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Fever: Views in Anthroposophic Medicine and Their Scientific Validity

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Objective . To conduct a scoping review to characterize how fever is viewed in anthroposophic medicine (AM) and discuss the scientific validity of these views. Methods . Systematic searches were run in Medline, Embase, CAMbase, and Google Scholar. Material from anthroposophic medical textbooks and articles was also used. Data was extracted and interpreted. Results . Most of the anthroposophic literature on this subject is in the German language. Anthroposophic physicians hold a beneficial view on fever, rarely suppress fever with antipyretics, and often use complementary means of alleviating discomfort. In AM, fever is considered to have the following potential benefits: promoting more complete recovery; preventing infection recurrences and atopic diseases; providing a unique opportunity for caregivers to provide loving care; facilitating individual development and resilience; protecting against cancer and boosting the anticancer effects of mistletoe products. These views are discussed with regard to the available scientific data. Conclusion . AM postulates that fever can be of short-term and long-term benefit in several ways; many of these opinions have become evidence-based (though still often not practiced) while others still need empirical studies to be validated, refuted, or modified.
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Review Article
Fever: Views in Anthroposophic Medicine and
Their Scientific Validity
David D. Martin1,2
1University Childrens Hospital, T ¨
ubingen, Germany
2Filderklinik, Filderstadt, Germany
Correspondence should be addressed to David D. Martin; david.martin@med.uni-tuebingen.de
Received  August ; Accepted  October 
Academic Editor: Konrad Urech
Copyright ©  David D. Martin. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective. To conduct a scoping review to characterize how fever is viewed in anthroposophic medicine (AM) and discuss the
scientic validity of these views. Methods. Systematic searches were run in Medline, Embase, CAMbase, and Google Scholar.
Material from anthroposophic medical textbooks and articles was also used. Data was extracted and interpreted. Results.Mostof
the anthroposophic literature on this subject is in the German language. Anthroposophic physicians hold a benecial view on fever,
rarely suppress fever with antipyretics, and oen use complementary means of alleviating discomfort. In AM, fever is considered
to have the following potential benets: promoting more complete recovery; preventing infection recurrences and atopic diseases;
providing a unique opportunity for caregivers to provide loving care; facilitating individual development and resilience; protecting
against cancer and boosting the anticancer eects of mistletoe products. ese views are discussed withregard to the available scientic
data. Conclusion. AM postulates that fever can be of short-term and long-term benet in several ways; many of these opinions
have become evidence-based (though still oen not practiced) while others still need empirical studies to be validated, refuted, or
modied.
1. Introduction
Personal Note and Outline of the Structure of is Article.We
were a family with  children. Our parents and our family
physician treated feverish illnesses with the greatest respect
and always managed to make us feel safe and comfortable
without suppressing the fever. None of us ever received an
antipyretic (nor for that matter an antibiotic, except for the
postnatal pneumonia of a prematurely born brother). e
uncritical and widespread use of antipyretics and antibiotics
I witnessed as a student and physician therefore seemed a
strange and unphysiological interruption of a natural and,
from my experience, healthy process. Our physician was
an anthroposophist, so I began to enquire: What is anthro-
posophic medicine? What are its main statements about
fever? Do these statements have any scientic basis? e rst
question will be addressed in Introduction; the results of
the second question are presented in Results as statements.
Discussion picks up each of these statements and relates them
to current scientic literature.
In their  editorial “Fever Phobia  Years Later: Did
We Fail?” [], Bertille et al. wonder why it has been so dicult
to inform the world population about how to think of, and
deal with, fever. ey summarize “large studies seem to indi-
cate that fever phobia persists and antipyretic drugs are still
overused [–]. Considering that we do seem to have failed
in part to provide eective guidance to parents, how did this
happen?” e present review is about a cultural strain within
medicine that is very successful in turning fever phobia into
what could be called “fever philia”: in large hospitals [] and
thousands of practices [] physicians and nurses interested
in anthroposophic medicine have, for decades, met their
patients with a contagiously appreciative attitude towards the
phenomenon of fever [, ]. is results in a very low use of
antipyretics and, perhaps more importantly, of antibiotics (-
% in airway infections) [–].
What Is Anthroposophic Medicine (AM)? Anthroposophy is
an approach to life that began its development a century ago
Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 2016, Article ID 3642659, 13 pages
http://dx.doi.org/10.1155/2016/3642659
Evidence-Based Complementary and Alternative Medicine
and has inspired countless ecologic, agricultural, social, edu-
cational, economic, pharmaceutical, and therap eutic ventures
throughout the world []. Anthroposophic physicians strive
for a scientically viable extension of their view of human
nature into the realms of life and psychosocial and spiritual
individuality and to perceive the interactions of these aspects
and their relationship to nature, health, and illness.
In AM each illness is understood as a challenge to the
human being as a whole, concerning, to various degrees, all
levels of existence []: biological, psychosocial, and spiritual.
Illnesses and instabilities are also considered to be salutogenic
opportunities for developing new and sustainable balances
of health, self-regulation, and development. is perspective
leads to what could be called a kind of “esthetic logic,” pro-
moting a low, and yet still safe, use of antipyretics, antibiotics,
and so forth.
AM is practiced in over  countries. erapeutic modal-
ities of AM include the whole range of allopathic mainstream
medicine, as well: as mineral, herbal, and animal-derived
medicines, some of which are called “anthroposophic medici-
nalproducts;counselingandpastoralcare;specictherapies
using movement (Bothmer Gymnastics; Spacial Dynamics,
eurythmy therapy; dancing), painting and modeling (art
therapy), music (music therapy), and speech (speech ther-
apy); various forms of physiotherapy and massage (Rhyth-
mical Massage erapy according to Ita Wegman, Massage
erapy according to Simeon Pressel, Massage erapy
according to Volkier Bentinck, Chirophonetics, Embodi-
ment, and others), oil dispersion baths, and external applica-
tions [–]. ere are to date over  publications on AM
[, ]. Several hospitals, including secondary/tertiary level
and regional/community hospitals, have been founded in
order to broaden the spectrum of conventional medicine in
this manner.
isarticleisaboutthekindoffever(bodytemperature
>.C) that develops in response to an acute infection. e
aim of this scoping review was to gather the views on fever
expressed in anthroposophic literature and to assess the vali-
dity of these views with respect to the available scientic data.
ANoteonContext.For the past  years the author has,
alongside his Professorship, worked as Senior Consultant in
aregionalhospitalthathasa-yearhistoryofthinkingand
dealing with fever in the way described in this paper. e
author would thus classify himself as an experienced “partic-
ipant observer” whose views on fever have been inuenced
bydailypracticeaswellasmaterialfromlecturesandarticles
in German, English, French, and Spanish and conversations
in these languages with specialists from around the world.
In the last paragraph of Section , the author summarizes
his experience of how fever is dealt with in anthroposophic
medicine.
2. Methods
e following searches were performed.
