Facts and Myths About Fevers in Children

Research underlines the importance of improved guidelines for naturopathic physicians working with the pediatric population

By Erin Psota, ND

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Abstract

Fever in children is one of the most common reasons that parents and caregivers seek the advice of healthcare practitioners. As an adaptive immune response against infectious agents, fevers are a beneficial process and a positive indicator of healthy immune function. Because of the risk of serious bacterial illness, it is of utmost importance that naturopathic physicians working with the pediatric population have clear guidelines for treating and referring their pediatric patients. Most cases of fever will resolve without complications and respond well to naturopathic therapies aimed to improve the child’s comfort while supporting the body’s ability to heal. The perceived need for antipyretics to maintain normal temperature is one of the many myths surrounding fevers. While fever phobia among parents is common, there is no evidence that fever prolongs or worsens the course of illness, nor do fevers themselves lead to permanent neurological damage.  Recognizing these common behaviors and beliefs among parents and caregivers regarding the treatment of fevers can help naturopathic physicians provide the best possible counseling and education for patients.
 

Introduction

Fever is defined as a rectal temperature above 100.4oF (>38oC).1 Infants and young children are susceptible to fevers because of their small body size, low amount of subcutaneous fat, and high ratio of body surface area to weight,2 coupled with an immature immune system. Healthcare practitioners are generally in agreement that, as an adaptive immune response against infectious agents, fevers are a beneficial process and a positive indicator of healthy immune function.3
 
While most cases of fever are self-limiting indicators of minor infections, they can also indicate more serious infections, such as pneumonia or meningitis.4 Understandably, the possibility of serious illnesses creates anxiety in the parents. Parents may also worry about possible febrile seizures and believe that a fever left untreated can induce brain damage. Such fears should be acknowledged and addressed by the practitioner. Paradoxically, despite their concerns, parents are often reluctant to subject their young children to invasive testing, including blood testing, urinary catheterization, or lumbar puncture.5,6,7 Indeed, in most cases such invasive testing is not indicated; however, the dichotomy of these parental desires can present a challenge in patient management for the practitioner. Fortunately, there are guidelines that any primary care practitioner can follow to ensure adherence to best practices. 
 

Guidelines Established in the Medical Community

The majority of febrile infants and children will show clinical signs of a source of infection; in cases in which the fever’s cause is evident, the evaluation is considered complete.8 The most contentious issue for the treating physician in evaluating a febrile child in practice is the possibility of a serious bacterial infection (SBI) in those presenting with fever without an apparent source. 
 
The attitudes of parents and physicians often differ in terms of the risks and costs of evaluation, with physicians wanting to be sure to rule out the possibility of SBI, and parents giving more consideration to potential pain and discomfort of their children.9,10 It is generally accepted that children over 3 months of age should be considered on a case-by case basis, using abnormal physical findings to direct laboratory evaluation (eg, stool culture for bloody diarrhea, rapid Strep test with pharyngitis).11 The clinical policy currently endorsed by the American College of Emergency Physicians outlines guidelines that serve to determine the appropriate diagnostic tests in the evaluation of infants and young children in a manner that minimizes unnecessary invasive testing without compromising patient care and safety.12
 
This policy specifically addresses the commonly held myth that responsiveness to antipyretic therapy is an indication that a diagnosis of an SBI is unlikely. Studies have indicated that there is in fact no correlation between the 2, and responsiveness to fever reduction should not be used to determine whether further work-up is necessary.13,14,15,16,17,18,19
 
A broad overview of this policy suggests the following that febrile infants between 1 and 28 days of age should be presumed to have an SBI and should be managed accordingly.20 Chest x-rays (CXR) are recommended in febrile children under 3 months with evidence of acute respiratory illness; however, the policy states there is insufficient evidence to determine when a CXR is indicated in children older than 3 months. Occult urinary tract infection is the most common SBI. Thus the policy recommends that all children under 1 year, and girls under 2 years, should be evaluated by urethral catheterization or suprapubic aspiration.21,22 This policy also states that empirical antibiotic therapy should be initiated in children ages 3–36 months with a temperature over 39oC (102.2 F) and white blood cell (WBC) counts over 15,000 /mm3.23,24
 
In an editorial comment in response to this policy, Larry Baraff, MD, from the UCLA Emergency Medicine Center addresses the grey area between 28 days and 3 months of age and suggests that this group may be evaluated on an outpatient basis, according to established low-risk criteria.25,26 Examples include the Rochester or the Philadelphia criteria, which take into account the infant’s birth and medical history, as well as current lab values, to aid the physician in determining the risk of SBI. 
 
