Parental and health care provider understanding of childhood fever: a Canadian perspective

Pediatrics

CJEM 2002;4(6):394-400

Abstract

Résumé

Introduction

Fever is a common problem in children, and one of the most common reasons parents bring their children to medical attention. Evidence suggests that most febrile episodes are not dangerous and may, in fact, be a beneficial response to infection.^1-4 In children, these are usually self-limited viral infections.^1,4 Several studies published in the early and mid-1980s evaluated parental "fever phobia" and found that parents had many misconceptions.^1,5,6 The investigators showed that parental education decreased misconceptions about fever, increased appropriate management of febrile episodes, and reduced inappropriate physician visits and telephone calls.^5-8 These findings prompted the investigators to recommend that fever teaching become a routine part of pediatric care. Similar studies found that many physicians have exaggerated concerns about fever and that physicians often give mixed messages by telling parents that fever is not dangerous while advising them to treat it aggressively.^9-11 A study of pediatric emergency nurses came to similar conclusions.¹²

Our primary objective was to assess parental and health care provider understanding of fever, its potential consequences and its treatment. Our secondary objective was to determine whether their sources of information on this subject have changed in recent years -- particularly with the increasing popularity of health issues in contemporary magazines and on the Internet. Our hypotheses were that parents of children presenting with fever would have different perceptions and attitudes than parents of nonfebrile children, and that different types of health care providers would have different perceptions depending on the patient population they serve.

Methods

This was a cross-sectional survey of 3 groups of parents and 4 groups of health care providers.

Parental survey

A questionnaire was developed, pilot tested on 15 parents presenting to the Alberta Children's Hospital (ACH) Emergency Department (ED), then revised to ensure clarity. The final 4-page survey contained questions pertaining to duration and treatment of fever, utilization of health care resources, sources of information and general knowledge of fever, its treatment and potential consequences. For most questions, parents were asked to choose responses from a checklist, and were given the opportunity to add items not on the checklist. In addition, demographic and postal code data were gathered for estimation of socioeconomic status. Investigators distributed the survey directly to a convenience sample of parents who brought their child to the ACH ED with fever (fever group) or injuries (injury group); a school nurse distributed the survey to parents of healthy children in kindergarten and grade 1 at local schools (school group).

Health care provider survey

A questionnaire was developed and pilot tested on a sample of 10 physicians and nurses from the ACH ED, then revised for clarity. The final 2-page survey contained questions pertaining to general knowledge about fever, its potential consequences, and the health care worker's recommendations for treatment. Four groups of health care providers were surveyed: pediatric emergency nurses, pediatric emergency physicians, general pediatricians and family physicians. The questionnaire was distributed directly to all pediatric emergency nurses and attending physicians in the ED (including 6 general pediatricians who work primarily in the ED, 6 Royal College-trained emergency physicians, 3 CCFP(EM)-trained emergency physicians, and 1 fellowship-trained pediatric emergency physician). In addition, the survey was mailed to all local general pediatricians and a random sample of local family physicians. A second and third mailing was performed for nonrespondents. Parental and health care provider surveys were self-administered.

Data analysis

Data was entered on Microsoft Access 97^® and analyzed on Microsoft SPSS Base 9.0^®. Descriptive statistics, including proportions, means, standard deviations, medians and ranges were calculated. One-way ANOVA (analysis of variance) was used to compare continuous variables with normal distribution. Kruskal-Wallis one-way ANOVA was used to compare continuous variables that did not have a normal distribution. Chi-squared analysis was used to compare group proportions. If a p value was <0.05 it was considered significant. This study was approved by the Medical Research Ethics Board at the University of Calgary, Faculty of Medicine.

Results

Parent groups

The survey response rate was 69.7% (209/300) in the fever group, 64.0% (160/250) in the injury group and 47.0% (141/300) in the school group. Parental respondents were mothers in 72.7%, 69.4% and 94.3% of cases, respectively. The mean age of the children was 2.8 ± 2.6 years in the fever group, 7.9 ± 4.4 years in the injury group and 5.5 ± 0.6 years in the school group, and the mean age of parental responders was approximately 30 years greater: 33.0 ± 6.5 years, 38.3 ± 7.2 years, and 35.5 ± 4.8 years in the fever, injury and school groups respectively. The level of parental education and socioeconomic status were similar in all 3 groups.