Search A. e databases PubMedCentral (PMC) and Embase
were searched in February  using the following terms:
(anthroposophic [All Fields] OR anthroposophical [All
Fields] OR anthroposophically [All Fields] OR anthroposo-
phics [All Fields] OR anthroposophie [All Fields] OR anthro-
posophique [All Fields] OR anthroposophiques [All Fields]
OR anthroposophisch [All Fields] OR anthroposophis-
che [All Fields] OR anthroposophischen [All Fields] OR
anthroposophischer [All Fields] OR anthroposophisches
[All Fields] OR anthroposophs [All Fields] OR anthropos-
ophy [All Fields] OR anthroposophy/history [All Fields]
OR anthroposophy/psychology [All Fields]) AND (“fever”
[MeSHTerms]OR“fever”[AllFields]OR“febrile”[All
Fields] OR “Fieber AND anthroposoph” [All Fields]).
Search B. CAMbase, a German bibliographical database sys-
tem for complementary and alternative medicine (http://
www.cambase.de/), was searched for the words “(Fieber OR
Fever) and anthropos” and for “Fieber OR Fever”. Google
Scholar was included to nd grey literature.
Textbooks on anthroposophic medicine [–] were also
used.
Inclusion criteria for a written publication to be used for
Section  were as follows:
(i) e publication is published in a peer-reviewed jour-
nal or is a text-book on anthroposophic medicine.
(ii) e publication contains views about fever.
ere were no further exclusion criteria.
Statements that present the anthroposophic perspective
on fever were extracted from the text, coded, sorted, and clus-
tered into generic statements by the author as personal
r´
esum´
e and interpretation. e statements are presented in
Section , annotated with their respective sources in anthro-
posophic medical literature.
Search C. Since the author has in the course of time collected a
lot of literature in favor of these statements, he concentrated
the further search on nding data that put these statements
intoquestion.emainofthesesearches,SearchC,was
performed in PubMedCentral (PMC) with the words “fever
AND (detrimental or harmful)”.
3. Results
Search A produced  hits from which  publications were
relevant to fever and AM. Of these (see also Figure ),
(i)  publications discussed or referenced either studies
examining the connection between atopy and chil-
dren living an “anthroposophic lifestyle” (the seminal
studybeingtheLancetarticlebyAlmetal.[]),or
studies where such a lifestyle impacted on low immu-
nization levels in various communities,
(ii)  publications discussed or reported the fever-induc-
ing eect of anthroposophic cancer remedies contain-
ing Viscum album, some of which discussing fever
as part of the anticancer action of Viscum album
extracts,
Evidence-Based Complementary and Alternative Medicine
93
hits
59
10
8
Anthroposophic lifestyle
Mistletoe preparations
General aspects of AM
10
relevant to
fever and AM
87
relevant to
AM
F : Results of literature search A on fever and anthroposophic
medicine (AM).
(iii)  publications discussed or referenced other or gen-
eral aspects of AM not directly related to the manage-
ment of fever,
(iv)  publications expressed anthroposophic opinions
about fever, including a focus group study of fac-
tors that inuence vaccination decision-making by
parents who visit an anthroposophical child welfare
center[,,].
e search in Embase did not add any more relevant
references.
Search B did not add any more relevant references.
e ndings were extracted from the text, coded, sorted,
and clustered into generic statements by the author, leading
to the following thirteen statements. In Section , each
statement is discussed in the context of present scientic data:
() e leading motif in anthroposophic medicine is that
warmth and, in desease, fever are direct manifesta-
tions of the “self” working on the body, making the
body more an instrument and expression of the “ego,”
the“I”(inGerman“dasIch)[,].
() Fever may allow faster and/or more complete resolu-
tion of infections [, –, –].
() Fever may prevent recurrent infection [–, ].
() Fever may assist immune maturation in children [–
, –].
() Fever may protect against developing allergic diseases
[,,].
() Fever may help resolve allergic disease [, –, ].
() Fever oers a unique opportunity for caregivers to
provide loving care [–, ].
() Fever may facilitate individual development and cre-
ativity [, , , , ].
() Febrile illness may help a developing child take
ownership of their body towards a better expression of
their unique individuality and to overcome inherited
(e.g., epigenetic) traits [–, , ].
() Febrile illnesses may be protective against cancer [–
,,,].
() Some febrile illnesses may contribute to curing cancer
[, , ].
() Febrile reactions to injecting mistletoe products in
cancer treatment may improve treatment outcome
[–, , ].
() Antipyretics such as acetaminophen and ibuprofen
should be used sparingly: only if other means of
relievingdiscomfortfailoriffeverneedstobesupp-
ressed for other medical reasons [, –, –].
Search C, in PubMedCentral (PMC) with the words
“fever AND (detrimental or harmful)”, led to  hits. A
scan of these papers and their respective reference lists for
evidence speaking against the above statements led to studies
indicating that fever may also be detrimental in rare, very par-
ticular circumstances [–] that cooling may [], or may
not [], be advantageous in sedated ventilated sepsis patients
that measles possibly impair the immune system for - years
[]. Furthermore, fever and cytokines may interfere with
fetal brain development, especially in birth-related hypox-
emia, which may be the reason for naturally subdued febrile
reactions in newborn (for review []). ese studies are
introduced in the respective places in Section .
4. Discussion
e discussion is structured around the anthroposophic
perspectives on fever as they are stated in thirteen resulting
statements listed in Section .
() e leading motif in anthroposophic medicine is that
warmth and, in diesease, fever are direct manifestations
of the “self” working on the body, making the body more
an instrument and expression of the “ego,” the “I” (In
German “das Ich”) [19–22, 25–27].
is is a notion specic to anthroposophy. It is related
to the whole breadth and depth of what human warmth
is and can be, including social life and human will, and
the increasingly autonomous and dierentiated relationship
that animals have had to warmth throughout evolution. is
topicgoesfarbeyondthescopeofthisarticle.Itis,however,
worth mentioning that human “warmth,” the most powerful
personality trait in social judgment, is enhanced by physical
warmth [, ].
() “Fever may allow faster and/or more complete resolu-
tion of infections” [8, 19–23, 26–29].
Case vignette: A publication on the anthroposophic
approach to pneumonia reports a -year-old girl with
apneumoniathatdevelopedfromaue(shehad
been stressed by fears of entering secondary school
and much discussion about this in the family). She
was treated without antibiotics and on the th day
still had fever despite the fact that the coughs were
loosening. Examination revealed cold feet and back
despite high fever, upon which she was treated with 
waterbottlesonherfeetandmassagedwithasilver
cream (Argentum .% Ungt.) on her back. On the
next day the temperature fell and  days later she was
free of fever. e subsequent entry into secondary
school was unproblematic [].
