Review article
Fever and childhood vaccination
Fiebre y vacunación infantil
V. Pineda Solas
Profesor Medicina Universidad Autónoma de Barcelona, Hospital Universitari Parc Taulí, Sabadell, Barcelona, Spain
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"apellidos" => "Reina" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S157698872030039X" "doi" => "10.1016/j.vacun.2020.07.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157698872030039X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2445146020300224?idApp=UINPBA00004N" "url" => "/24451460/0000002100000002/v1_202011280950/S2445146020300224/v1_202011280950/en/main.assets" ] "itemAnterior" => array:17 [ "pii" => "S244514602030025X" "issn" => "24451460" "doi" => "10.1016/j.vacune.2020.10.008" "estado" => "S300" "fechaPublicacion" => "2020-07-01" "aid" => "150" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Vacunas. 2020;21:95-104" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Confidence toward vaccination as reported by parents of children admitted to a tertiary care hospital in Riyadh, Saudi Arabia: A cross sectional study" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "95" "paginaFinal" => "104" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Confianza en la vacunación reportada por los padres de niños ingresados en un hospital de atención terciaria en Riad, Arabia Saudí: estudio transversal" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Y.M. AlGoraini, N.N. AlDujayn, M.A. AlRasheed, Y.E. Bashawri, S.S. Alsubaie, D.A. AlShahrani" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Y.M." "apellidos" => "AlGoraini" ] 1 => array:2 [ "nombre" => "N.N." "apellidos" => "AlDujayn" ] 2 => array:2 [ "nombre" => "M.A." "apellidos" => "AlRasheed" ] 3 => array:2 [ "nombre" => "Y.E." "apellidos" => "Bashawri" ] 4 => array:2 [ "nombre" => "S.S." "apellidos" => "Alsubaie" ] 5 => array:2 [ "nombre" => "D.A." "apellidos" => "AlShahrani" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S244514602030025X?idApp=UINPBA00004N" "url" => "/24451460/0000002100000002/v1_202011280950/S244514602030025X/v1_202011280950/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review article</span>" "titulo" => "Fever and childhood vaccination" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "105" "paginaFinal" => "110" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "V. Pineda Solas" "autores" => array:1 [ 0 => array:3 [ "nombre" => "V." "apellidos" => "Pineda Solas" "email" => array:1 [ 0 => "vpineda@tauli.cat" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Profesor Medicina Universidad Autónoma de Barcelona, Hospital Universitari Parc Taulí, Sabadell, Barcelona, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fiebre y vacunación infantil" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Vaccines are tools that prevent many infectious diseases that can cause different degrees of morbimortality. Some vaccines prevent diseases that although they are very common are less severe, while others prevent rarer diseases that are highly lethal. Most vaccines contain the deactivated or attenuated derivates of a virus, bacterium or parasite which causes a disease. After administering a vaccine by intramuscular or subcutaneous injection or orally, our organism produces antibodies against the germ components in the vaccine. These antibodies will protect us against the germs that cause the disease we have been vaccinated against, and they will remain in the immunological memory of our organism to protect us in case of future contact. Vaccines made a decisive contribution to changing the profile of infectious diseases, reducing their mortality and morbidity to an extraordinary degree worldwide. After the administration of the first vaccines, we have witness a spectacular fall in some of transmissible diseases that had decimated humanity for most of history. For example, it was the decisive strategy in eliminating smallpox from the world in 1976, and in eliminating or substantially reducing in some geographical areas diseases such as diphtheria, poliomyelitis, measles or rubella.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Like any other medication, vaccines may cause mild, moderate or severe adverse reactions. Absolute safety (no adverse reactions at all) therefore does not exist when administering a vaccine or any other medical product. However, unlike other medicines, vaccines are administered to healthy individuals with a preventive intention, and this is why it is necessary for their safety profile to be maximum. This is an essential requisite if a healthy population is to accept a preventive vaccination. In recent years technological development in vaccine manufacturing has achieved a combination of vaccines that are more effective and safer. Lastly, we have to take into account the fact that only post-commercialisation monitoring, when vaccines are administered to a large number of people, makes it possible for us to know the real incidence of adverse reactions.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The usual symptoms that children experience after vaccination, which are known as adverse reactions, are largely the normal immunological reactions of our body to inoculation with vaccine components. We always have to bear in mind that any possible adverse effects that may arise are without doubt far less important than the benefits vaccines offer.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Adverse reactions to vaccines</span><p id="par0020" class="elsevierStylePara elsevierViewall">The following adverse reactions to vaccination may be classified according to their cause. The World Health Organisation (WHO) classifies them into five categories<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0025" class="elsevierStylePara elsevierViewall">Vaccination-induced adverse reactions (including allergic reactions). These are an individual response to the intrinsic properties of the product, when the vaccine in question has been correctly handled and administered.