In children with fever, the median duration of fever prior to presentation was 36 hours (range 1-336 hours). In this cohort, 84.2% of parents measured their child's temperature with a thermometer, most often using the axillary route. Parents checked their child's temperature a median of 6 times in a 24-h period (range = 0-48 times) and recorded temperatures from 37.4°C to 41.7°C (median = 39.5°C). Ninety-five percent of parents treated the fever prior to arrival. Most (177/209; 84.7%) used acetaminophen, some (20/209; 9.6%) used ibuprofen, and none used aspirin. Seventeen percent (36/209) used cold water baths or sponging, 29% (61/209) used tepid water baths or sponging, 5.3% (11/209) removed excess clothing, 4.3% (9/209) applied cool cloths, 1% (2/209) used alcohol rubs and 1% used other over-the-counter cold remedies. A third (64/197) had been to one physician, and 5.6% (11/197) had seen 2 or more physicians in the 48 hours preceding their ED visit. Fifty-five percent (114/207) of parents in the fever group, 45.9% (72/157) in the injury group and 34.5% (48/139) in the school group stated that they had previously brought their child to an ED because of a fever.

Table 1 shows that parents in all 3 groups had similar perceptions regarding the significance of different degrees of temperature elevation. Table 2 outlines what parents felt were potential consequences of fever. In addition to the concerns described in Table 2, 20 parents were worried about "missing an infection," 9 about "not knowing the cause of the fever," 3 about "organ damage" and 2 about sterilization. Table 3 summarizes the information sources that parents used to learn about fever.

Health care providers

All 16 pediatric emergency physicians, 39 (73.5%) of 53 pediatric emergency nurses, 26 (62.0%) of 42 general pediatricians and 79 (43.0%) of 185 family physicians returned the questionnaire. Table 1 shows that the health care provider groups had similar definitions of fever, high fever and treatable fever. Table 4 summarizes physician and nurse beliefs regarding the potential consequences of fever.

Two pediatricians (9.1%) and 1 ED nurse (4.5%) stated that they would treat any fever. Four (25.9%) ED physicians, 5 (22.7%) ED nurses, 3 (13.6%) pediatricians and 6 (9.1%) family physicians stated that they based treatment decisions on the clinical state of the child. Eight (50.0%) ED physicians, 21 (95.5%) ED nurses, 11 (42.3%) pediatricians, and 7 (10.6%) family physicians said they would treat the fever only if the child was experiencing discomfort. Table 5 summarizes health care provider recommendations for the treatment of fever. There were no significant differences between groups in the recommended frequency of checking the temperature, or in whether a specific route was encouraged.

Discussion

In this study, we found that most parents believed that fever may cause seizures, dehydration and brain damage, that parents of febrile children were significantly more concerned about the possibility dehydration and brain damage (than parents of otherwise well school children), and that many parents believe fevers in the range of 39.7°C or higher are dangerous. A similar majority of physicians (all types) were concerned about dehydration and seizures, and ED nurses were significantly less concerned about seizures. A surprisingly high proportion of family physicians expressed concerns about brain damage (40.5%) and death (34.1%), and family physicians were more likely than surveyed parents to express concerns about all of the potential complications (dehydration, seizures, brain damage and death).

Like Kramer and colleagues,¹³ we found that parents of febrile children tended to be more worried about adverse effects of fever than parents of otherwise well children. This may be in part because parents of febrile children are younger and have younger children, but we found no other potentially explanatory sociodemographic differences. Knowledge was otherwise comparable between the 3 groups: all had similar definitions of fever, high fever and dangerous fever and all had similar treatment thresholds for fever.

Treatment decisions

More health care providers than in a previous study¹¹ indicated that they consider the child's clinical state and comfort level when making treatment decisions; however, parents did not indicate that clinical factors influence their decision to treat. This supports previous studies showing that most parents treat fevers aggressively regardless of the clinical state of the child.^1,5-8,13,14 In addition, many parents stated that they woke their child at night to check the temperature -- also consistent with previous findings.^1,13

In this study, like others,¹⁵ parents more often treated their child's fever with medicine than with comfort measures alone, and acetaminophen was the medication of choice for both physicians and parents. Although doctors and nurses often recommended ibuprofen, parents seldom used it, probably because it has only recently been approved for use in Canada (i.e., October 1997 for ages 2-12 years and July 2000 for ages 3-24 months).

Despite the fact that sponging may increase discomfort and does not reliably reduce fever, many physicians, particularly family physicians,¹⁶ still recommend tepid water baths or sponging, and one-third of parents in this study reported still using these modalities. It is reassuring that no parent in the study admitted to using aspirin, but it is concerning that there are physicians who still recommend its use despite the association with Reye's syndrome.