Some experts have called for these guidelines to be modified to more accurately reflect current epidemiology. The widespread use of the haemophilus influenzae type B (Hib) vaccine and pneumococcal conjugate vaccine (PCV) has dramatically reduced the likelihood of an SBI such as bacteremia or meningitis due to these organisms.27,28 This also makes non-specific screening techniques, such as WBC counts, less useful because high counts previously tended to be associated with these common sources of infection.29,30 It is important however, to recognize that many families seeking alternative and complementary healthcare may choose to defer or forego vaccinations altogether, and these infectious agents should not be ruled out.
 
After decisions regarding further workup and diagnostic testing have been made, the question still remains regarding antipyretic treatment—not only whether or not to initiate therapy, but also which type and dosing method to choose. Acetaminophen at a dose of 10–15 mg/kg/dose every 4–6 hours or ibuprofen at a dose of 5–10 mg/kg/dose every 8 hours are the most commonly employed antipyretics.31 There is often no particular reason that practitioners recommend, or caregivers choose to give, either acetaminophen or ibuprofen other than familiarity and availability.32
 
One recent review brings to light answers to a few common questions regarding the treatment of fevers, including data showing that antipyretic therapy does not shorten the duration of illness or prevent the recurrence of febrile seizures.33,34,35,36 While there is some evidence to suggest that ibuprofen is more effective than acetaminophen, additional research has shown that alternating the 2 is marginally more effective than either one on its own.37 This idea of alternate dosing may have led to the widespread belief that administering both at the same time is most effective, though there is no evidence to suggest this.
 

Naturopathic Overview of the Management of Fevers

In a primary care setting, naturopathic physicians should follow similar practice guidelines as their allopathic counterparts when evaluating febrile children. In the majority of cases, an SBI will be ruled out, and an appropriate treatment strategy can be determined Naturopathic physicians have a long anecdotal history of supporting rather than suppressing fevers using hydrotherapy techniques, as well as botanical and homeopathic remedies. As fevers are seen as a beneficial healing process, naturopathic physicians tend to use conventional antipyretics more sparingly than allopathically trained practitioners, depending on patient, parent, and professional comfort. 
 
Hydrotherapy techniques have a long history of use in naturopathic practice. These treatments are safe and easy to implement with children at home. As the body’s largest organ, the skin and its vasculature have much control over heat elimination and conservation. Thus by considering both the temperature of applications to the skin and the length of time applied, caregivers can manipulate body temperature to promote patient comfort. The most common hydrotherapy treatments recommended in young children are tepid (81–92oF) or neutral (93–96oF) sponge baths or the “warming sock” treatment, which consists of dry wool socks put on over cold, wet cotton socks with the patient covered and warm. Both of these treatments promote cooling by conduction and heat loss by evaporation. Sponge bathing also provides gentle friction, which further promotes peripheral circulation and therefore increased heat loss.38 Hydrotherapy techniques have not been well explored in conventional literature, and well-conducted randomized controlled trials are lacking; a 2003 Cochran review found that tepid sponging did help to reduce fevers in children in a few small studies, while subsequent reviews found insufficient evidence to support tepid sponging as a method to control fevers.39,40
As fevers are seen as a beneficial healing process, naturopathic physicians tend to use conventional antipyretics more sparingly than allopathically trained practitioners, depending on patient, parent, and professional comfort.
Botanical preparations are similarly used for their diaphoretic and cooling effects on the body. Herbal medicines also have the advantage of being prepared in combination to suit the needs of each patient’s individual condition. Well-known diaphoretics include yarrow (Achillea millefolium), catnip (Nepeta cataria), linden (Tilia tomentosa), elderflower (Sambucus nigra), meadowsweet (Filipendula ulmaria), and peppermint (Mentha piperita), which can be combined with immune-enhancing herbs such as echinacea (Echinacea spp.) or andrographis (Andrographis paniculata). In addition to this, chamomile (Matricaria chamomilla) may be added to soothe a restless or uncomfortable child, and herbs with an affinity for a specific organ system may also be incorporated into the treatment. For example, one might use buchu (Barosma betulina) for a urinary tract infection, goldenseal (Hydrastis canadensis) for gastrointestinal concerns, or hyssop (Hyssopus officinalis) for respiratory tract infections in combination with the diaphoretic and immune-stimulating herbs. These preparations can be administered as teas or tinctures or frozen into popsicles, dosed appropriately to the child’s age and weight. Herbal teas may also be cooled to a comfortable temperature and used as enemas or combined with hydrotherapy principles and used as a sponge bath.41,42,43
 