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0030" class="elsevierStylePara elsevierViewall">Reactions due to vaccine quality defects.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0035" class="elsevierStylePara elsevierViewall">Reactions due to program errors: errors in storage, handling or administration. Unlike the previous case, these causes can be prevented and avoided.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0040" class="elsevierStylePara elsevierViewall">Reactions due to anxiety associated with the act of vaccination: these are unrelated to the product, as they are connected with “fear of the vaccination act”. The four most common types described are fainting (syncope), hyperventilation (dizziness, headache, tingling in the hands and mouth, vomiting and convulsions.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0045" class="elsevierStylePara elsevierViewall">Coincidental events that have nothing to do with the vaccination.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6</span><p id="par0050" class="elsevierStylePara elsevierViewall">Idiosyncratic reactions or ones with an unknown cause.</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Vaccination-induced adverse reactions</span><p id="par0055" class="elsevierStylePara elsevierViewall">It is very important that the personnel who vaccinate know the adverse reactions that may occur after the administration of each vaccine, as if they are aware of these reactions, they will be able to detect them and inform the adverse reactions registry of pharmacovigilance programs that evaluate the causes of such event and their relationship with the vaccine used. On the other hand, it is also high important to inform parents of possible adverse reactions, to maintain and encourage trust in vaccines in the population.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Vaccine-induced reactions may be LOCAL and SYSTEMIC, and they can be sub-classified as COMMON, which are usually mild, RARE and more serious.<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">1</span><p id="par0065" class="elsevierStylePara elsevierViewall">Local reactions</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall">Common local reactions: pain, swelling and reddening of the injection site, hardening and oedema, a nodule at the point of injection, vesicles (vaccine varicella), papules (BCG vaccine) and regional lymphadenitis. These occur during the first 48 h after vaccination and may vary in intensity between individuals. They remit spontaneously in one or two days.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0075" class="elsevierStylePara elsevierViewall">Rare local reactions: an abscess at the injection site and local hypersensitivity reactions (tetanus and diphtheria toxoids).</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">2</span><p id="par0080" class="elsevierStylePara elsevierViewall">Systemic reactions</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall">Common systemic reactions: <span class="elsevierStyleBold">fever</span>, irritability, muscle pain, general discomfort, headache, vomiting, diarrhoea and other unspecific symptoms, late appearing generalised exanthema (MMR and varicella vaccine), polymorph exanthema, urticarial exanthema, arthralgia (from one to three weeks after the administration of the MMR vaccine), generalised adenopathies. These are less common than local reactions. They occur in fewer than 10% of vaccinated patients, except in the case of DTPe vaccine and meningococcal B vaccine, where fever may occur in 50% of cases.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">•</span><p id="par0090" class="elsevierStylePara elsevierViewall">Rare systemic reactions: an episode of hypotonía-hyporesponse (EHH), persistent crying (during hours or more, which may occur from two to eight hours after vaccination), osteitis and osteomyelitis, (BCG vaccination), acute anaphylactic hypersensitivity reaction, adverse neurological reactions (acute post-vaccination paralysis, Guillain-Barré syndrome, facial paralysis, meningitis, convulsions (with or without fever), brachial neuritis (tetanus toxoid) and encephalopathy (whole cell whooping cough vaccine).</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Fever and vaccines</span><p id="par0095" class="elsevierStylePara elsevierViewall">Fever occurs when body temperature rises above the normal range, and it is generally part of a complex physiological reaction to the presence of substances that trigger the production of endogenous cytokines.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Fever is usually caused by viral, bacterial, fungal or parasitic infections, or by the administration of a derivate of these germs in the form of a vaccine. It may also be exceptionally caused by excessive heat production after exhausting exercise, excessive exposure to environmental heat, heat stroke or defective hypothalamic thermoregulation (hyperthermia).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In 1868, Carl Wunderlich determined that “normal body temperature” consists of a range of values rather than one specific temperature, although 38 °<span class="elsevierStyleSmallCaps">C</span> (100.4 °F) was set as the upper limit of normality. The concepts of slight fever emerged later on (body temperature ≤ 38 °C), moderate fever (from 38 °C to 39 °C) and high fever (>39 °C). Fever due solely to exogenic effects rarely rises above 41 °C (105.8 °F). Hyperthermia is defined as a core body temperature > 41 °C (> 105.8 °F). It may cause cell damage and multiple organ dysfunction, and it is generally the result of excessive exposure to heat together with failure of thermoregulation, and it rarely occurs as a response to an external agent such as a vaccine.