Pediatric emergency department nurses' perspectives on fever in children

The Dangers of Acetaminophen for Neurodevelopment Outweigh Scant Evidence for Long-Term Benefits

Based on available data that include approximately 20 lines of evidence from studies in laboratory animal models, observations in humans, correlations in time, and pharmacological/toxicological considerations, it has been concluded without reasonable doubt and with no evidence to the contrary that exposure of susceptible babies and children to acetaminophen (paracetamol) induces many, if not most, cases of autism spectrum disorder (ASD). However, the relative number of cases of ASD that might be induced by acetaminophen has not yet been estimated. Here, we examine a variety of evidence, including the acetaminophen-induced reduction of social awareness in adults, the prevalence of ASD through time, and crude estimates of the relative number of ASD cases induced by acetaminophen during various periods of neurodevelopment. We conclude that the very early postpartum period poses the greatest risk for acetaminophen-induced ASD, and that nearly ubiquitous use of acetaminophen during early development could conceivably be responsible for the induction in the vast majority, perhaps 90% or more, of all cases of ASD. Despite over a decade of accumulating evidence that acetaminophen is harmful for neurodevelopment, numerous studies demonstrate that acetaminophen is frequently administered to children in excess of currently approved amounts and under conditions in which it provides no benefit. Further, studies have failed to demonstrate long-term benefits of acetaminophen for the pediatric population, leaving no valid rationale for continued use of the drug in that population given its risks to neurodevelopment.

Childhood fever and medical students: A multicentre, educational intervention

AIM

Misconceptions and non-evidence-based practices toward childhood fever are reported worldwide. Medical students might be ideal candidates to introduce long-lasting changes in clinical practice. However, no study has gauged the effectiveness of an educational intervention to improve fever management in this population. We conducted an educational, interventional study on childhood fever among final-year medical students.

METHODS

We conducted a prospective, multicentre interventional study employing a pre/post-test design. Participants from three Italian Universities filled in a questionnaire just before the intervention (T0), immediately after (T1) and 6 months later (T2) in 2022. The intervention was a two-hour lecture focused on the pathophysiology of fever, recommendations for its treatment and risks associated with improper management.

RESULTS

188 final-year medical students (median age of 26 years, 67% females) were enrolled. Relevant improvements in the criterion for treating fever and conceptions about the beneficial effects of fever were observed at T1 and T2. Similar data were found for the reduction of physical methods advice to decrease body temperature and concerns for brain damage from fever.

CONCLUSION

This study shows for the first time that an educational intervention is effective in changing students' conceptions and attitudes toward fever both in the short and medium term.

Approach to fever in children among final-year nursing students: a multicenter survey

BACKGROUND

Unfounded concerns regarding fever are increasingly observed among nurses worldwide. However, no study has so far explored the preferred approach towards pediatric fever among nursing students. Therefore, we aimed to investigate the attitude towards pediatric fever among final-year nursing students.

METHODS

Between February and June 2022, final-year nursing students of 5 Italian university hospitals were asked to answer an online survey on their approach to fever in children. Both quantitative and qualitative methods were utilized. Multiple regression models were employed to explore the existence of moderators on fever conceptions.

RESULTS

The survey was filled in by 121 nursing students (response rate 50%). Although most students (98%) do not consider discomfort to treat fever in children, only a minority would administer a second dose of the same antipyretic in nonresponsive cases (5.8%) or would alternate antipyretic drugs (13%). Most students would use physical methods to decrease fever (84%) and do not think that fever has mainly beneficial effects in children (72%). The own know-how adequacy on fever was inversely associated (OR 0.33, 95% CI 0.13-0.81) with the beliefs that high fever might lead to brain damage. No further predictive variable was significantly associated with the concern that fever might be associated with brain damage, the advice of physical methods use, and the assumption that fever has mostly positive effects.

DISCUSSION

This study shows for the first time that misconceptions and inappropriate attitudes towards fever in children are common among final-year nursing students. Nursing students could potentially be ideal candidates for improving fever management within clinical practice and amongst caregivers.