Evidence-Based Complementary and Alternative Medicine
e positive attitude of anthroposophic physicians with
regard to fever has support from the evolutionary point of
view. Fever is a highly conserved evolutionary host response
with survival and salutary benet. Fever is one component of
theacutephaseresponse,whichisacomplexphysiological
reaction to disease or injury, and elicits cytokine mediated
rise in core temperature, generation of acute phase reactants,
and activation of a number of physiologic, endocrinologic,
and immunological eects []. Even though increasing
the body temperature is energy-costly (–.% increase
in metabolic rate for C increase in body temperature in
warm-blooded animals []), it is an established mechanism
in response to injury and infection in sh, amphibians,
reptiles, birds and mammals, and many invertebrates such as
insects []. Even cold-blooded animals seek external ways
of increasing their body temperature when they are infected
and their mortality increases if they are prevented from
doing so []. Studies point to potentially harmful eects of
suppressing fever in mammals and humans [, –]. e
protective eects of fever against invading organisms result
from a variable combination of direct thermic eects []
and humoral [] and cellular [] defense enhancement.
With few exceptions [], from the point of view of immunity
and survival, fever oers the host an adaptive advantage
[]. Human studies on malaria [], chicken pox [], and
inducedrhinovirus[]infectionsalsosuggestthatfeversup-
pression delays recovery. Fever was associated with decreased
mortality in Gram-negative bacteremia []. Hospitalized
elderly patients with community-acquired pneumonia were
seven times more likely to die if they did not display fever
and leukocytosis []. ere are several reports of treating
Sydenham’s Chorea by inducing fever [, ].
But if fever really were so important, would we not have
geneticmodelsofanimalsorhumanswhoareunableto
producefeverandhaveworseoutcomes?eremaybesuch
models on the horizon: In a study showing that early and
strong immune responses are associated with control of viral
replication and recovery in Lassa virus-infected Cynomolgus
monkeys, the authors noted absence of signicant fever in
nonsurvivors despite high levels of IL- []. In another
study, sepsis patients with mitochondrial DNA haplogroup H
had the best survival and the most extreme core temperature
within the rst  hours []. Closest to a genetic model is the
report of two consanguine siblings with RANK mutations:
two siblings with autosomal-recessive osteopetrosis had a
markedly abrogated fever response to pneumonia and worse
course of disease compared to age-matched children [].
e improved immune function during febrile temper-
atures has to be weighed up against metabolic costs and
potential damage to sensitive organs such as the brain,
possibly the fetus [, ], and, in mice infected with Klebsiella
pneumoniae,thelung[].us,insomecases,hypothermia
or suppression of fever may reduce mortality, even though it
increases bacterial load []. Nevertheless, weighing up the
pros and contras leads to the conclusion that, for acute febrile
infections under normal circumstances, it is better to not
suppress the fever []. A very large recent study has shown
that, even on the ICU unit, suppressing fever does not seem
to convey an advantage to the patient [].
() “Fever may prevent recurrent infection” [19–22, 26].
() “Fever may assist immune maturation in children” [19–
22, 25–27].
In analogy to the loss of memory performance when sleep
is disturbed, AM proposes that interrupting the fever phases
may impair disease resolution and long-term immunity.
Anthroposophic physicians report that patients, especially
children, oen stop having recurrent infections aer experi-
encing an acute febrile illness without use of antipyretics or
antibiotics [–], although studies to this regard are lacking.
Conversely, there is evidence that the use of paracetamol
in conjunction with vaccination can lead to less fever and
reducedantibodyresponse[].
endingsthattheriskofisletautoantibodysero-
conversion and subsequent development of type  diabetes
was associated with respiratory infections during the rst 
months of life (a time at which the children are oen not yet
able to develop fever and when height of fever is correlated
with severity of disease []), but not thereaer, raises inter-
esting questions in this context []. On the other hand some
infections, such as measles, may initially impair immunity
[].
() “Fever may protect against developing allergic diseases”
[7,1922,26].
() “Fever may help resolve allergic disease” [7, 19–22, 26].
ese are topics that deserve future research. ere is con-
troversial evidence that use of acetaminophen in the rst year
of life and in later childhood is associated with an increased
risk of asthma, rhinoconjunctivitis, and eczema in children
and adults [, ]. However, this may be more linked to
acetaminophen itself than to suppressing fever, since prenatal
exposuretoacetaminophenpredictedwheezeatageofyears
in an inner-city minority cohort, and the risk was modied
byafunctionalpolymorphisminGSTP,suggestingamech-
anism involving the glutathione pathway []. Furthermore,
use of ibuprofen seems to cause less increase in asthma
morbidity than use of acetaminophen []. Nevertheless, an
inverserelationshipbetweenfebrilediseasesinearlychild-
hood life and allergy has been found in most studies [–
] (one study shows a positive correlation [] but did not
control for antipyretic use), despite the fact that antipyretic
[–] and antibiotic [] treatment of febrile infections may
increase the risk of asthma. e lower rate of atopy in younger
siblings further suggests that cross-infections acquired early
in infancy or childhood might prevent development of atopy
[]. Children who are raised in an anthroposophic lifestyle,
which includes very restricted use of antipyretics, show less
allergies [].
() “Fever oers a unique opportunity for caregivers to pro-
vide loving care” [19–22, 26].
Some children with autism appear to become more
socially adept during and aer a febrile infection [, ].
Such improvements are not associated with hyperthermia by
high ambient temperature or exercise so alternative mecha-
nisms mediated by acute phase cytokine actions, heat shock
Evidence-Based Complementary and Alternative Medicine
proteins, or alterations in the hypothalamic-pituitary-adrenal
axis may be responsible for the temporary behavioral
changes. Whether other children with febrile infections are
particularly receptive to love and care and whether the given
attention is particularly formative in this situation have not
been studied to date; anecdotal evidence from those with the
opportunityofcaringforafebrilechildorwhoremember
theircarefromtheirownchildhoodseemstosuggestthat
febrile illnesses oer a great and usually thankfully short
opportunity for nurturing a relationship []. Studies on
oxytocin levels, bonding, and empathy during febrile illnesses
are lacking, while physical warmth has been shown to
increase empathy, trust and generosity [, ]. Paracetamol,
by contrast, can reduce empathy [].
() “Fever may facilitate individual development and cre-
ativity” [19, 20, 22, 23, 28].
() “Febrile illness may help a developing child take owner-
ship of their body towards a better expression of their
unique individuality and to overcome inherited (e.g.,
epigenetic) traits” [19–23, 26, 28].