Infants and young children respond very well to homeopathic remedies, which are known for their safety and ease of administering. Seeking to support the patient’s innate ability to heal and encourage the body to shift from disease to health, homeopathy treats the whole person, not the disease. For this reason, homeopathic remedies should be symptom-specific to the individual. However, it can be useful for parents to keep the most common fever remedies on hand. Chamomilla can be used for fevers in irritable infants and children with great sensitivity to pain, while China may be a good choice for intermittent or periodic fevers, with chills and drenching sweats. Ferrum phosphoricum can be used for moderate fevers without differentiating symptoms. It is common for children to need more than one remedy over the course of an acute illness. There are dozens of possible homeopathics to consider for each case, and a thorough review is beyond the scope of this paper. Combination homeopathic remedies are now readily available and convenient for caregivers without immediate access to an experienced homeopathic prescriber. These combinations typically contain the most common fever remedies, and while they may not be the exact correct remedy, some benefit may still be observed without any safety concerns.44, 45
 
Traditional Chinese Medicine also views fever as an expression of heat in response to an external pathogen. Treatment principles seek to help to fully express the fever and dispel excess heat, primarily through the use of herbal medicines, and secondarily using acupuncture.46 A review of complementary and alternative medicine approaches to fevers found that a traditional Japanese herbal combination called Mao-to (a combination of Ephedra herba, Cinnamomi cortex, Armeniacae semen, and Glycyrrhizae radix), used to treat fever and influenza-like symptoms in children, had better fever-reducing results when compared to an antiviral drug.47,48 While acupuncture use will vary depending on the age of the child, parents can easily be instructed to perform acupressure at home, which may be helpful in calming a restless child and reducing heat.
 

Naturopathic Principles in Fever Management

Recovering from an infection is one of the body’s most important self-healing processes. Fevers stimulate the production of leukocytes, interleukins, interferons, and tumor necrosis factor as part of an acute inflammatory response to the infectious agent.49 In accordance with the naturopathic principle of identifying and removing the underlying cause of illness, naturopathic physicians seek to support immune function in dealing with these pathogens as opposed to suppressing the beneficial physiologic response of a fever. A recent report in the American Academy of Pediatrics’ journal states treatment should address patient discomfort rather than focus on achieving normothermia. This reminds us that it is more often parents, not practitioners, who are fever-phobic.50,51
 
Encouraging parents to monitor an ill child for signs of dehydration, irritability, activity level, and feeding, instead of simply medicating based on a number, follows the naturopathic principle of treating the whole person. Collected data show that approximately half of parents and caregivers consider children to have a fever at lower temperatures than the defined 100.4oF (38oC) and tend to medicate accordingly to maintain the child’s “normal” temperature. One study also found that the majority of parents wake sleeping children to administer antipyretics, despite not being given any such advice by healthcare providers.52,53,54
 
Another guiding principle of naturopathic medicine is “doctor means teacher.” Patient education is of utmost importance in the treatment of a febrile child. Many parents are, of course, concerned about the potential neurological consequences of fevers. While febrile seizures, occurring in approximately 2–4% of children, are potentially frightening to parents, they are typically harmless and are not indicative of an underlying neurological condition.55,56 The height of the temperature does not predict the occurrence of a seizure, nor is there evidence to suggest that antipyretic therapy reduces the recurrence of such seizures.57 Parents and caregivers can be reassured that even in temperatures as high as 107.6oF (42oC), brain damage has not been shown to be caused by the fever itself.58 Complications however, may result from the underlying illness, and thus fevers should not be ignored.
 