Delta Neutrophil Index Does Not Differentiate Bacterial Infection without Bacteremia from Viral Infection in Pediatric Febrile Patients

Introduction: We sought to determine whether the delta neutrophil index (DNI), a marker that is reported to be used to predict the diagnosis, prognosis, and disease severity of bacteremia and sepsis, is useful in differentiating bacterial infection without bacteremia (BIWB) from viral infections (VI) in pediatric febrile patients in the emergency department (ED). Method: We conducted a retrospective analysis of febrile patients’ medical records from the pediatric ED of the teaching hospital. The patients with BIWB and those with VI were identified with a review of medical records. The primary outcome was the diagnostic performance of DNI in differentiating BIWB from VI. The secondary outcome was a comparison of the diagnostic performances of DNI, CRP, WBC, and neutrophil count between the two groups. Results: A total of 151 (26.3%) patients were in the BIWB group, and 423 (73.7%) were in the VI group. There was no significant difference in DNI between the two groups (3.51 ± 6.90 vs. 3.07 ± 5.82, mean ± SD, BIWB vs. VI). However, CRP levels were significantly higher in the BIWB group than in the VI group (4.56 ± 5.45 vs. 1.39 ± 2.12, mean ± SD, BIWB vs. VI, p < 0.05). The AUROCs of DNI, WBC count, neutrophil levels, RDW, and CRP levels were 0.5016, 0.5531, 0.5631, 0.5131, and 0.7389, respectively, and only CRP levels were helpful in differentiating BIWB from VI. Conclusion: In the absence of bacteremia, DNI would not be helpful in differentiating BIWB from VI in pediatric febrile patients.

Paediatric fever management practices and antipyretic use among doctors and nurses in New Zealand emergency departments

OBJECTIVES

To assess (i) paediatric fever management practices among New Zealand ED doctors and nurses, including adherence to best practice guidelines; and (ii) the acceptability of a randomised controlled trial (RCT) of antipyretics for relief of discomfort in young children.

METHODS

A cross-sectional survey of doctors and nurses across 11 New Zealand EDs. The primary outcome of adherence to paediatric fever management best practice guidelines was assessed with clinical vignettes and defined as single antipyretic use for the relief of fever-related discomfort.

RESULTS

Out of 602 participants (243 doctors, 353 nurses and six unknown; response rate 47.5%), only 64 (10.6%, 95% confidence interval [CI] 8.3-13.4%) demonstrated adherence to best practice guidelines. In a febrile settled child with normal fluid intake, the percentage of participants that would use antipyretics doubled with abnormal vital signs (33.7% vs 72.9%, difference -39.2%, 95% CI -44.4% to -34.0%). Most participants would use antipyretics for reduced fluid intake (n = 494, 82.1%, 95% CI 78.8-85.0%) in a febrile settled child. Over half (n = 339, 57.1%, 95% CI 53.0-61.1%) would advise giving antipyretics to prevent febrile convulsions. Most (n = 467, 80.0%, 95% CI 76.5-83.1%) participants agreed that a RCT of antipyretics in febrile children <2 years of age with relief of discomfort as a primary outcome is needed.

CONCLUSIONS

Just over 10% of New Zealand ED doctors and nurses demonstrated adherence to paediatric fever management best practice guidelines. A RCT of antipyretics in febrile children <2 years of age specifically addressing relief of discomfort as a primary outcome is strongly supported.

Diagnostic value of mid-regional pro-Adrenomedullin as a biomarker of invasive bacterial infection in children: a systematic review

Background

Invasive bacterial infections (IBI) in children present a difficult clinical challenge. They are often life-threatening, however in the early stages they can be hard to differentiate from benign viral infections. This leaves clinicians with the risk of missing a serious IBI diagnosis or inappropriately using antimicrobials in a child with a viral infection- contributing to the ongoing development of increased antimicrobial resistance. Hence, biomarkers which could aid in early detection of IBI and differentiation from viral infections are desirable. Mid-Regional pro-Adrenomedullin (MR-proADM) is a biomarker which has been associated with IBI. The aim of this systematic review was to determine its diagnostic accuracy in identifying children with IBI.

Methods

A strategy was devised to search online databases MEDLINE, Embase, Web of Science and Scopus for human clinical trials reporting the accuracy of MR-proADM in children. Against predesigned inclusion and exclusion criteria full texts were selected for inclusion and data extraction. True positives, false positives, true negatives and false negatives were extracted from each included study to fill 2 × 2 tables. Using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool methodological quality of each study was assessed.