Biographical accounts of the role of acute febrile illnesses
in facilitating developmental steps and helping to nd new
individual creativity are aspects of fever that have yet to
become subject to scientic investigation. Johann W. von
Goethe, for example, suered several severe acute febrile
illnesses and felt he came through each time with new
impulses []. Laurens van der Post has written stunning
words about his experience of fever and of its relationship
with transpersonal past and future, for example, “All I would
suggest is that the future had begun to register a new design
in my blood, and that the fever marked the beginnings of
its struggle for awareness” []. In anthroposophic medical
practice, these considerations are part of promoting the best
possible outcome. Many anthroposophic oriented caregivers,
parents, and teachers believe and seem to have oen expe-
rienced [, , , , –] that febrile illnesses oer a
child the chance to optimize the process of making their
body a better expression of their “true self.” It would be
interesting to study how the catabolic activity of fever and
the anabolic convalescence that follows it promote human
development. We know that other kinds of catabolic activity,
such as enthusiastic physical, musical, artistic, and mental
exercise and work, do so when they are felt to be meaningful
and are properly balanced by anabolic phases of nutrition,
rest, and sleep. Such thoughts certainly help many parents
andpatientsgothroughtheprocessofanillnesswitha
positive attitude and many interesting observations have
been collected [, , , , –]. Indeed, in a study
of  children with measles, of whom  children were
studied prospectively, % of children were judged as having
proted from having measles, and % of parents whose
children had measles said they would, in hindsight, again
decide to not vaccinate their children against measles. In
contrast only, .% would rather have vaccinated them and
.% of children developed measles despite having been
vaccinated []. However, this study may be biased by the
parents potentially having a critical stance to vaccination:
a recent study using population-level data suggests that
measles may be followed by long-lasting immunodeciency
for about  years, correlating with an increase in nonmeasles
related mortality during this time and perhaps explaining
the disproportionately large reductions in mortality seen
aer the introduction of measles vaccination []. No such
associations were found for pertussis or pertussis vaccination
and the author is not aware of such studies for other acute
infectious diseases. Future studies on the eects of various
feverish illnesses on individual development would thus be
needed to answer these questions.
() “Fever may be protective against cancer” [19–22, 24, 25,
30].
From an anthroposophic point of view, health arises in an
actively maintained, ongoing, and dynamic balance between
polarities, each of which represents a pathological direction.
Living nature manifests itself everywhere within polar oppo-
site forces, which are working together in rhythmical alterna-
tions []. One such polarity in living organisms is between
the tendencies to form, condense, or harden on the one hand
andtoswell,grow,anddissolveontheotherhand.eformer
is related to coldness and “sclerosis,” and the latter to heat and
“inammation.” From a broad developmental perspective,
theyoungchildisbothpsychologicallyandbiologicallycloser
to the warm inammatory pole, whereas an older person
is closer to the cold sclerotic pole. is may be expressed
inthedecreaseofmeanbodytemperatureandtemperature
responsiveness with old age [] and in the fact that young
children are more able to develop fever and generally tolerate
it better than the elderly []. Adults oen appear to suer
more headaches and pains during fever. Some feel drained
and exhausted for a long time aer a feverish illness while oth-
ers report feeling rejuvenated and “lighter” or “cleansed” and
this may be dependent on the health of the host, the nature
of the causative agent, the way the illness was dealt with, and
the self-awareness of the individual (personal experience of
theauthor;studiesinthisregardarelacking).isleadstothe
question as to whether a febrile disease can help to overcome
hardening tendencies in a person’s physical, immunological,
and psychological make-up.
From an anthroposophic point of view, many illnesses
can be assessed in terms of their relationship to the “inam-
matory” and “hardening” poles: childhood cancers such as
leukemias and embryonic tumors are more related to the
“inammation” pole whereas the common solid tumors of the
adult develop in a more “hardening” context. Life processes
that lose their organic connection with their antagonists may
become isolated and move towards the direction of “hard-
ening”: this may lead to microcalcication, autoimmune
processes, or even cancer as a consequence of loss of immune
surveillance. ese “hardening” processes can trigger more
or less helpful “inammatory” counterregulations. While
chronic inammation can lead to sclerosis and cancer [],
there is evidence to suggest that acute febrile inammations
in children and young adults could be protective against
cancer development in later life []. Cancer patients report a
history of fewer fevers during infections than healthy controls
[, ]. An inverse relationship between the number of
Evidence-Based Complementary and Alternative Medicine
children’s febrile infections and the incidence of melanoma
has been reported []. Taking these concepts into the animal
world, it is interesting to note that animals with hardly any
“hardening” or aging tendencies and with a strong ability to
rebuild lost limbs, such as hydra, hardly ever develop cancer
[].ereisanastoundinglackofinvitroandinvivodata
comparing immune function and cancerogenesis at various
temperatures. Recent experiments have shown that housing
mice at thermoneutral temperature (-C) instead of stan-
dard laboratory temperature (–C) reduces tumor for-
mation, growth rate, and metastasis. Furthermore, given the
choice, tumor-bearing mice select a higher ambient temper-
ature than non-tumor-bearing mice [].
() Some febrile illnesses may contribute to curing cancer
[19, 20, 25].
Anthroposophic physicians may at times actually attempt
to support and elicit fever, particularly in cancer treatment.
Metabolic processes and biochemical reaction rates across
numerous cellular functions of immune cells are increased
at temperatures that simulate naturally occurring fever, for
example, leucocyte proliferation, maturation, and activation,
neutrophil and monocyte motility, migration, phagocytosis
and pinocytosis, T cell expansions, activation and cytotoxic
activity, antibody production, dendritic cell antigen pro-
cessing [] and presentation to T cells and migration to
the draining lymph nodes, and lysis of bacteria and the
bactericidal eect of antibiotics [–]. Some tumor cells
may be more vulnerable to higher temperatures than healthy
cells, a possibility which hyperthermia therapy of cancer
attempts to address. is leads to the question as to whether
the heat alone is responsible for the reported possible cancer
regressions or whether actively generated fever is essential.
is question was the starting point of a fascinating story
of cancer research and personal courage in the course of
which surgeon Coley (re)discovered that erysipelas (strepto-
coccal cellulitis) can lead to complete cancer remission. Of
thedocumentedpatientshetreatedwithColey-Toxin
 patients with nonoperable, oen metastasized, cancer
reportedly went into complete remission [, ]. In fact,
about % of the reported spontaneous remissions from
cancer are found to be related to infections [] and the
connection between febrile infection and spontaneous tumor
regression is the most frequent association found in literature
[, –]. is suggests that more than just increased
heat is needed to ght cancer [, , ]: immunologic
events that accompany some forms of fever may play a role
in overcoming immunological escape mechanisms of tumor
development.
() “Febrile reactions to injecting mistletoe products in can-
cermayimprovetreatmentoutcome”[19,20,2022,24,
30].
e use of mistletoe (Visc um album L.) for cancer treat-
ment was rst suggested by Steiner, who emphasized that
fever induction was essential for the success [, ]. Aer
a pioneering phase with substantial (but all reversible) acute
phase reaction side eects, mistletoe was mainly used in more
easily tolerable doses during the past decades [, ]. A
local inammatory reaction at the injection site, fever and u-
like syndrome belong to the expected “adverse events” (there
are several hundred publications on this []). e reported
cases of remission, regression, and stable disease in patients
treated solely with mistletoe extracts, however, suggest that
high doses and more targeted use may be more likely to
achieve an eect and that a strong febrile reaction to the
mistletoe extract may be a prognostically positive factor [,
–] and perhaps part of the anticancer eect of mistletoe
[, , , ]. It must be noted, however, that nonfer-
mented Viscum album extract usually only induces fever
in the rst weeks []. Chronothermometric examinations
suggest that the fever generated by mistletoe injection may
enhance endogenic rhythms, thereby increasing and harmo-
nizing heart-rate variability []. Interestingly, tumor-related
fever in cases of lymphomas can apparently be overcome by
mistletoe-induced fever []. ese chronothermobiological
aspectsofcancertherapymaybecomeafocusofresearchin
the future.