A central principle common to all systems of medicine, “First, do no harm,” should also be applied to the decision-making process. While acetaminophen and ibuprofen can be dangerous, they are generally considered safe by both parents and practitioners. A number of studies highlight potential safety concerns with incorrect dosing, or giving adult rather than children’s preparations.59,60,61 As previously discussed, alternating acetaminophen and ibuprofen is a common practice among parents and practitioners;however this practice increases the risk of accidental overdose, as does the use of other combination products, such as cough syrups, which may also contain these medications.
 
Furthermore, Doran et al. found that acetaminophen may prolong the duration of illness in children with varicella.62 This implies it is important to allow the developing immune system to properly mount a response to infections. Similarly, recent studies suggest that antipyretic therapy initiated following vaccinations may result in a decreased immune response to the vaccine. 
 

Conclusion

Naturopathic physicians have a long history of respecting the innate ability of the body to heal itself. Fever management has been a combination of assessing the patient to rule out serious infectious disease processes, educating the caregivers about the beneficial effects of fevers on immune function, and providing therapies designed to strengthen the immune system while providing symptom relief. The American Academy of Pediatrics ultimately shares the fundamental practices of the naturopathic approach to fever management.63 While remembering to give special consideration to neonates and children with central nervous system conditions or compromised immune systems, recognizing common behaviors and beliefs among parents and caregivers regarding the treatment of fevers can help all practitioners provide the best possible counseling and education for patients.

About the Author

Erin Psota, ND, completed her medical studies at the Canadian College of Naturopathic Medicine (CCNM) in 2005 after obtaining her bachelor of science degree from the University of Waterloo. In 2010, her passion for pediatric medicine led her to the Southwest College of Naturopathic Medicine in Arizona to pursue a pediatric residency. In addition to maintaining a private practice in downtown Toronto, Psota is a clinical supervisor at CCNM and is actively involved with the College of Naturopaths of Ontario, the provincial regulatory body for naturopathic medicine.