Results

A total of 501 articles were initially identified. After the removal of duplicates and abstract screening 11 texts were fully reviewed and four texts (totaling 1404 patients) were included in the systematic analysis. Only one study was of a high quality and that study accounted for the vast majority of patients. A single study reported the diagnostic accuracy of MR-proADM for invasive bacterial infection reporting an Area under the Curve of 0.69. The paucity of available studies made meta-analysis and studies of heterogeneity impossible.

Conclusion

There is a paucity of research regarding the diagnostic accuracy of MR-proADM in the diagnosis of invasive bacterial infections in children. Initial results would suggest that MR-proADM testing alone is poor at identifying IBI in young children. It remains unclear if MR-proADM performs differently in older children or in children with signs and symptoms of IBI.

Trial registration

PROSPERO CRD42018096295.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03255-9.

Racial/Ethnic Disparities in Triage Scores Among Pediatric Emergency Department Fever Patients

OBJECTIVES

Emergency department (ED) triage scores are assigned to patients in a short period based on assessment of need for lifesaving measures, risk and pain levels, resource needs, and vital signs. Racial/ethnic disparities have been found across a number of outcomes but are not consistent across all studies. This study examines pediatric ED cases reporting fever, a commonly reported triage symptom, to explore racial/ethnic and age disparities in triage score assignment.

METHODS

This study uses the 2009-2015 National Hospital Ambulatory Medical Care Survey, an annual national sample of ED visits in the United States. Pediatric cases where fever is the sole reported reason for visit are analyzed for racial/ethnic disparities, controlling for sex, age, insurance status, body temperature, region, and hospital type.

RESULTS

Among all pediatric fever cases, temperature is the sole significant predictor of triage scores. However, non-Hispanic (NH) black pediatric patients older than 1 year have approximately 22% greater risk of being given a less urgent triage score relative to NH white patients.

CONCLUSIONS

Findings suggest racial disparities in the triage of NH black pediatric patients older than 1 year for fever. Although fever is a single and often non-life-threatening condition, especially after infancy, findings of racial disparities in triage scores suggests a need for further evaluation of the assignment of patient urgency in emergency medicine.

Knowledge, beliefs and management of childhood fever among nurses and other health professionals: A cross-sectional survey

BACKGROUND

Fever phobia, the unfounded fear regarding the potential harms of fever in children, has been internationally documented among parents. This fear causes anxiety in parents and health professionals are regularly consulted for advice.

OBJECTIVES

This study aimed to investigate the knowledge, beliefs and recommended treatments among Australian nurses, pharmacists, general practitioners and paediatricians in the management of febrile children.

DESIGN, SETTING AND PARTICIPANTS

This was an online cross-sectional survey of Australian nurses, pharmacists, general practitioners and paediatricians designed to evaluate the knowledge and preferred recommendations in the management of febrile children.

METHODS

The health professionals were recruited via Facebook. Demographic information, knowledge, beliefs and preferred treatments were collected through the online survey, and responses were compared across professions.

RESULTS

Of the 839 health professionals who completed the survey, 52.0% correctly identified a fever as 38 °C or above. Overall, 23.6% underestimated the temperature that constitutes a fever. Respondents reported concerns leaving fever untreated in children, with dehydration (65.1%), seizures (65.2%), serious illness (34.4%) and brain damage (29.9%) the most common concerns. Pharmacists were more likely to hold these concerns. The beliefs that reducing a child's fever with medication will reduce the risk of harm (34.7%) and prevent febrile convulsions (51.1%) were prevalent among respondents. These beliefs were more common among pharmacists. Pharmacists were also more likely to recommend parents monitor a child's temperature (48.5%) and give medication to reduce fever (64.6%).

CONCLUSIONS

Australian nurses, pharmacists, general practitioners and paediatricians reported many misconceptions surrounding the definition of fever, the potential harms of fever and its management, which may perpetuate parental fears. These misconceptions were most common among pharmacists. Continuing professional development is essential to ease unfounded concerns and ensure the safe and judicious care of febrile children.