Mistletoeinjectionproductshavebeenshowntoincrease
quality of life [, , , –] in patients with cancer and
there is a wealth of literature on their immunomodulatory
eects [, , ]. High-quality clinical studies on the anti-
cancer eects of mistletoe on survival time are rare and the
juryisstilloutastowhen,how,andforwhommistletoemay
be benecial. Recent randomized trials show increased sur-
vival time in advanced pancreatic cancer [] and osteosar-
coma [].
() “Antipyretics such as acetaminophen and ibuprofen
should be used sparingly: only if other means of reliev-
ingdiscomfortfailoriffeverneedstobesuppressedfor
othermedicalreasons”[8,1922,2527].
Although many mainstream hospitals and practices have
not yet translated this into practice [], there is broad
scientic consensus that the potential benets of the febrile
reaction are to be weighed up against the discomfort or
exhaustion experienced by a minority [].
Beyond suppressing the benets of fever, pharmacologi-
cal antipyresis has its own risks: a review nanced by ibupro-
fen distributors [] could not convincingly disprove that
ibuprofen may increase the risk of necrotising fasciitis caused
by Group A Streptococcus (GAS) secondary to varicella or
herpes zoster [–] while mice inoculated with GAS
had increased wound area and mortality when receiving
ibuprofen []. ere is increasing evidence that ibuprofen
in case of respiratory infections or pneumonia may facilitate
empyema and complicated pneumonia in children [–]
and adults [], possibly via modication of neutrophil and
alveolar macrophages functionality (chemotaxis, adhesion,
aggregation, and degranulation []) and the inhibition of
prostaglandin synthesis as well as via cover-up eects on sub-
jectivesymptoms,therebydelayingdiagnosisandtreatment.
is may explain the correlation between increased sales of
ibuprofen for children and complicated pneumonia in France
[], although reverse causation is also possible. Further
Evidence-Based Complementary and Alternative Medicine
risks associated with antipyretic use include systemic reac-
tions, asthma (especially for paracetamol [–]), gastroin-
testinal complications and anorexia [], low white blood
cell count (ibuprofen) [], hepatic injury (paracetamol)
[], overdose (paracetamol) [], and, extremely rarely,
anaphylaxis [, ] (although sometimes the reaction may
beduetoothersubstancessuchasmannitol[]).
e suppression of the acute phase reaction symptoms
and the slightly euphorizing eect of antipyretics is likely
to increase interaction with other people and the rate and
duration of viral shedding, as has been shown in human
volunteers [] and ferrets []. Indeed, recent modeling of
available data suggests a signicant increase in contagion and
mortalityriskthroughantipyretics[].Consideringfurther
that accidental acetaminophen overdose has caused over 
deaths per year in the USA [], one wonders how many
lives may have been saved had anthroposophic physicians
popularized their positive attitude towards fever even more
([] has been a bestseller for several years in German-
speaking countries but has only recently been translated into
English).
Using antipyretics to relieve symptoms may not always
be straightforward: in a placebo controlled study paracetamol
did not increase well-being or uid intake but suppressed the
urge to rest (which is part of an acute phase reaction seen in
all mammals) []. Another reason oen cited for treating
fever is the fear of febrile seizures. However, febrile seizures
tend to occur with rapidly rising temperatures in susceptible
individuals and not necessarily at high temperatures []
and are not preventable with antipyretics [, ]. ere are
no studies on the oen-observed phenomenon that febrile
seizures occur when the child is beginning to shiver and
may thus be avoidable through rapid heat application as
soon as one notices that the child may be developing fever.
Febrile seizures are a terrible experience for the parents, but
so-called “simple febrile seizures” are fortunately harmless
and leave no neurological sequels [, ]. Febrile seizures
must be clearly dierentiated from epileptic seizures. e
relationship between the latter and fever is highly variable:
some are induced by fever, others are suppressed, and many
are indierent.
Anthroposophic physicians rarely resort to antipyretics
butareaware,rstly,thatfevercanbethesignthatthebody
is reacting against something going seriously wrong, such
as meningitis or pyelonephritis. Second, just as the normal
and necessary blood pressure reaction to exertion can be
dangerous for some, so can fever, and there are situations in
that it may be maladaptive and deleterious as reected by
naturally occurring cold-seeking behavior in such cases. A
brain that has just been damaged by hyp oxia may benet from
hypothermia []. In some extreme circumstances, such as
severe sepsis in a cool environment, the cost of developing
fever may exceed its benets [, , ]. In patients without
cerebral or cardiovascular problems, however, suppressing
fever with antipyretics has been associated with a sevenfold
increase in mortality in the Miami intensive care unit; aer
this study the colleagues there have become much more
restrictive in their use of antipyresis ([] and personal com-
munication to the author). Anthroposophic physicians strive
to provide patients, parents, and caregivers with information
that enables them to develop views and inclinations with
regard to fever that reduce “fever phobia” [, ] and are
in harmony with the scientic facts, to oer a sense of trust
and condence in the febrile process and knowledge of when
professional examination is needed [–, , ].
5. Implications for Clinical Practice
Anthroposophic medicinal products are prescribed by
approximately , physicians in  of the  EU member
states and in  other countries throughout the world [].
Caregivers should be aware of the attitudes held in anthro-
posophic circles and be orientated as to which attitudes stand
on solid scientic grounds, which attitudes may be wrong,
and which attitudes still require validation or refutation.
6. Summary of an (Experienced
Participant Observer)on How Fever
Is Dealt with in AM-Settings
Patients beginning fever due to an acute infection usually feel
cold and shiver despite rising temperature. In this case they
need to be warmed until they feel warm all the way into the
extremities. is reduces () the work of increasing body tem-
perature,()theuncomfortablechills,and()maybeeventhe
risk of febrile seizures; there are no studies on this to date.
Note that this does not apply to exceptional situations such
as brain injury, in which case cooling may be advantageous.
In anthroposophic households, ne wool or cotton nightwear
and cotton sheets are used to maximize “breathing” capacity;
cheap synthetic bers oen lead to heat congestion. Plenty of
warm teas (e.g., elderower, lime, or lemon) and, if hungry,
easily digestible food (soups and ne porridges for the
younger children) are recommended in this phase. Once the
plateau of fever has been reached, heat can be gently released
so as to prevent sweating, yet avoiding chills. e caregivers
should be able to judge the warmth, breathing, color, and
circulation of the patient. Cold feet need attention. Attention
must also be paid to the excretory capacity of the body in
terms of urine, stools, and sweat. An atmosphere of peace
and quiet, free of electronic media and social stress, is seen
as conductive to a good and salutogenic course of the illness.