Information sources

A recent study concluded that health care providers are in a unique position to educate parents with regard to fever,¹⁷ and our data suggest that physicians, family members and nurses are the most common source of information about fever. Our data also suggest that books and magazines are increasingly important information sources. We were surprised that relatively few parents reported using the Internet as an information source; however, we noted that its use more than doubled in the group with younger parents and children. This suggests that the Internet may be a growing source of health information or that parents are more likely to use it when their child is acutely ill (since more acutely ill children were younger). We have noted a similar trend in the use of the ACH advice line, which has been heavily advertised as a resource for parents in the last few years. Hopefully, information sources like this will enable parents to avoid unnecessary ED visits in the future.

Education and utilization

Given the apparent concern of health care providers for fever, it is not surprising that all provider groups recommended checking the temperature regularly and that some even recommended waking children to check for fever. In this context it is also understandable that most parents worried about major complications and were quick to seek medical attention for their febrile children. The fact that one-third of patients had seen a physician during the 48 hours prior to presentation to the ED, despite relatively short fever duration, suggests that failure of education at the initial visit, concern about the cause of the ongoing fever, or parents' fear of fever itself may lead to over-utilization of health care resources. Our data suggest that health care providers require education in order to dispel their own misconceptions about fever, that parents would benefit from better fever awareness, and that closer scrutiny of information presented in lay publications is warranted.

Limitations

One of the limitations of this study is the difficulty in distinguishing "fever phobia" related to fear of the cause of the fever vs. fear of the fever itself. We feel that this distinction was made clear to the health care providers, but it is possible that uncertainty may have affected some parental responses. We are also concerned about the external validity of our findings relating to emergency physician perceptions. Although the emergency physicians surveyed have a variety of training backgrounds, all work in a tertiary care pediatric centre, and their experience, knowledge base and perspective may differ from physicians working in a general ED.

Conclusions

Childhood fever continues to inspire fear in both parents and health care providers, and "fever phobia" is more pronounced in parents of febrile children. Health care providers are a primary information source and may transmit mixed messages that increase parental anxiety and trigger avoidable health care utilization. Physicians and nurses must be trained to give parents correct and consistent information in order to counteract "fever phobia."

Contributors: All of the authors participated in the concept, design; analysis and interpretation of data. Dr Karwowska was primarily responsible for drafting the manuscript, but all authors participated in revisions and have all approved the manuscript submitted.

References

1. Schmitt BD. Fever phobia; misconceptions of parents about fevers. Am J Dis Child 1980;134:176-81.
2. Kluger M.J. Fever. Pediatrics 1980;66:720-4.
3. Kluger M.J. Fever revisited. Pediatrics 1992;90:846-50.
4. Fruthaler G.J. Fever in children: phobia vs facts. Hosp Pract 1985;20:49-53.
5. Anderson A. Parental perception and management of school-age children's fevers. Nurse Practitioner 1988;13:8-9,12-8.
6. Kilmon C.A. Parent's knowledge and practices related to fever management. J Pediatr Health Care 1987;1:173-9.
7. Casey R, McMahon BA, McCormick MC, Pasquariello PS, Zavod W, King FH. Fever therapy: an educational intervention for parents. Pediatrics 1984;73:600-5.
8. Robinson JS, Schwarz M-L, Magwene KS, Krengel SA, Tamburello D. The impact of fever health education on clinic utilization. AJDC 1989;143:698-704.
9. May A, Bauchner H. Fever phobia: the pediatrician's contribution. Pediatrics 1992;90:851-4.
10. Ipp M, Jaffe D. Physicians' attitudes toward the diagnosis and management of fever in children 3 months to 2 years of age. Clin Pediatr 1993;66-70.
11. Mayoral CE, Marino RV, Rosenfeld W, Greensher J. Alternating antipyretics: Is this an alternative? Pediatrics 2000;105:1009-12.
12. Poirier MP, Davis PH, Gonzalez-del-Rey JA, Monroe KW. Pediatric emergency department nurses' perspectives on fever in children. Pediatr Emerg Care 2000;16:9-12.
13. Kramer MS, Naimark L, Leduc DG. Parental fever phobia and its correlates. Pediatrics 1985;75:1110-3.
14. Impicciatore P, Nannini S, Pandolfini C, Bonati M. Mothers' knowledge of, attitudes toward and management of fever in preschool children in Italy. Preven Med 1998;27:268-73.
15. Kinmonth A-L, Fulton Y, Campbell MJ. Management of feverish children at home. BMJ 1992;305:1134-6.
16. Sharber J. The efficacy of tepid sponge bathing to reduce fever in young children. Am J Emerg Med 1997;15:188-92.
17. Crocetti M, Moghbeli N, Serwint J. Fever phobia revisited: Have parental misconceptions about fever changed in 20 years? Pediatrics 2001;6:1241-6.