Pediatric tuina for the treatment of fever in children: A protocol for systematic review and meta-analysis

BACKGROUND

Infantile fever is a common symptom of the pediatric diseases, which is often caused by cold, food accumulation, or other pathogenic factors. Pediatric tuina is regarded as an acceptable non-pharmaceutical therapy for children with optimal effects, which has been widely used for infantile fever around China. But there is still a lack of systematic evaluation and research on its safety and effectiveness during the treatment of infantile fever. Thus the protocol is to collect clinical evidence and demonstrate the efficacy and safety of antipyretic manipulation by pediatric tuina.

METHODS

The systematic electronic search will be executed in Cochrane Library (1991-2020.6), EMBASE (1980-2020.6), PubMed (1996-2020.6), WHOICTRP (2004-2020.6), Web of Science (1900-2020.6), CNKI (1994-2020.6), CBM (1994-2020.6), WANFANG (1980-2020.6), and VIP (2000-2020.6) Database. The Review Manager (V.5.3) will be use to assess the risk of bias and data analyses. The methodological quality will be assessed by using the online GRADEpro tool. If the quality of numeric data is favorable, a meta-analysis will be carried out.

RESULTS

A high-quality evidence of pediatric tuina for the treatment of infantile fever.

CONCLUSION

The systematic review will provide a reliable basis for judging whether pediatric tuina is safe and effective in the treatment of pediatric fever.

INPLASY REGISTRATION NUMBER

INPLASY202060032.

A protocol for a systematic review and meta-analysis of the diagnostic accuracy of mid-regional pro-adrenomedullin in predicting invasive bacterial infection in children

BACKGROUND

The early recognition of invasive bacterial infections (IBI) in children can be difficult. Clinically it is often challenging to differentiate between the early stages of an IBI and a benign self-limiting viral infection. These challenges mandate a cautious approach resulting in the overuse of antimicrobial drugs with resultant antimicrobial resistance. Due to these challenges, there is growing research into the role of biomarkers for the early identification of children with IBI. Earlier and more accurate diagnoses may lead to improved clinical outcomes for children and reduced antimicrobial resistance. Mid-regional pro-adrenomedullin (MR-proADM) is a biomarker that has been shown to be elevated in patients with IBI. The aim of this systematic review is to determine the diagnostic accuracy of MR-proADM at identifying children with IBI.

METHODS

To identify relevant studies we will search MEDLINE, Embase, Web of Science and Scopus from 1980 to the present day for all human clinical trials involving children that report the test accuracy of MR-proADM. We will include case-control studies, cohort studies and randomised control trials reported in any language. In addition, we will hand-search reference lists and grey literature including conference abstracts and web searches. Two reviewers will independently screen study titles and abstracts for eligibility followed by full-text assessment and data extraction including population, setting, timing and use of index test and reference standard used. Methodological quality will be assessed, by two authors, according to the revised tool for the quality assessment of diagnostic accuracy studies (QUADAS-2), any discrepancies will be resolved by a third author. The following test characteristics will be extracted into 2 × 2 tables for all included studies: true positives, false positives, true negatives and false negatives. Study-specific estimates of sensitivity and specificity with 95% confidence intervals will be displayed in forest plots.

DISCUSSION

This review will report the normal ranges for MR-proADM in health and the diagnostic accuracy of MR-proADM at identifying children with IBI. The review will help to define where in the diagnostic pathway MR-proADM could be useful including potential as a point-of-care test for children at first presentation with IBI.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018096295.

Fever Characteristics and Risk of Serious Bacterial Infection in Febrile Infants

BACKGROUND

Fever is a common complaint in the pediatric emergency department (ED), but the vast majority of children evaluated with fever do not have a serious bacterial infection (SBI). However, in the neonate, a missed SBI can have devastating consequences.

OBJECTIVES

To determine the association between various fever characteristics and the risk of SBI in febrile infants.

METHODS

This is a secondary analysis of the Pediatric Emergency Care Applied Research Network study on febrile infants. Infants with a fever were prospectively enrolled at 26 enrolling EDs between 2008 and 2013. We analyzed association of height of fever, location of where temperature was taken (enrolling ED vs. non-health care location), and duration of fever with SBI.