Caregivers who interpret febrile illnesses as opportunities for
bonding, for cuddly times, and for stories read or told, gentle
massages, songs sung, beautiful candle-light surroundings,
and warm bonding can engender a lasting feeling of trust,
thankfulness, and fond memories in their patients, be they
young or old. Various forms of internal and external appli-
cations can be learned by parents and carers to help patients
through the course of an infection. e most common appli-
cations are compresses using lemon (on feet and/or calves),
ginger (on kidney/chest area), mustard (on chest), or quark
(on chest), depending on the need and constitution of the
patient. Enema can relieve discomfort, constipation, and
dehydration (enemas must be seen critically and are only
acceptable in appropriate safe settings, yet families who have
learnt to deal with enemas hardly ever have to bring their
Evidence-Based Complementary and Alternative Medicine
small children into hospital for IV rehydration, making
enemas very relevant for third-world and remote areas)
[]. Anthroposophic physicians will additionally recom-
mend various herbal remedies depending on the symptoms,
stage, and etiology of the illness [–, , , ]. Two
prospective outcomes studies on  [] and  []
patients with acute respiratory and ear infections suggest
that anthroposophic physicians have the lowest documented
antibiotic prescription rate at .% [] and .% (with faster
recovery, better satisfaction, and half as many side eects [])
versus a moderate rate of .% antibiotic prescription by
conventionalphysiciansinthesameGermanstudy[].
7. Conclusion
Scoping the available literature and views within the anthro-
posophic medical community led to thirteen opinion state-
ments about fever. Many of these views are now well sub-
stantiated scientically and slowly nding their way into
the practice of mainstream medicine []: Fever is a self-
regulated phenomenon and does not, in a normal healthy
patient with an acute infection, cause harm of itself. Going
through a feverish illness may contribute to individual devel-
opment and long-term health and should be accompanied in
a way that fosters salutogenic competencies. Since it is self-
regulated, there is no temperature above which the natural fever
ofacuteinfectionsmustbeloweredper se in normal children
[]. Antipyretics should be reserved for the cases in which
the fever is endangering the patient, such as in severe sepsis or
brain injury, where cooling is advantageous, or causing distress
and malaise and alternative ways of easing their suering fail
or seem inadequate. Beware of the underlying causes of fever
and carefully accompany fever instead of suppressing it.Other
views with regard to the long-term benets of fever still await
empirical conrmation, negation, or dierentiation through
further research.
It is important for anthroposophically inclined practi-
tioners, carers, and patients to be aware of the fact that the
scientic investigation of the eects of febrile infections on
short- and long-term health and development in humans is
only beginning and that many salutogenic eects [, , ,
, , –, , , –, –, –, , –] are
emerging. However, fever needs special attention in late ges-
tation [], infancy [] (particularly the rst three months
of life, babies with fever should always be promptly and thor-
oughly examined by a competent health worker []), sedated
ventilated sepsis patients [, ], brain injury [], and
patients with Brugada syndrome (it may be recommendable
to perform an ECG during fever if there is a positive family
history of sudden death or syncope [, ], bearing in mind
that % of the population may have asymptomatic Brugada-
ECG signs in febrile conditions).
Competing Interests
e author declares that he has no competing interests.
Acknowledgments
Dr. Tido von Schoen-Angerer, Dr. Till Reckert, Dr. Maurice
Orange, Dr. Broder von Laue, Professor Dr. Wolfgang Schad,
Dr. Ren´
e Madeleyn, Professor Dr. Georg Seifert, Professor Dr.
Alfred L¨
angler, Professor Dr. Florian Stintzing, Julia, H´
el`
ene,
and Je Martin are thanked for helpful conversations.
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... Given the lack of evidence, one may appeal to knowledge of the fever process to determine that appropriate use of physical measures depends on the fever phase: As the fever is rising, the child should be kept warm or even actively warmed-thus reducing the energy needed to develop fever and thereby discomfort. Once the child is warm all the way to its feet and starts sweating, layers of sheets and clothing can be carefully removed (level 5 [154]). Despite high level evidence (level 1) that tepid sponging increases discomfort and should be avoided [150,151], 61% of guidelines are still in favor of its use. ...
... Level 5; cover according to phase of fever[154] RCT on uncovering[155] vs. paracetamol and sponging that showed very little benefit to unwrapping ...
Article
Full-text available
Introduction Divergent attitudes towards fever have led to a high level of inconsistency in approaches to its management. In an attempt to overcome this, clinical practice guidelines (CPGs) for the symptomatic management of fever in children have been produced by several healthcare organizations. To date, a comprehensive assessment of the evidence level of the recommendations made in these CPGs has not been carried out. Methods Searches were conducted on Pubmed, google scholar, pediatric society websites and guideline databases to locate CPGs from each country (with date coverage from January 1995 to September 2020). Rather than assessing overall guideline quality, the level of evidence for each recommendation was evaluated according to criteria of the Oxford Centre for Evidence-Based Medicine (OCEBM). A GRADE assessment was undertaken to assess the body of evidence related to a single question: the threshold for initiating antipyresis. Methods and results are reported according to the PRISMA statement. Results 74 guidelines were retrieved. Recommendations for antipyretic threshold, type and dose; ambient temperature; dress/covering; activity; fluids; nutrition; proctoclysis; external applications; complementary/herbal recommendations; media; and age-related treatment differences all varied widely. OCEBM evidence levels for most recommendations were low (Level 3–4) or indeterminable. The GRADE assessment revealed a very low level of evidence for a threshold for antipyresis. Conclusion There is no recommendation on which all guidelines agree, and many are inconsistent with the evidence–this is true even for recent guidelines. The threshold question is of fundamental importance and has not yet been answered. Guidelines for the most frequent intervention (antipyresis) remain problematic.
... Early detection, immediate cooling and organ support are the main pillars of treatment ( Walter et al., 2016 ). According to other medical orders, fever above 41.5 °C may not dangerous during the course of an infection, moreover, immune-protective character of fever is discussed so that a fundamental lowering of the fever with medication may have a negative effect on the course of the disease, which is why many guidelines have increased the threshold above which antipyretics is recommended, or removed it altogether ( Cannon, 2013 ;Mader & Riedl, 2018 ;Martin, 2016 ;Plaisance & Mackowiak, 20 0 0 ). ...