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Although fever is an adverse event that may arise frequently after immunisation, its incidence varies depending on immune response of each subject and the vaccine that is administered. The role of fever as a physiological reaction to external agents is unclear, as is how to measure it and, definitively, how to interpret fever as an adverse event after vaccination. However, there seems to be no doubt that it is a common and benign clinical sign, except in rare episodes of febrile convulsions that always require urgent medical attention.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Almost any vaccine may cause fever after administration, although this occurs more often after triple viral vaccination (measles-mumps-rubella), 13-valent conjugated pneumococcal vaccine, meningococcal B vaccine and after vaccination with DTPe (whole cell diphtheria-tetanus-whooping cough) although the launch of new acellular whooping cough vaccines (DTPa) has made this reaction less common. In the case of triple viral vaccine, fever usually appears several days after vaccination (five to ten days afterwards) (Appendix <a class="elsevierStyleCrossRef" href="#sec0080">B</a>).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">How should we measure fever?</span><p id="par0115" class="elsevierStylePara elsevierViewall">Consult the following list for the determination of fever after vaccination<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">•</span><p id="par0120" class="elsevierStylePara elsevierViewall">A fever is considered to exist when a body temperature of 38 °C measured anywhere using any validated device is detected <a class="elsevierStyleCrossRef" href="#fn0005">*</a>.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">•</span><p id="par0125" class="elsevierStylePara elsevierViewall">Determinations of fever by touch are not acceptable forms of measurement unless they are confirmed using a thermometer. The terms used to describe fever (such as, “low grade”, “slight”, “moderate”, “high”, “severe” or “significant”) are highly subjective and liable to a broad range of interpretations, so that they should be avoided.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">•</span><p id="par0130" class="elsevierStylePara elsevierViewall">If fever is detected, the patient’s temperature should be taken at least twice a day (in the morning and at night) or when it is clinically appropriate to do so, until two consecutive measurements give the result of 38 °C.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">•</span><p id="par0135" class="elsevierStylePara elsevierViewall">Any validated device to offer exact and reproducible results is an acceptable means of measuring body temperature. The appropriate anatomical sites, the duration of measurement and the times application lasts/standardisation must be specified for each device and recorded on the record card.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">•</span><p id="par0140" class="elsevierStylePara elsevierViewall">The time interval between immunisation and fever should be recorded.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">•</span><p id="par0145" class="elsevierStylePara elsevierViewall">The duration of fever in terms of number of days must be analysed.</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">The importance of fever</span><p id="par0160" class="elsevierStylePara elsevierViewall">Fever is generally a physiological reaction to an underlying disease rather than a disease in itself. Nevertheless, a high temperature causes worry and is often wrongly interpreted due to erroneous concepts by parents, patients and sometimes even medical personnel. These erroneous concepts may give rise to unjustified fear about suffering severe side effects, such as permanent brain damage, leading to inappropriate or excessive temperature measurements (“fever phobia”). Additionally, when high fever or a febrile convulsion occurs patients are often taken to the Emergency Department, where they may be admitted to hospital for aggressive complementary tests such as lumbar puncture, imaging tests or even treatment with antibiotics that would be hard to justify. Therefore, as well as controlling the physical effects of fever, psychological and social concerns that are often unjustified must also be considered when evaluating the importance of fever as a vaccination-induced adverse reaction.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In spite of all of the above considerations, it is important to ensure that fever as a vaccination-induced adverse reaction is evaluated not solely in the context of its coincidence in time with vaccination, but rather that other causes in the history and symptoms of the child (mainly infections) unconnected with immunisation should be ruled out.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Fever as a vaccination-induced adverse reaction</span><p id="par0165" class="elsevierStylePara elsevierViewall">Fever as the adverse reaction induced by vaccination is the most common “severe” and “non-severe” adverse reaction reported in patients < 18 years old (VAERS). Nevertheless, there are problem in evaluating monitoring system data, as the causal relationship of vaccination is often not established in case of fever. This is because it is very difficult to analyse other clinical signs and symptoms that may link a fever with a current infection. Reported fever in a monitoring system may be only one sign among many other signs and symptoms that, if taken into account, would often indicate a probable cause other than vaccination. Such causes of fever, as well as sore throat and coughing after immunisation, would probably include the common cold caused by a virus and not by a vaccine. Difficulties may also arise when we wish to calculate the percentage of cases in which fever occurs after vaccination, as this varies for each vaccine and each individual. Routine clinical trials of paediatric vaccines have therefore shown that fever generally occurs in from 1% to 10% of those vaccinated, although it may be as common as 30% to 70% of those who receive multiple vaccines, the DTPe vaccine or meningococcal B vaccine.