RESULTS

We included 4821 patients who had at least a blood culture completed. Height of fever was significantly associated with risk of SBI, with an odds ratio of 1.5 (95% confidence interval 1.2-1.8). Duration of fever was not associated with risk of SBI, and a fever taken in the enrolling ED vs. at a non-health care facility was minimally associated with risk of SBI (odds ratio 1.3, 95% confidence interval 1.0-1.5).

CONCLUSION

In all analyses, height of fever was associated with all three major types of SBI in febrile infants. Duration and location of fever were less reliably associated with risk of SBI, but there was a small association of risk of SBI and a fever taken at the enrolling ED vs. at a non-health care location.

Utilization of Antipyretics for Nonurgent Fever in a Pediatric Emergency Department

This retrospective cohort study aimed to describe antipyretic use among healthy patients in a pediatric emergency department (ED) with nonurgent fever defined as: triage level 4 or 5, chief complaint fever or temperature 38°C to 39°C, and otherwise normal vital signs, and determine if antipyretic administration is associated with increased ED length of stay (LOS). We compared continuous variables using Kruskal-Wallis and Wilcoxon rank sum testing. We adjusted confounding variables using logistic regression modeling. A total of 22 169 patients were included. Of these, 52% received antipyretic: acetaminophen (38%), ibuprofen (19%), or both antipyretics (5%). ED LOS (median hours) varied by number of antipyretic types given (none, 2.2; ibuprofen, 2.7; acetaminophen, 2.7; and both 3.4, P < .001) and number of doses (0 doses, 2.2, 1 dose, 2.7; 2 doses, 3.4, P < .001). Patients who received antipyretic were more likely to have ED LOS greater than 2 hours (adjusted odds ratio 1.99, 95% CI 1.88-2.11) compared with those with no antipyretic, controlling for age, imaging studies, laboratory studies, antibiotic administration, and disposition.

Healthcare professionals approach paediatric fever in significantly different ways and fever phobia is not just limited to parents

AIM

Fever is a benign process, but it is still frequently regarded as harmful. We aimed to evaluate the knowledge of parents and healthcare professionals on fever.

METHODS

Data were obtained through questionnaires administered to a sample of parents and nurses in the paediatric emergency rooms of two hospitals and to family doctors and paediatricians currently practising in Portugal.

RESULTS

We collected 265 answers from parents, 49 from nurses and 525 from doctors. Most nurses (74%), doctors (55%) and parents (43%) considered fever as a temperature above 38°C. The parents' first reaction to a febrile child was to give them antipyretics, and acetaminophen was used most frequently (44%). Nurses considered that a child with fever must always be treated and that a history of febrile seizures was the most decisive factor in initiating treatment. On the other hand, the most important factor for paediatricians was the presence of discomfort. For parents (74%) and nurses (92%), the most feared effect of untreated fever was seizures, and for paediatricians (97%), it was irritability.

CONCLUSION

The parents' and nurses' attitudes demonstrated fear of fever and its consequences. The approach to paediatric fever was significantly different among healthcare professionals.

Drivers for inappropriate fever management in children: a systematic review

Background Fever is one of the most common childhood symptoms and accounts for numerous consultations with healthcare practitioners. It causes much anxiety amongst parents as many struggle with managing a feverish child and find it difficult to assess fever severity. Over- and under-dosing of antipyretics has been reported. Aim of the review The aim of this review was to synthesise qualitative and quantitative evidence on the knowledge, attitudes and beliefs of parents regarding fever and febrile illness in children. Method A systematic search was conducted in ten bibliographic databases from database inception to June 2014. Citation lists of studies and consultation with experts were used as secondary sources to identify further relevant studies. Titles and abstracts were screened for inclusion according to pre-defined inclusion and exclusion criteria. Quantitative studies using a questionnaire were analysed using narrative synthesis. Qualitative studies with a semi-structured interview or focus group methodology were analysed thematically. Results Of the 1565 studies which were screened for inclusion in the review, the final review comprised of 14 studies (three qualitative and 11 quantitative). Three categories emerged from the narrative synthesis of quantitative studies: (i) parental practices; (ii) knowledge; (iii) expectations and information seeking. A further three analytical themes emerged from the qualitative studies: (i) control; (ii) impact on family; (iii) experiences. Conclusion Our review identifies the multifaceted nature of the factors which impact on how parents manage fever and febrile illness in children. A coherent approach to the management of fever and febrile illness needs to be implemented so a consistent message is communicated to parents. Healthcare professionals including pharmacists regularly advise parents on fever management. Information given to parents needs to be timely, consistent and accurate so that inappropriate fever management is reduced or eliminated. This review is a necessary foundation for further research in this area.