Article
Full-text available
Background Compresses are one of the water treatments of Traditional European Medicine and are used for a variety of indications in patient care. Calf compresses are used for gentle fever reduction. However, little is known about the origin and effectiveness of calf compresses. Aim We aimed to provide an overview regarding the evidence of the effects of the use of calf-compresses to reduce fever by means of a scoping review. Methods Five electronic databases and the “Library of the Institute for the History of Medicine” were searched in English and German language. Gray literature was also considered. The "PRISMA Scoping Review Guideline" was applied for the methodological preparation of the review. Results 45 articles were included and divided into the sections history and origins (eight references), nursing guidance (eight references), trials regarding nursing inpatients (13 trials), and trials regarding patients at the Intensive Care Unit (16 trials). While several articles and trials regarding the use of sponging and other cooling strategies were available, the use of calf-compresses was only found in a minority of German speaking articles. Only two studies demonstrated the use of calf-compresses for gentle fever reduction. Overall, the literature and studies found a support for physical cooling practices mostly along with pharmacologic antipyretics. The way of cooling, cooling application temperatures, duration of applications and the definition of fever at all demonstrate controversy approaches of methods. In clinical trials worldwide, physical cooling to lower fever is associated with side effects and discomfort. Conclusion Calf compresses are well established in German-speaking countries. Based on the knowledge gaps identified in this scoping review, further studies would be needed to explore calf compresses in their antipyretic properties and in particular their mode of application including physiological considerations. Observation to fever onset and/or phases could be an identified key useful starting point for future research. Contraindications to a fever-reducing calf wrap must be strictly observed.
... Early detection, immediate cooling and organ support are the main pillars of treatment ( Walter et al., 2016 ). According to other medical orders, fever above 41.5 °C may not dangerous during the course of an infection, moreover, immune-protective character of fever is discussed so that a fundamental lowering of the fever with medication may have a negative effect on the course of the disease, which is why many guidelines have increased the threshold above which antipyretics is recommended, or removed it altogether ( Cannon, 2013 ;Mader & Riedl, 2018 ;Martin, 2016 ;Plaisance & Mackowiak, 20 0 0 ). ...
... However, these studies point to an interesting and valuable hypothesis and are consistent with the anthroposophic view that both acute febrile childhood illnesses and fever in general can be beneficial. 60,62,225 As noted above, an anthroposophic lifestyle that involves selective vaccinations, restricted use of antipyretics and antibiotics, and a higher incidence of childhood febrile illnesses can lead to less atopy, 167,168,[171][172][173][174][175] which has been on the increase over the last several decades. ...
Article
Full-text available
Introduction: Anthroposophic medicine is a form of integrative medicine that originated in Europe but is not well known in the US. It is comprehensive and heterogenous in scope and remains provocative and controversial in many academic circles. Assessment of the nature and potential contribution of anthroposophic medicine to whole person care and global health seems appropriate. Methods: Because of the heterogenous and multifaceted character of anthroposophic medicine, a narrative review format was chosen. A Health Technology Assessment of anthroposophic medicine in 2006 was reviewed and used as a starting point. A Medline search from 2006 to July 2020 was performed using various search terms and restricted to English. Books, articles, reviews and websites were assessed for clinical relevance and interest to the general reader. Abstracts of German language articles were reviewed when available. Reference lists of articles and the author's personal references were also consulted. Results: The literature on anthroposophic medicine is vast, providing new ways of thinking, a holistic view of the world, and many integrating concepts useful in medicine. In the last 20 years there has been a growing research base and implementation of many anthroposophical concepts in the integrated care of patients. Books and articles relevant to describing the foundations, scientific status, safety, effectiveness and criticisms of anthroposophic medicine are discussed. Discussion: An objective and comprehensive analysis of anthroposophic medicine finds it provocative, stimulating and potentially fruitful as an integrative system for whole person care, including under-recognized life processes and psycho-spiritual aspects of human beings. It has a legitimate, new type of scientific status as well as documented safety and effectiveness in some areas of its multimodal approach. Criticisms and controversies of anthroposophic medicine are often a result of lack of familiarity with its methods and approach and/or come from historically fixed ideas of what constitutes legitimate science.
... In fact, characterizing fever as part of the immune response first started with Hippocrates in the 5th century BC (Ray & Schulman, 2015). Benefits of fever include fighting against infections, fighting against allergies, and in recent studies; fever induction to treat and complete remission of cancer (Martin, 2016;Reuter et al., 2018). Keep in mind that a mild fever is considered a body temperature above 100.4°F ...
... Furthermore, the association of fever as an activity of the child's personality and a possible protective factor against allergies can be found in several studies concerning anthroposophic medicine [45]. ...
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Background Physicians who include complementary medicine in their practice are thought to have an understanding of health and disease different from that of colleagues practicing conventional medicine. The aim of this study was to identify and compare the thoughts and concepts concerning infectious childhood diseases (measles, mumps, rubella, chickenpox, pertussis and scarlet fever) of physicians practicing homeopathic, anthroposophic and conventional medicine. Methods This qualitative study used semistructured interviews. Participating physicians were either general practitioners or pediatricians. Data collection and analysis were guided by a grounded theory approach. Results Eighteen physicians were interviewed (6 homeopathic, 6 anthroposophic and 6 conventional). All physicians agreed that while many classic infectious childhood diseases such as measles, mumps and rubella are rarely observed today, other diseases, such as chickenpox and scarlet fever, are still commonly diagnosed. All interviewed physicians vaccinated against childhood diseases. A core concern for physicians practicing conventional medicine was the risk of complications of the diseases. Therefore, it was considered essential for them to advise their patients to strictly follow the vaccination schedule. Homeopathic-oriented physicians viewed acute disease as a biological process necessary to strengthen health, fortify the immune system and increase resistance to chronic disease. They tended to treat infectious childhood diseases with homeopathic remedies and administered available vaccines as part of individual decision-making approaches with parents. For anthroposophic-oriented physicians, infectious childhood diseases were considered a crucial factor in the psychosocial growth of children. They tended to treat these diseases with anthroposophic medicine and underlined the importance of the family’s resources. Informing parents about the potential benefits and risks of vaccination was considered important. All physicians agreed that parent-delivered loving care of a sick child could benefit the parent-child relationship. Additionally, all recognized that existing working conditions hindered parents from providing such care for longer durations of time. Conclusions The interviewed physicians agreed that vaccines are an important aspect of modern pediatrics. They differed in their approach regarding when and what to vaccinate against. The different conceptual understandings of infectious childhood diseases influenced this decision-making. A survey with a larger sample would be needed to verify these observations.
... antimicrobial resistance because antibiotics may be less effective when combined with antipyretics [12], asthma [13,14]) and long-term (e.g. cancer [15,16], ADHD when used in pregnancy [17]). ...
