常见原因。许多患儿家长会在孩子轻微发热甚至无发热的情况下使用退热药,因为他们认为孩子的体温必须正常。发热并非一种疾病,它是机体对抗感染的一种生理机制。目前并无证据显示发热是某种疾病的导因或会导致神经系统并发症。因此,对发热患儿的首要任务并非将体温降至正常水平而是让孩子感到舒服。

Parents are frequently concerned with the need to maintain a “normal” temperature in their ill child. Many parents administer antipyretics even though there is either minimal or no fever. Approximately one-half of parents consider a temperature of less than 38°C (100.4°F) to be a fever, and 25% of caregivers would give antipyretics for temperatures of less than 37.8°C (100°F). Furthermore, 85% of parents (n = 340) reported awakening their child from sleep to give antipyretics. Unfortunately, as many as one-half of parents administer incorrect doses of antipyretics; approximately 15% of parents give supratherapeutic doses of acetaminophen or ibuprofen. Caregivers who understand that dosing should be based on weight rather than age or height of fever are much less likely to give an incorrect dose.

译文:家长通常都有一种要求——保持患儿的体温“正常”。许多家长在低热甚至无发热状态下给孩子以退热药物。大约有一半的家长认为38℃以下也算发热,同时有25%的护理人会在体温低于37.8℃时给予退热药物。更甚,85%的家长(统计总数为340)有叫醒睡眠中的孩子服用退烧药的经历。不幸的是,有一半以上的家长都给予了孩子不恰当剂量的退热药物;大约15%的家长会给予孩子超剂量的对乙酰氨基酚或布洛芬。了解药物剂量按体重计算优于年龄或发热高低的护理人会更不容易给予错误的剂量。

Physicians and nurses are the primary source of information on fever management for parents and caregivers, although there are some disparities between the views of parents and physicians regarding antipyretic treatment. The most common indications for initiating antipyretic therapy by pediatricians are a temperature higher than 38.3°C (101°F) and improving the child’s overall comfort. Although only 13% of pediatricians specifically cite discomfort as the primary indication for antipyretic use, this intent is generally implied in their recommendations. Most pediatricians (80%) believe that a sleeping ill child should not be awakened solely to be given antipyretics.

译文:尽管对于退热药物的使用,儿科医生和家长之间存在着些许分歧,但是儿科医生和护士仍为家长和护理人发热患儿获取有关发热的治疗信息的主要来源。儿科医生关于退热药物使用的普遍共识为高于38.3℃可使用退热药物同时提升孩子的整体舒适度。尽管有13%的儿科医生特别强调孩子不舒适为使用退热药物的主要指征,但是这一条目通常都会被纳入标准之中。绝大多数(80%)的儿科医生认为不应在患儿的睡眠过程中唤醒患儿以服用退热药物。

It should be emphasized that fever is not an illness but is, in fact, a physiologic mechanism that has beneficial effects in fighting infection. Fever retards the growth and reproduction of bacteria and viruses, enhances neutrophil production and T-lymphocyte proliferation, and aids in the body’s acute-phase reaction. The degree of fever does not always correlate with the severity of illness. Most fevers are of short duration, are benign, and may actually protect the host. Data show beneficial effects on certain components of the immune system in fever, and limited data have revealed that fever actually helps the body recover more quickly from viral infections, although the fever may result in discomfort in children. Evidence is inconclusive as to whether treating with antipyretics, particularly ibuprofen alone or in combination with acetaminophen, increases the risks of complications with certain types of infections. Potential benefits of fever reduction include relief of patient discomfort and reduction of insensible water loss, which may decrease the occurrence of dehydration. Risks of lowering fever include delayed identification of the underlying diagnosis and initiation of appropriate treatment and drug toxicity.

译文:值得强调的是,发热并非一种疾病,事实上,它是一种有助于机体对抗感染的正常生理反应。发热可以阻止细菌和病毒的生长繁殖,促进中性粒细胞数的升高及T-淋巴细胞的增殖并辅助急性期反应。发热时体温高低不与病情严重程度成正比,多数发热持续时间较短且为良性,发热还具有保护患儿的作用。数据显示,发热对免疫系统某些特定组分具有促进作用,同时有限的数据先是发热实质上可以帮助机体从病毒感染中恢复,但副作用为引起患儿感觉不适。

A discussion of the use of antipyretics in febrile children must begin with consideration of the therapeutic end points. When counseling families, physicians should emphasize the child’s comfort and signs of serious illness rather than emphasizing normothermia. A primary goal of treating the febrile child should be to improve the child’s overall comfort. Most pediatricians observe, with some supporting data from research, that febrile children have altered activity, sleep, and behavior in addition to decreased oral intake. Unfortunately, there is a paucity of clinical research addressing the extent to which antipyretics improve discomfort associated with fever or illness. It is not clear whether comfort improves with a normalized temperature, because external cooling measures, such as tepid sponge baths, can lower the body temperature without improving comfort. The use of alcohol baths is not an appropriate cooling method, because there have been reported adverse events associated with systemic absorption of alcohol. Furthermore, antipyretics have other clinical outcomes, including analgesia, which may enhance their overall clinical effect. Regardless of the exact mechanism of action, many physicians continue to encourage the use of antipyretics with the belief that most of the benefits are the result of improved comfort and the accompanying improvements in activity and feeding, less irritability, and a more reliable sense of the child’s overall clinical condition. Because these are the most important benefits of antipyretic therapy, it is of paramount importance that parental counseling focus on monitoring of activity, observing for signs of serious illness, and appropriate fluid intake to maintain hydration.