References

1 Nield LS, Kamat D. Fever. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RF. eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Saunders Elsevier; 2011:e169-1-169-3.
2 Sarrell EM, Wielunsky E, Cohen HA. Antipyretic treatment in young children with fever: acetaminophen, ibuprofen or both alternating in a randomized, double-blind study. Ach Pediatr Adolesc Med. 2006; 160(2): 197-202.
3 Nield LS, Kamat D. Fever. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RF. eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Saunders Elsevier; 2011:e169-1-169-3.
4 Ibid.
5 Jhaveri R, Byington CL, Klein JO, Shapiro ED. Management of the non-toxic appearing acutely febrile child: A 21st century approach. J Peds. 2011; 159(2): 181-185.
6 Kramer MS, Naimark L, Leduc DG. Parental fever phobia and its correlates. Pediatrics. 1985;75(6):1110–1113.
7 Baraff LJ. Management of infants and young children with fever without source in infants and children. Pediatr Ann. 2008;37(10): 673-679.
8 Nield LS, Kamat D. Fever. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RF. eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Saunders Elsevier; 2011:e169-1-169-3.
9 Jhaveri R, Byington CL, Klein JO, Shapiro ED. Management of the non-toxic appearing acutely febrile child: A 21st century approach. J Peds. 2011;159(2)181-185.
10 Kramer MS, Naimark L, Leduc DG. Parental fever phobia and its correlates. Pediatrics. 1985;75(6):1110–1113.
11 Nield LS, Kamat D. Fever. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RF. eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Saunders Elsevier; 2011:e169-1-169-3.
12 Clinical policy for children younger than three years presenting to the emergency department with fever. Ann Emerg Med. 2003;42(4):530-545.
13 Ibid.
14 Torrey SB, Henretig F, Fleisher G, et al. Temperature response to antipyretic therapy in children: relationship to occult bacteremia. Am J Emerg Med. 1985;3(3):190-192.
15 Weisse ME, Miller G, Brien JH. Fever response to acetaminophen in viral vs. bacterial infections. Pediatr Infect Dis J. 1987;6(12):1091-1094.
16 Baker MD, Fosarelli PD, Carpenter RO. Childhood fever: correlation of diagnosis with temperature response to acetaminophen. Pediatrics. 1987;80(3):315-318.
17 Mazur LJ, Jones TM, Kozinetz CA. Temperature response to acetaminophen and risk of occult bacteremia: a case-control study. J Pediatr. 1989;115(6):888-891.
18 Baker RC, Tiller T, Bausher JC, et al. Severity of disease correlated with fever reduction in febrile infants.Pediatrics. 1989;83(6):1016-1019.
19 Yamamoto LT, Wigder HN, Fligner DJ, et al. Relationship of bacteremia to antipyretic therapy in febrile children.Pediatr Emerg Care. 1987;3(4):223-227.
20 Clinical policy for children younger than three years presenting to the emergency department with fever. Ann Emerg Med. 2003;42(4):530-545
21 Ibid.
22 Jhaveri R, Byington CL, Klein JO, Shapiro ED. Management of the non-toxic appearing acutely febrile child: A 21st century approach. J Peds. 2011;159(2)181-185.
23 Clinical policy for children younger than three years presenting to the emergency department with fever. Ann Emerg Med. 2003;42(4):530-545
24 Baraff LJ. Management of infants and young children with fever without source in infants and children. Pediatr Ann. 2008;37(10): 673-679.
25 Baraff LJ. Editorial: Clinical policy for children younger than three years presenting to the emergency department with fever. Ann Emerg Med. 2003; 42(4):546-549.
26 Nield LS., Kamat D. Fever without a Focus. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RF. eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Saunders Elsevier; 2011:896-902.
27 Ibid.
28 Jhaveri R, Byington CL, Klein JO, Shapiro ED. Management of the non-toxic appearing acutely febrile child: A 21st century approach. J Peds. 2011;159(2)181-185.
29 Ibid.
30 Baraff LJ. Editorial: Clinical policy for children younger than three years presenting to the emergency department with fever. Ann Emerg Med. 2003; 42(4):546-549.
31 Nield LS, Kamat D. Fever. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RF. eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Saunders Elsevier; 2011:e169-1-169-3.
32 Hay AD, Redmond NM, Costelloe C, Montgomery AA, Fletcher M, Hollinghurst S, Peters TJ. Paracetamol and ibuprofen for the treatment of fever in children: the PITCH randomised controlled trial. Health Technol Assess. 2009;13(27) iii-iv, ix-x, 1-163.