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Background: Fever is one of the most common symptoms of pediatric consultations and its mismanagement is a health care burden. Guidelines on fever management are incoherent and data on fever management are still missing. This study protocol describes an app-based registry to evaluate the fever management of parents. Objective: The primary objectives are to assess guideline adherence (primary outcome) and parental confidence in managing fever, and thus to reduce overuse of antipyretics, antibiotics and healthcare providers. Secondary objectives include creating a "FeverApp" that will enable parents to handle fever safely and to use the FeverApp registry as symptom and fever management diary. Further objectives include developing and testing a symptom-led registry model by app-based acquisition of parental entries of febrile illness cycle data and developing and testing models of how an interactive app-based registry can enable nationwide EMA information to inform science, guideline and policy makers, and the public. Methods: A FeverApp, guiding parents and carers in handling and documenting fever, will be developed with family pediatricians according to current guidelines and recommended for all parents in Germany. A registry will anonymously document features, management and outcomes of febrile episodes: basic sociodemographic and medical information, initial symptoms, course of fever, pharmacological and non-pharmacological interventions, consultations with doctors, outcomes, fever-associated fears, and app satisfaction. Results: This app may improve communication quality and health, e.g. asthma and antimicrobial resistance. Results will be published via website www.feverapp.de . Trial registration: This app-based registry protocol is registered in the German Clinical Trials Register (DRKS) with registration number: DRKS00016591 .
... [10] [11] Antipyretics are used only when children are very uncomfortable or unable to hydrate themselves and not for the purpose of lowering temperature. [12,13] ...
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Introduction Reducing antibiotic use is a global priority, but the extent to which antibiotic prescriptions can be reduced in children hospitalized for community-acquired pneumonia is unknown. This study aimed to analyse the prescribing experience from a facility with a long-standing practice of restrictive antibiotic use. Methods We conducted a retrospective analysis of children from birth to 18 years, hospitalized for pneumonia at an integrative medicine hospital in Germany. Antibiotic prescription rate and clinical outcomes were analyzed. The Moreno Bacterial Pneumonia Score, a composite laboratory, clinical and radiologic score, was applied to estimate the proportion of viral and bacterial pneumonia. Results 252 pneumonia episodes were included, with 172 categorized as probably viral and 80 as bacterial pneumonia. Antibiotic prescription rate was 32 % overall, 26 % for presumed viral and 51 % for presumed bacterial pneumonia. Children with probable bacterial pneumonia who were managed with antibiotics had higher CRP values than those managed without antibiotics (p < 0.001). 13 % of bacterial pneumonia episodes initially managed without antibiotics received antibiotics after hospital day 2. Hospitalization duration was longer for bacterial pneumonia episodes managed with antibiotics than those managed without (7.0 versus 4.9 days, p = 0.003). Conclusions The observed antibiotic prescription rate of 32 % was much lower than rates reported in the literature - 88–98 %. Children were safely managed with a restrictive antibiotic prescription strategy when physicians judged this to be appropriate. Our findings suggest that a delayed prescription strategy for childhood pneumonia deserves further study. Trial registration the study was registered at clinicaltrials.org, NCT03256474.
... ey also include multimodal concepts (e.g., for fatigue and other quality-of-life issues in chronic NCDs and chronic infections) [46,47]; models of patient-centered care (e.g., for pediatric diabetic care or depressive disorder) [48][49][50]; community care (e.g., for chronic pain with associated multimorbidity) [51]; strategies for dealing with fever (http://warmuptofever.org/en/) [52]; prevention strategies (for atopic diseases and allergies) [53,54]; and support of self-efficacy [55] and perspectives on both the patient's and the care provider's needs [56,57]. e investigation of a whole healthcare system like AM [13] entails a number of specific challenges: ...
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Background: Whole medicine and health systems like traditional and complementary medicine systems (T&CM) are part of healthcare around the world. One key feature of T&CM is its focus on patient-centered and multimodal care and the integration of intercultural perspectives in a wide range of settings. It may contribute to good health and well being for people as part of the Sustainable Development Goals of the United Nations. The authentic, rigorous, and fair evaluation of such a medical system, with its inherent complexity and individualization, imposes methodological challenges. Hence, we propose a broad research strategy to test and characterize its possible contribution to health. Methods: To develop a research strategy for a specific T&CM system, Anthroposophic Medicine (AM), applying multimodal integrative healthcare based on a four-level concept of man, we used a three-phase consensus process with experts and key stakeholders, consisting of (1) premeeting methodological literature and AM research review and interviews to supplement or revise items of the research strategy and tailor them to AM research, (2) face-to-face consensus meetings further developing and tailoring the strategy, and (3) postmeeting feedback and review, followed by finalization. Results: Currently, AM covers many fields of medical specialties in varied levels of healthcare settings, such as outpatient and inpatient; primary, secondary, and tertiary care; and health education and pedagogy. It is by definition integrated with conventional medicine in the public healthcare system. It applies specific medicines, nursing techniques, arts therapies, eurythmy therapy, rhythmical massage, counseling, and psychotherapy, and it is provided by medical doctors, nurses, therapists, midwives, and nutritionists. A research strategy authentic to this level of complexity should comprise items with a focus on (I) efficacy and effectiveness, divided into (a) evaluation of the multimodal and multidisciplinary medical system as a whole, or of complex multimodal therapy concept, (b) a reasonable amount of methodologically rigorous, confirmatory randomized controlled trials on exemplary pharmacological and nonpharmacological therapies and indications, (c) a wide range of interventions and patient-centered care strategies with less extensive formats like well-conducted small trails, observational studies, and high-quality case reports and series, or subgroup analyses from whole-system studies, or health service research; (II) safety; (III) economics; (IV) evidence synthesis; (V) methodologic issues; (VI) biomedical, physiological, pharmacological, pharmaceutical, psychological, anthropological, and nosological issues as well as innovation and development; (VI) patient perspective and involvement, public needs, and ethics; (VII) educational matters and professionalism; and (IX) disease prevention, health promotion, and public health. Conclusion: The research strategy extends to and complements the prevailing hierarchical system by introducing a broad "evidence house" approach to evaluation, something many health technology assessment boards today support. It may provide transparent and comprehensive insight into potential benefits or risks of AM. It can serve as a framework for an evidence-informed approach to AM for a variety of stakeholders and collaborating networks with the aim of improving global health.
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Introduction A comprehensive assessment of the recommendations made by clinical practice guidelines (CPGs) on symptomatic fever management in children has not been carried out. Methods Searches were conducted on Pubmed, google scholar, pediatric society websites and guideline databases to locate CPGs from each country. Rather than assessing overall guideline quality, the level of evidence for each recommendation was evaluated according to criteria of the Oxford Centre for Evidence-Based Medicine (OCEBM). A GRADE assessment was undertaken to assess the body of evidence related to a single question: the threshold for initiating antipyresis. Results 74 guidelines were retrieved. Recommendations for antipyretic threshold, type and dose; ambient temperature; dress/covering; activity; fluids; nutrition; proctoclysis; external applications; complementary/herbal recommendations; media; and age-related treatment differences all varied widely. OCEBM evidence levels for most recommendations were low (Level 3-4) or indeterminable. The GRADE assessment revealed a very low level of evidence for a threshold for antipyresis. Conclusion There is no recommendation on which all guidelines agree, and many are inconsistent with the evidence – this is true even for recent guidelines. The threshold question is of fundamental importance and has not yet been answered. Guidelines for the most frequent intervention (antipyresis) remain problematic.