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Febrile convulsions</span><p id="par0170" class="elsevierStylePara elsevierViewall">Although fever is usually transitory and has no long-lasting effects, a high risk of febrile convulsions has been detected after certain immunisations.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Although these episodes cause great alarm in parents and lead to associations of immunisation with “brain damage”, the fact that febrile convulsions are common during childhood and affect from 3% to 5% of children < 5 years old, that children who experience febrile convulsions after immunisation do not seem to be at higher risk of subsequent convulsion or disability in their neurological development, and that they are rare events with a risk attributable to DTwP and measles-mumps-rubella (MMR) vaccines from six to nine and 25–35 cases per 100,000 children immunised.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Vaccination against rotavirus has recently been associated with a reduction in the frequency of convulsions seen in hospital Emergency departments. This fact indicates that rotavirus infection is probably an agent that caused convulsions, and that preventing it not only leads to a spectacular fall in gastroenteritis,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> but also does the same for convulsions.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Fever and meningococcal B vaccine</span><p id="par0185" class="elsevierStylePara elsevierViewall">Tetravalent meningococcal B vaccine (4 CMenB) is known to be a reactogenic vaccine, given that it may cause fever > 38 °C in 61% of breast-feeding babies who receive it concomitantly with other routine vaccines.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Although it is not harmful in itself, this fever is associated with temporary anxiety in the child and may also cause concern for their parents, which sometimes leads them to seek medical assessment in Emergency departments. The doctors who evaluate these babies may commence invasive studies or give intravenous antibodies, given the low threshold for these interventions in feverish infants who are younger than three months old. A recent publication<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> presents a study by the Emergency Department of University Hospital, Oxford, from September 2013 to August 2016, on whether the introduction in the UK of the MenB4C vaccine increased visits to the Emergency Department due to adverse post-vaccination effects. This study analysed adverse effects following the systematic vaccination with meningococcal vaccine against serum group B (MenB4C) that was introduced in the UK at the end of 2015 for use at from two to four and 12 months old. Three types of adverse effects were categorised: probable reaction to vaccination (fever and other symptoms during 48 h after vaccination without any other possible explanatory cause), possible reaction to vaccination (fever and other symptoms during 48 h after vaccination with another possible explanatory cause), not associated with vaccination (a clear cause of the fever and other symptoms, or without previous vaccination).</p><p id="par0190" class="elsevierStylePara elsevierViewall">Adverse effects after vaccination (chiefly fever) with MenB4C increased by three times in children aged two months and by up to 10 times in children aged four months. The introduction of the MenB4C vaccine was also associated with an increase in hospital admissions, invasive complementary tests and the use of intravenous antibiotic therapy.</p><p id="par0195" class="elsevierStylePara elsevierViewall">The authors conclude that the increase in visits to the Emergency department, as well as the performance of invasive complementary tests and the use of intravenous antibiotics, may influence cost-effectiveness studies of the implementation of systematic vaccination in the UK with MenB4C vaccine, and they suggest administering MenB4 separately from other vaccines in the calendar, or otherwise using prophylactic paracetamol.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">The treatment of fever</span><p id="par0200" class="elsevierStylePara elsevierViewall">When a child has fever the main aim is to find the cause and treat it, although simultaneously symptomatic treatment with antipyretics to improve their general condition. Whether or not to treat fever has always been controversial; the fact that fever contributes to combating infection is an argument against treating it, while the fact that administering antipyretic drugs increases the well-being of feverish patients is in favour of treatment, as these agents are usually also analgesics.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Consult the following list when deciding whether or not to administer antipyretics:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">•</span><p id="par0210" class="elsevierStylePara elsevierViewall">It is not necessary to reduce fever using antipyretics in all circumstances, but rather only when it affects the general state of a child, normally when their temperature is ≥ 38.5 °C.