Symptomatic Management of Fever in Children: A National Survey of Healthcare Professionals' Practices in France

Despite the production and dissemination of recommendations related to managing fever in children, this symptom saturates the practices of primary healthcare professionals (HPs). Data on parent practices related to fever are available, but data on HPs’ practices are limited. We studied HPs’ practices, determinants of practices and concordance with recommendations in France. We conducted a national cross-sectional observational study between 2007 and 2008 among French general practitioners, primary care pediatricians and pharmacists. HPs were asked to include 5 consecutive patients aged 1 month to 12 years with acute fever. HPs completed a questionnaire about their practices for the current fever episode. We used a multilevel logistic regression model to assess the joint effects of patient- and HP-level variables associated with this behavior. In all, 1,534 HPs (participation rate 13%) included 6,596 children (mean age 3.7 ± 2.7 years). Physicians measured the temperature of 40% of children. Primary HPs recommended drug treatment for 84% of children (including monotherapy for 92%) and physical treatment for 62% (including all recommended physical treatments for 7%). HPs gave written advice or a pamphlet for 13% of children. Significant practice variations were associated with characteristics of the child (age, fever level and diagnosis) and HP (profession and experience). In France, despite the production and dissemination of national recommendations for managing fever in children, primary HPs’ observed practices differed greatly from current recommendations, which suggests potential targets for continuing medical education.

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

Objectives:

Fever is common in children and causes misconceptions among parents. Many investigators have called for improved parental education to dispel “fever phobia.” Our objectives were to assess parental and health care provider understanding of fever, its treatment, and beliefs about its consequences, as well as to identify parental sources of information about fever.

Methods:

Self-administered surveys were distributed to 3 parent groups and 4 health care provider groups. Parent groups included parents of children with fever presenting to the emergency department (ED) (fever group, n = 209), parents of children with an injury presenting to ED (injury group, n = 160), and parents of healthy school children (school group, n = 141). Provider groups included pediatric ED physicians (n = 16), pediatric ED nurses (n = 39), general pediatricians (n = 26) and family physicians (n = 79).

Results:

Parent groups considered a temperature of 37.9°C to be a fever, 39.1°C to be a high fever, and 39.9°C to be a dangerous fever. Parents were most concerned about discomfort, seizures and dehydration, and parents in the “fever group” worried more about dehydration (p = 0.01) and brain damage (p = 0.03) than other parents. Most physicians were concerned about dehydration and seizures, but family physicians were most likely to express concerns about brain damage (40.5%) and death (34.1%).

Conclusions:

Fever phobia exists among parents and health care providers and is most likely in parents of febrile children and family physicians. Health care providers varied in their knowledge of fever and its treatment. Greater education of health care workers is required in order to provide families with appropriate information.

The knowledge, attitudes and beliefs of carers (parents, guardians, healthcare practitioners, crèche workers) around fever and febrile illness in children aged 5 years and under: protocol for a qualitative systematic review

BACKGROUND

Many parents consider fever a disease in itself and feel disempowered when their child is ill. Numerous guidelines have been produced; however, their target audience remains healthcare professionals and not carers of children in general. A reliable source of information will decrease worry in parents and carers when managing a febrile child.

METHODS/DESIGN

A systematic search will be conducted in nine electronic databases. Articles published in English, or with an abstract published in English, will be eligible for inclusion in the review. Unpublished literature, grey literature and consultation with experts in the area will be used to supplement database searching. Titles and abstracts of studies will be screened for inclusion in the study by two independent reviewers against pre-determined inclusion and exclusion criteria. A data extraction form will be designed and data will be extracted to provide detail of the included studies by a further two reviewers. Quality assessment of studies will be conducted by two additional independent reviewers and results will be used to moderate included studies. All disagreements will be resolved through discussion until consensus is reached. Thematic synthesis will be used to analyse results.

