Thursday, October 29, 2020

美國兒科學會:兒童發熱與退熱藥物的應用

國人對於兒童發熱及退熱藥物的應用存在很多誤區,這裡引用美國兒科學會(American Academy of Pediatrics)的《兒童發熱與退熱藥物應用》(Fever and Antipyretic Use in Children)中的部分內容,供大家參考。

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.

譯文:兒童發熱是兒科醫生及醫護人員常遇見的臨床癥狀之一,同時也是引發家長焦慮的常見原因。許多患兒家長會在孩子輕微發熱甚至無發熱的情況下使用退熱葯,因為他們認為孩子的體溫必須正常。發熱並非一種疾病,它是機體對抗感染的一種生理機制。目前並無證據顯示發熱是某種疾病的導因或會導致神經系統併發症。因此,對發熱患兒的首要任務並非將體溫降至正常水平而是讓孩子感到舒服。

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.

譯文:家長通常都有一種要求——保持患兒的體溫“正常”。許多家長在低熱甚至無發熱狀態下給孩子以退熱藥物。大約有一半的家長認為38℃以下也算髮熱,同時有25%的護理人會在體溫低於37.8℃時給予退熱藥物。更甚,85%的家長(統計總數為340)有叫醒睡眠中的孩子服用退燒藥的經歷。不幸的是,有一半以上的家長都給予了孩子不恰當劑量的退熱藥物;大約15%的家長會給予孩子超劑量的對乙酰氨基酚或布洛芬。了解藥物劑量按體重計算優於年齡或發熱高低的護理人會更不容易給予錯誤的劑量。

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.

譯文:儘管對於退熱藥物的使用,兒科醫生和家長之間存在着些許分歧,但是兒科醫生和護士仍為家長和護理人發熱患兒獲取有關發熱的治療信息的主要來源。兒科醫生關於退熱藥物使用的普遍共識為高於38.3℃可使用退熱藥物同時提升孩子的整體舒適度。儘管有13%的兒科醫生特彆強調孩子不舒適為使用退熱藥物的主要指征,但是這一條目通常都會被納入標準之中。絕大多數(80%)的兒科醫生認為不應在患兒的睡眠過程中喚醒患兒以服用退熱藥物。

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.

譯文:值得強調的是,發熱並非一種疾病,事實上,它是一種有助於機體對抗感染的正常生理反應。發熱可以阻止細菌和病毒的生長繁殖,促進中性粒細胞數的升高及T-淋巴細胞的增殖並輔助急性期反應。發熱時體溫高低不與病情嚴重程度成正比,多數發熱持續時間較短且為良性,發熱還具有保護患兒的作用。數據顯示,發熱對免疫系統某些特定組分具有促進作用,同時有限的數據先是發熱實質上可以幫助機體從病毒感染中恢復,但副作用為引起患兒感覺不適。

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.

譯文:在對發熱兒童使用退熱藥物的討論中,必須首先考慮治療目標。當給家庭進行諮詢的時候,兒科醫生應該重點強調孩子的整體舒適性和危重疾病的癥狀而非強調正常體溫。治療發熱兒童的首要目標是讓孩子的整體舒適度提升。根據研究數據,除了進食減少以外,絕大多數兒科醫生可以觀察到發熱兒童具備以下方面的改變:活動、睡眠以及行為。可惜的是,臨床上缺乏針對退熱藥物可改善因發熱或疾病引發的不適的程度的相關研究。目前尚未明確舒適度改善是夠與體溫正常相關,因為物理降溫措施,例如溫水擦浴可以降低體溫但不一定能提高舒適度。酒精擦浴並非適合的降溫措施,因為酒精會被吸收。此外,退熱藥物的使用也會有一些臨床後果,包括鎮痛作用,這有提升總體臨床效果的可能。不管作用機制,許多兒科醫生都建議使用退熱藥物,他們認為退熱藥物的作用為提升舒適度和加強活動活躍度以及增強食慾,減少煩躁,以及讓孩子整體的狀況更加好。以上這些都是使用退熱藥物的重要效應,因此觀察孩子的活動活躍度,危重疾病的癥狀以及恰當的補液以防止脫水非常重要。

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).

譯文:在出現水楊酸鹽和瑞氏綜合征之間關聯充分的證據後,對乙酰氨基酚基本上取代阿司匹林作為發燒的主要治療藥物。對乙酰氨基酚的安全有效劑量為10〜15毫克/每公斤,每4〜6小時口服。典型地,起效時間為30至60分鐘內;約80%的孩子將會在這個時間內降低體溫(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.

譯文:使用布洛芬來治療持續升溫的發熱患兒是因為它似乎具有更加長效的降溫效果(表1)。研究中,布洛芬和對乙酰氨基酚的效果進行了比較,並得出了不同的結果;共識是這兩種藥物在降溫方面比安慰劑組更有效,同時布洛芬(10mg/kg)與對乙酰氨基酚(15mg/kg)相比,在單獨使用或者是重複使用時至少一樣有效甚至更加有效。數據還表明,發熱程度和兒童的年齡(而不是所使用的特定的藥物)可能為影響退熱藥物治療發熱療效的主要決定因素;對於 6 歲以上的較高體溫的發熱兒童而言,他們對於退熱藥物的治療效果會有所下降。

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.

退熱藥物信息

條目 對乙酰氨基酚 布洛芬
溫度下降(°C) 1–2 1–2
生效時間(小時) <1 <1
藥物峰值時間(小時) 3–4 3–4
效果持續時間(小時) 4–6 6–8
劑量(mg/kg) 10–15 every 4 h 10 every 6 h
每日最大劑量(mg/kg) 90 mg/kg ↵a 40 mg/kg
成人每日最大劑量(g/d) 4 2.4
年齡下限(月) ↵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:https://pediatrics.aappublications.org/content/127/3/580.full
二喵居士翻譯的中文版(僅供參考,建議閱讀原文)下載:http://vdisk.weibo.com/s/u9Zrvl-v9A2JJ

 

One comment

  1. 兒科病症多為呼吸性疾病,從而導致了發熱癥狀。

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