</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">•</span><p id="par0215" class="elsevierStylePara elsevierViewall">The aim of not that the child should feel the same was when they have no fever, but rather to relieve their general discomfort.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">•</span><p id="par0220" class="elsevierStylePara elsevierViewall">Respect the recommended dose of antipyretic and the dosage timetable, even if fever appears beforehand.</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">•</span><p id="par0225" class="elsevierStylePara elsevierViewall">Antipyretic drugs are best taken orally, as rectal absorption is erratic.</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">•</span><p id="par0230" class="elsevierStylePara elsevierViewall">Alternating antipyretic medicines has not been proven to be more effective.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">•</span><p id="par0235" class="elsevierStylePara elsevierViewall">Preventive treatment of fever with paracetamol immediately after vaccination is not usually recommended, although it is recommended after administration of meningococcal B vaccine if it is co-administered with other vaccines.</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">•</span><p id="par0240" class="elsevierStylePara elsevierViewall">To treat fever after vaccination a child may be given a 10–15 mg/kg/dose of paracetamol, a 10 mg/kg/dose of ibuprofen and/or a 5–10 mg/kg/dose of metamizole.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a></p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">•</span><p id="par0245" class="elsevierStylePara elsevierViewall">Ibuprofen may be given after six months of life, and metamizole should not be the treatment of choice.</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">•</span><p id="par0250" class="elsevierStylePara elsevierViewall">It is important to teach parents that fever in itself causes no harm to children, explaining to them that it may be difficult to bring their temperature down, at first above all.</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">•</span><p id="par0255" class="elsevierStylePara elsevierViewall">If a high fever does not come down with medication, physical means may be used to do so. It is advisable to place cool (not cold) compresses on the forehead, neck, armpits, groin or arms, and/or to use a bath of tepid water. The child should not be submerged in cold water or rubbed with alcohol.</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">•</span><p id="par0260" class="elsevierStylePara elsevierViewall">Given that fever favours dehydration, abundant liquid should be given (water, soft drinks, soup, infusions or ice creams) or jellies.</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Special considerations in antipyretic treatment</span><p id="par0265" class="elsevierStylePara elsevierViewall">It is possible to have a conservative attitude in children aged from three months to five years old (without administering antipyretics) when their temperature < 38.5 °C, although when their temperature ≥ 38.5 °C irritability, loss of appetite and the risk of convulsions (2%–5% of cases < 5 years) are more frequent.</p><p id="par0270" class="elsevierStylePara elsevierViewall">Patients with a severe basal disease that may be upset (cardiovascular or pulmonary diseases) are more sensitive to the adverse effects of fever, with tachycardia, polypnoea and increased metabolic needs and oxygen consumption.</p><p id="par0275" class="elsevierStylePara elsevierViewall">In children with a history of febrile convulsions, even though antipyretic drugs have not been proven to prevent the recurrence of new episodes, the symptomatic treatment of fever should be considered due to the high level of anxiety in their family and among medical staff.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Antipyretics and vaccine immunogenicity</span><p id="par0280" class="elsevierStylePara elsevierViewall">Since 2009 it has been suggested that administering antipyretics after vaccination may alter and reduce the immunogenic response to them. The Centres for Disease Control (CDC) in the United States studied the first works published on this subject and found no significant proof for this association.</p><p id="par0285" class="elsevierStylePara elsevierViewall">Subsequently, in 2016, American Paediatrics Academy issued an alert about this hypothesis and stated that the evidence does not support the routine use of analgesics before or at the moment of vaccination due to a possible reduction in the efficacy of the same.</p><p id="par0290" class="elsevierStylePara elsevierViewall">Nevertheless, the truth is that the works published to date are contradictory, and the researchers admit that further work is necessary to gain an exact understanding of how and under which circumstances pain relieving and antipyretic medication may reduce the efficacy of vaccines.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0295" class="elsevierStylePara elsevierViewall">All vaccines may cause fever following administration in children, and the frequency and intensity of this will be directly associated with the type of vaccine and how each individual responds. Nevertheless, the resulting fever will usually be slight to moderate and it will almost always disappear in 24–48 hours.</p><p id="par0300" class="elsevierStylePara elsevierViewall">We therefore have to understand post-immunisation fever as a normal host reaction that is not always severe, and in no case should the cost-benefit of systemic vaccines in infancy be altered by the appearance of fever after a vaccine injection.