DISCUSSION

Correct management of fever in children is not well understood in the general population. Although carers can identify fever and febrile illness in children, determination of the severity of fever proves challenging. Research is needed to cohere existing evidence and identify knowledge gaps. It is envisaged that results of this review will contribute to the development of trustworthy, accessible guidelines for parents and carers of children with fever or febrile illness.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014009812.

Development and evaluation of simulation-based fever management module for children with febrile convulsion

BACKGROUND

A reliable and valid checklist for the evaluation of simulation learning outcomes has great value in nursing education. This study focuses on simulation-based fever management module including checklist for febrile convulsion in pediatric nursing.

PURPOSES

This study has two aims; (a) to develop a simulation-based fever management module for treating children with febrile convulsion, and (b) to evaluate students' performance and satisfaction.

PARTICIPANTS

A convenient sample of 147 senior nursing students from two nursing schools in South Korea participated in this study from April 29 to June 14, 2013.

METHODS

This study was a three-stage process: developing the simulation-based module including algorithm with scenarios, items in checklist, and contents of debriefing (Stage I), performing simulation and debriefing for nursing students (Stage II), and evaluating the evaluation checklist of simulation performance and satisfaction of nursing students (Stage III). Student satisfaction was measured using the Satisfaction of Simulations Experience [SSE] scale. Debriefing data were analyzed using the Matrix Method.

RESULTS

A scenario script was created to treat the patient's health issues. The algorithm proceeded as follows: identification of patient's condition (Step I), nursing interventions (Step II), and outcome evaluation and feedback (Step III). The total mean score of the evaluation checklist was 2.67 (±.32). The debriefing categories were as follows: non-technical skills, self-efficacy, critical thinking, and technical skills. The total mean score of the SSE was 4.48 (±.42).

CONCLUSION

This study provides a blueprint for simulation-based practice for both nursing educators and nursing students. Further studies of checklists used in different contexts would be valuable for expanding upon this research.

Paracetamol: a focus for the general pediatrician

Paracetamol (acetaminophen) is one of the most popular and widely used drugs for the treatment of pain and fever in children. This drug has multiple mechanisms of action, but its pharmacodynamic is still not well known. The central nervous system is the main site of action and it mirrors the paracetamol effect compartment. The recommended dosages and routes of administration should be different whether paracetamol is used for the treatment of pain or fever. For example, the rectal route, while being efficacious for the treatment of fever, should be avoided in pain management. Paracetamol is a safe drug, but some clinical conditions and concomitant drugs, which are frequent in clinical practice, may increase the risk of paracetamol toxicity. Therefore, it is important to optimize its administration to avoid overdoses and maximize its effect. The principal mediator of the paracetamol toxicity is the N-acetyl-p-benzo-quinone imine (NAPQI), a toxic product of the paracetamol metabolism, which could bind cysteine groups on proteins forming paracetamol-protein adduct in the liver.

CONCLUSION

Although frequently prescribed, the concept of "effect compartment concentration" and the possible co-factors that could cause toxicity at recommended doses are not familiar to all pediatricians and general practitioners. We reviewed the literature concerning paracetamol mechanisms of action, we highlighted some relevant pharmacodynamic concepts for clinical practice, and we summarized the possible risk factors for toxicity at therapeutic dosages.

Nurses' knowledge of and attitudes towards fever and fever management in one Irish children's hospital

This study aims to describe nurses' knowledge of and attitudes towards the management of fever in one children's hospital in Ireland. A descriptive, quantitative research design was employed. One hundred and nineteen nurses working in one children's hospital completed a self-report questionnaire. Nurses' mean knowledge score about the physiology of fever, fever management and antipyretics was 51 per cent (n = 119), which was lower than expected. Nurses had both appropriate and inappropriate attitudes towards fever and fever management. Inconsistent attitudes between nurses were identified. Nurses who participated in this study are not expert managers of fever. Their lack of knowledge and inconsistent attitudes are affecting the care of febrile children, and may be fuelling parents' fever phobia. Further education is required to improve nurses' knowledge of fever and fever management. Inappropriate attitudes need to be challenged and addressed in an effort to promote evidence-based care for febrile children.