33 Miller RJ, Bailey J, Sullivan K. Clinical Inquiries: Does lowering a fever > 101 F in children improve clinical outcomes? J Fam Pract. 2010;59(6)353, 360.
34 American Academy of Pediatrics, Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures. Febrile seizures: clinical practice guidelines for the long-term management of the child with simple febrile seizures. Pediatrics. 2008;121(6):1281–1286.
35 Duffner PK, Baumann RJ. A synopsis of the American Academy of Pediatrics practice parameters on the evaluation and treatment of children with febrile seizures. Pediatr Rev. 1999;20(8):285–287.
36 Sadleir LG, Scheffer IE. Febrile seizures. BMJ. 2007;334(7588):307–311.
37 Mayoral CE, Marino RV, Rosenfield W, Greensher J. Alternating antipyretics: Is this an alternative?  Pediatrics.2005;105(5):1009-1012.
38 Boyle W, Saine A. Lectures in Naturopathic Hydrotherapy. Sandy, OR: Eclectic Medical Publications; 1988.
39 Meremikwu M, Oyo-Ita A. Physical methods for treating fever in children. Cochrane Database Syst Rev. 2003;(2):CD004264.
40 Wang D, Bukutu C, Thompson A, Vohra S. Complementary, Holistic, and Integrative Medicine: Fever. Pediatr. Rev. 2009;30(3);75-78.
41 Santich R, Bone K. Common childhood infections and fever management. In: Phytotherapy Essentials: Healthy Children Optimising Children’s Health with Herbs. Warwick, Australia: Phytotherapy Press; 2008.
42 Bove M. Fever. In: An Encyclopedia of Natural Healing for Children and Infants. 2nd ed. Harrisonburg, VA: Keats Publishing; 2001.
43 Zand J, Rountree R, Walton R. Fever. In: Smart Medicine for a Healthier Child. 2nd ed. New York, NY: Avery; 2003.
44 Ibid.
45 Ullman R, Reichenberg-Ullman J. Homeopathic Self-Care: The Quick and Easy Guide for the Whole Family. New York, NY: Three Rivers Press;1997: 165-167.
46 Lu HC. Philosophy and methods. In: Chinese Natural Cures: Traditional Methods for Remedy and Prevention.New York, NY: Black Dog and Leventhal Publishers;2005. 
47 Wang D, Bukutu C, Thompson A, Vohra S. Complementary, Holistic, and Integrative Medicine: Fever. Pediatr. Rev. 2009;30(3);75-78.
48 Kubo T, Nishimura H. Antipyretic effect of Mao-to, a Japanese herbal medicine, for treatment of type A influenza infection in children. Phytomedicine. 2007;14(2-3):96–101.
49 Nield LS, Kamat D. Fever. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RF. eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Saunders Elsevier; 2011:e169-1-169-3.
50 Sullivan JE, Farrar HC. Fever and antipyretic use in children. Pediatrics. 2011;127(3):580-587.
51 Kramer MS, Naimark L, Leduc DG. Parental fever phobia and its correlates. Pediatrics. 1985;75(6):1110–1113.
52 Sullivan JE, Farrar HC. Fever and antipyretic use in children. Pediatrics. 2011;127(3):580-587.
53 Kramer MS, Etezadi-Amoli J, Ciampi A, Tange SM, Drummond KN, Mills EL, et al. Parents’ versus physicians values for clinical outcomes in young febrile children. Pediatrics. 1994;93(5):697-702.
54 Crocetti M, Moghbeli N, Serwint J, et al: Fever phobia revisited: have parental misconceptions about fever changed in 20 years?. Pediatrics 2001; 107(6):1241-1246.
55 Avner JR. Acute fever. Pediatr. Rev. 2009;30(1):5-13.
56 Mayo Foundation for Medical Education and Research. Mayo Clinic Website. http://www.mayoclinic.com/health/febrile-seizure/DS00346. Accessed March 29, 2011.
57 Miller RJ, Bailey J, Sullivan K. Clinical Inquiries: Does lowering a fever > 101 F in children improve clinical outcomes? J Fam Pract. 2010;59(6)353, 360.
58 Avner JR. Acute fever. Pediatr. Rev. 2009;30(1):5-13.
59 Crook J. Fever management: evaluating the use of ibuprofen and paracetamol. Paediatr Nurs. 2010;22(3):22-26.
60 Hay AD, Redmond NM, Costelloe C, Montgomery AA, Fletcher M, Hollinghurst S, Peters TJ. Paracetamol and ibuprofen for the treatment of fever in children: the PITCH randomised controlled trial. Health Technol Assess. 2009;13(27) iii-iv, ix-x, 1-163.
61 Sarrell EM, Wielunsky E, Cohen HA. Antipyretic treatment in young children with fever: acetaminophen, ibuprofen or both alternating in a randomized, double-blind study. Ach Pediatr Adolesc Med. 2006;160(2):197-202.
62 Doran TF, De Angelis C, Baumgardner RA, Mellits ED. Acetaminophen: more harm than good for chickenpox? J Pediatr. 1989;114(6):1045-8.
63 Sullivan JE, Farrar HC. Fever and antipyretic use in children. Pediatrics. 2011;127(3):580-587.