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0305" class="elsevierStylePara elsevierViewall">The author has no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:19 [ 0 => array:3 [ "identificador" => "xres1423013" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1300917" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1423014" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1300918" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Adverse reactions to vaccines" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Vaccination-induced adverse reactions" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Fever and vaccines" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "How should we measure fever?" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "The importance of fever" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Fever as a vaccination-induced adverse reaction" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Febrile convulsions" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Fever and meningococcal B vaccine" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "The treatment of fever" ] 14 => array:2 [ "identificador" => "sec0055" "titulo" => "Special considerations in antipyretic treatment" ] 15 => array:2 [ "identificador" => "sec0060" "titulo" => "Antipyretics and vaccine immunogenicity" ] 16 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusions" ] 17 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflict of interests" ] 18 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-04-16" "fechaAceptado" => "2020-05-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1300917" "palabras" => array:5 [ 0 => "Vaccine" 1 => "Vaccination" 2 => "Fever" 3 => "Adverse event" 4 => "Antipyretics" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1300918" "palabras" => array:5 [ 0 => "Vacuna" 1 => "Vacunación" 2 => "Fiebre" 3 => "Reacción adversa" 4 => "Antitérmicos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Vaccines are a tool for the prevention of many infectious diseases that can cause different morbidity and the cost-benefit of those administered systematically is clear. In the cost of vaccines are the adverse effects that cannot currently question the benefit of vaccines administered in vaccine schedules around the world. Fever is perhaps the most common systemic side effect of vaccines and despite being a self-limiting effect causes concern and sometimes unnecessary medical consultations and tests. It describes the physiopathology of post-vaccine fever as well as practical aspects about its detection and treatment.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las vacunas son una herramienta para la prevención de muchas enfermedades infecciosas que pueden causar distinta morbimortalidad y el coste-beneficio de las que se administran de forma sistemática es indiscutible. En el coste de las vacunas están los efectos adversos que actualmente no pueden poner en duda el beneficio de las vacunas que se administran en los calendarios vacunales de todo el mundo. La fiebre es quizás el efecto adverso sistémico más común de las vacunas y a pesar de ser un efecto autolimitado provoca preocupación y en ocasiones consultas y pruebas médicas innecesarias. Se describe la fisiopatología de la fiebre post-vacunal, así como aspectos prácticos sobre su detección y tratamiento.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:3 [ "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Although the majority believe that rectal temperature is the most closely associated with core body temperature, this form of measurement gives rise to several problems. These include slow response to changes in core temperature (rectal delay), inappropriate placement of the thermometer, discomfort, concerns about safety and cultural unacceptability. Moreover, none of the external sites for measuring body temperature (oral, rectal, axillary and ear) has been proven to be definitively superior, and it is still impossible to predict the temperature differences between these different anatomical sites.</p> <p class="elsevierStyleNotepara" id="npar0011">In spite of the above considerations we often find tables like the following one, which set temperature limits to determine fever according to the anatomical site where the temperature is taken:<elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p>" "identificador" => "fn0005" ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pineda Solas V. Fiebre y vacunación infantil. Vacunas. 2020;21:105–110.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0315" class="elsevierStylePara elsevierViewall">The following are Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0080" ] ] ] ] "multimedia" => array:2 [ 0 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.docx" "ficheroTamanyo" => 42630 ] ] 1 => array:5 [ "identificador" => "tbl0005" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Measurement \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Temperature (°C) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Fever (°C) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rectal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36.6 – 38.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>38.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.5 – 37.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>37.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Axillary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.7 – 37.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>37.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ear \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.8 - 38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>38.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2440569.png" ] ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Comité Asesor de Vacunas. 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