译文:在对发热儿童使用退热药物的讨论中,必须首先考虑治疗目标。当给家庭进行咨询的时候,儿科医生应该重点强调孩子的整体舒适性和危重疾病的症状而非强调正常体温。治疗发热儿童的首要目标是让孩子的整体舒适度提升。根据研究数据,除了进食减少以外,绝大多数儿科医生可以观察到发热儿童具备以下方面的改变:活动、睡眠以及行为。可惜的是,临床上缺乏针对退热药物可改善因发热或疾病引发的不适的程度的相关研究。目前尚未明确舒适度改善是够与体温正常相关,因为物理降温措施,例如温水擦浴可以降低体温但不一定能提高舒适度。酒精擦浴并非适合的降温措施,因为酒精会被吸收。此外,退热药物的使用也会有一些临床后果,包括镇痛作用,这有提升总体临床效果的可能。不管作用机制,许多儿科医生都建议使用退热药物,他们认为退热药物的作用为提升舒适度和加强活动活跃度以及增强食欲,减少烦躁,以及让孩子整体的状况更加好。以上这些都是使用退热药物的重要效应,因此观察孩子的活动活跃度,危重疾病的症状以及恰当的补液以防止脱水非常重要。

After sufficient evidence emerged of an association between salicylates and Reye syndrome, acetaminophen essentially replaced aspirin as the primary treatment of fever. Acetaminophen doses of 10 to 15 mg/kg per dose given every 4 to 6 hours orally are generally regarded as safe and effective. Typically, the onset of an antipyretic effect is within 30 to 60 minutes; approximately 80% of children will experience a decreased temperature within that time (Table 1).

译文:在出现水杨酸盐和瑞氏综合征之间关联充分的证据后,对乙酰氨基酚基本上取代阿司匹林作为发烧的主要治疗药物。对乙酰氨基酚的安全有效剂量为10〜15毫克/每公斤,每4〜6小时口服。典型地,起效时间为30至60分钟内;约80%的孩子将会在这个时间内降低体温(表1)。

The use of ibuprofen to manage fever has been increasing, because it seems to have a longer clinical effect related to lowering of the body temperature (Table 1). Studies in which the effectiveness of ibuprofen and acetaminophen were compared have yielded variable results; the consensus is that both drugs are more effective than placebo in reducing fever and that ibuprofen (10 mg/kg per dose) is at least as effective as, and perhaps more effective than, acetaminophen (15 mg/kg per dose) in lowering body temperature when either drug is given as a single or repetitive dose. Data also show that the height of the fever and the age of the child (rather than the specific medication used) may be the primary determinants of the efficacy of antipyretic therapy; those who have a higher fever and are older than 6 years show decreased efficacy or response to antipyretic therapy. Studies that compare the effect of ibuprofen versus acetaminophen on children’s behavior and comfort are generally lacking.

译文:使用布洛芬来治疗持续升温的发热患儿是因为它似乎具有更加长效的降温效果(表1)。研究中,布洛芬和对乙酰氨基酚的效果进行了比较,并得出了不同的结果;共识是这两种药物在降温方面比安慰剂组更有效,同时布洛芬(10mg/kg)与对乙酰氨基酚(15mg/kg)相比,在单独使用或者是重复使用时至少一样有效甚至更加有效。数据还表明,发热程度和儿童的年龄(而不是所使用的特定的药物)可能为影响退热药物治疗发热疗效的主要决定因素;对于 6 岁以上的较高体温的发热儿童而言,他们对于退热药物的治疗效果会有所下降。

Antipyretic Information

Variable Acetaminophen Ibuprofen
Decline in temperature, °C 1–2 1–2
Time to onset, h <1 <1
Time to peak effect, h 3–4 3–4
Duration of effect, h 4–6 6–8
Dose, mg/kg 10–15 every 4 h 10 every 6 h
Maximum daily dose, mg/kg 90 mg/kg ↵a 40 mg/kg
Maximum daily adult dose, g/d 4 2.4
Lower age limit, mo ↵b 3 6

Data represent approximate averages from referenced sources.42,43,52,54,71,82

↵a Label is for 75 mg/kg; 90 mg/kg per day should be limited to less than 3 consecutive days.83,–,85

↵b Unless specifically recommended by a health care provider for the younger patient and, then, only after the infant has been examined by a health care provider.

退热药物信息

条目 对乙酰氨基酚 布洛芬
温度下降, °C 1–2 1–2
生效时间, h <1 <1
药物峰值时间, h 3–4 3–4
效果持续时间, h 4–6 6–8
剂量, mg/kg 10–15 every 4 h 10 every 6 h
每日最大剂量, mg/kg 90 mg/kg ↵a 40 mg/kg
成人每日最大剂量, g/d 4 2.4
年龄下限, mo ↵b 3 6

Data represent approximate averages from referenced sources.

↵a Label is for 75 mg/kg; 90 mg/kg per day should be limited to less than 3 consecutive days.

↵b Unless specifically recommended by a health care provider for the younger patient and, then, only after the infant has been examined by a health care provider.

英文原文地址:http://pediatrics.aappublications.org/content/127/3/580.full
二喵居士翻译的中文版(仅供参考,建议阅读原文)下载:http://vdisk.weibo.com/s/u9Zrvl-v9A2JJ

 

One comment

  1. 儿科病症多为呼吸性疾病,从而导致了发热症状。

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