Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.  
The NP sees a well, 18-month-old with a two-day history of clear nasal discharge, dry cough, intermittent fever to 101.4 or 38.5C, and mild crankiness. She's up to date with all recommended vaccination. Parents report everyone at home has this cold. Testing for RSV, COVID-19, influenza are all negative. She is alert, age appropriately resists the exam, which is consistent with viral URI. Her father states, “We got her fever under control by giving her two different medicines around the clock.” He presents two medication bottles, one with liquid acetaminophen and one with liquid ibuprofen. The NP considers that alternating between ibuprofen and acetaminophen for a child with fever will:

Result in additive effect in fever reduction.
Is encouraged in order to prevent febrile seizures.
Is only recommended in higher fever, such as when the fever is 100 degrees F or 38.8 degrees C or greater.
Is not recommended due to higher potential for adverse effects.

The correct answer here is D. Not recommended due to higher potential for adverse effects.

Where should you start? First, determine what kind of a question this is. Given the child's working diagnosis is given, and the NP is responding to parental comment about intervening in fever. This is an intervention/plan question.

Let's take a look at some background information. Fever is one of the most common clinical symptoms in children being seen for a sick visit, as we have in this scenario. While fever is often viewed by parents and caregivers as being potentially harmful, in reality, healthy children, as we have in this scenario, will find that fever is actually a healthy physiologic response to infection, minimizing the growth and reproduction of viruses and bacteria. Often, the well-meaning caregivers of the sick child feel the need to keep the body temperature normal or break that fever or control that fever, administering antipyretics even though there is minimal to no fever. Indeed, one study demonstrated that about 85% of parents will awaken a sleeping child to give medication to prevent or control fever. According to guidance from the American Academy of Pediatrics, the primary goal of treating a febrile child is to improve the child's overall comfort, not get the temperature down. In other words, let the fever do its work. Indeed, numerous studies have demonstrated that children with minor illness as described in this scenario, will actually get better quicker if fever is untreated. The dialogue that I have with parents is about letting fever do its work. I will also put this in as well. I'll say, listen, this isn't a contest to see who can put up with this fussy, clearly miserable toddler who's got a fever. The child looks uncomfortable, miserable, isn't sleeping well. Go ahead, give them something. But it's not to bring down the fever. It's to make them more comfortable. And I believe all of us at one time or another in our lives have had a febrile illness. It can be mighty, mighty uncomfortable. So, remember, fever is a good thing. Almost all the time, there are a few scenarios where it's not good, and letting fever do its work is what we should be doing largely in the pediatric and the adult population, particularly people without chronic health problems. So, let's take a look at the question and the answer choices.

The NP sees a well, 18-month-old with a two-day history of clear nasal discharge, dry cough, intermittent fever to 101.4F or 38.5C and mild crankiness. The child is up-to-date with all vaccines. Parents report everyone at home has this cold. Testing for RSV, COVID-19, influenza is all negative. She is alert, age appropriately resists the exam, which is consistent with viral URI. Her father states, “We got her fever under control by giving her two different medications around the clock.” He presents with two medication bottles, one with liquid acetaminophen and one with liquid ibuprofen. The NP considers that alternating between ibuprofen and acetaminophen for a child with fever:

A. Is helpful in maintaining normothermia in children of this age with an episodic self-limiting febrile illness. This is an example of an answer that technically is correct, but it's not a good choice. Yes, giving two antipyretics will certainly help with fever control and yield normothermia. But it's not the right answer. Even if it was simply saying, Oh, just give the child one of these two medicines by the clock, that wouldn't be the right answer either. As mentioned above, let fever do its work wherever possible. And I'll say one more time the goal of treating the febrile child with an antipyretic is not bringing down body temperature, but simply making the child more comfortable.

Is encouraged to prevent febrile seizures. This is not correct. While one of the most powerful fears in parents and caregivers of the child is that a fever-producing illness will trigger a febrile seizure, using around-the-clock antipyretics doesn't minimize the risk of seizure triggered by fever. Keep in mind, febrile seizure usually is noted in illnesses where the body temperature rises quite quickly, such as Roseola, rather than how high the fever goes. This to me reads like an answer that sounds good, plausible, but it's not based in best evidence.
Is only recommended when fever is higher, like greater than 102 degrees Fahrenheit, greater than 38.8 degrees Centigrade. Again, this is incorrect. There's little correlation between the degree of fever and the severity of illness and this child is described as being mildly ill. In addition, and this is a key point, she's up to date with all vaccines. And at this age, what that would include, but not be limited to, immunization against the two most common forms of meningitis seen in early childhood. That's meningitis caused by Haemophilus influenzae type B. She's up to date with the vaccines, so she's had her Hib vaccine. Or the pneumococcal organism can also cause meningitis in younger children. She's had her Prevnar vaccine since we're told that she's up to date with vaccines. COVID 19 and influenza, which are both vaccines that would be recommended in a child this age. Those are all potentially serious febrile illnesses. And when I tell you, I've been in practice long enough to remember when we didn't have vaccines for children of any of the four diseases I just mentioned, we used to see children with very, very high fevers because we didn't have the benefit of these vaccines. In immunized children, we hardly see super high fevers anymore.
Is not recommended due to higher potential of adverse effects. This is the correct answer. Alternating between acetaminophen and ibuprofen so the child gets an antipyretic every 2 to 4 hours is not recommend, it as there's lack of evidence supporting this practice and it can increase the risk of dosing errors and adverse effects in the younger child.

Key take away: Often practices that are widely advised, such as keeping fever under control, are not based in best evidence. On the NP boards, you will be tested on best practices.

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