Beliefs and expectations of Canadian parents who bring febrile children for medical care

OBJECTIVES

The purpose of this survey was to study the beliefs, expectations, and satisfaction of Canadian parents regarding fever and the treatment of their febrile children.

METHODS

A survey was developed exploring caregiver beliefs and treatment strategies, as well as expectations and satisfaction with medical care. Some items were modeled after previous studies to allow comparison. Caregivers with febrile children were recruited from 2005 to 2007 at 3 urgent care centers and emergency departments in Edmonton, Canada: a pediatric emergency department (n = 376), an urban urgent care center (n = 227), and a suburban urgent care clinic (n = 173).

RESULTS

High and rapidly rising temperature, as well as physical symptoms associated with fever, caused concern in most parents surveyed. Seventy-four percent of parents felt that the elevated temperature from fever was dangerous and 90.3% always try to treat it. Forty degrees Celsius was the most commonly sited threshold for danger. Identifying the cause (80.6%) and seriousness (87.4%) of fever were the most com-mon stressors identified. Caregivers expected to receive information about the child's illness and appropriate treatment. The parents most often wanted information about febrile seizures and the potential dangers of febrile illness. Only 16.7% of caregivers expected anti-biotics. Nearly 92% of subjects were usually satisfied with medical care.

CONCLUSIONS

Fever phobia continues to be a significant issue for Canadian parents. As a result, they treat fever aggressively and often seek medical attention. Good communication is important for medical staff caring for febrile children and typically leads to satisfied parents.

Knowledge, attitudes and misconceptions of primary care physicians regarding fever in children: a cross sectional study

Background

Fever is an extremely common sign in paediatric patients and the most common cause for a child to be taken to the doctor. The literature indicates that physicians and parents have too many misconceptions and conflicting results about fever management. In this study we aim to identify knowledge, attitudes and misconceptions of primary care physicians regarding fever in children.

Methods

This cross-sectional study was conducted in April-May 2010 involving primary care physicians (n=80). The physicians were surveyed using a self-administered questionnaire. Descriptive statistics were used.

Results

In our study only 10% of the physicians knew that a body temperature of above 37.2°C according to an auxiliary measurement is defined as fever. Only 26.2% of the physicians took into consideration signs and symptoms other than fever to prescribe antipyretics. 85% of the physicians prescribed antipyretics to control fever or prevent complications of fever especially febrile seizures. Most of the physicians (76.3%) in this study reported that the height of fever may be used as an indicator for severe bacterial infection. A great majority of physicians (91.3%) stated that they advised parents to alternate the use of ibuprofen and paracetamol.

Conclusions

There were misconceptions about the management and complications of fever. There is a perceived need to improve the recognition, assessment, and management of fever with regards to underlying illnesses in children.

Parental and medical knowledge and management of fever in Italian pre-school children

BACKGROUND

Guidelines for the management of fever in children have been recently published, however "fever phobia" is still spreading. To provide information which may sustain educational interventions tailored to our population we investigated the parental and medical knowledge and management of fever in preschool children.

METHODS

A questionnaire was administered to a convenient sample of Italian parents and paediatricians. The questionnaire elicited information about definition and cause of fever, concerns about fever, method of temperature measurement, and treatment modalities.

RESULTS

Overall, 388 parents and 480 paediatricians were interviewed. All the parents believed that fever could cause at least one harmful effect and 89.9% (n = 349) believed that, if left untreated, it can cause brain damage or seizures. Parents used multiple resources to obtain information about fever but 67.8% (n = 264) considered paediatricians as their primary resource. Several wrong behaviours were found in the same proportions among parents and paediatricians: 78.5% of paediatricians (n = 377) and 77.8% of parents (n = 302) used physical method to reduce fever (P = 0.867); 27.0% of paediatricians (n = 103) and 21.4% (n = 83) of parents declared to alternate ibuprofen and acetaminophen (P = 0.953). Differently, 73.1% (n = 351) of paediatricians preferred oral to rectal administration of antipyretics compared to 48.7% (n = 190) of parents (P < 0.0001). Worrisomely, 1.4% of paediatricians and 1.2% of parents declared to use acetylsalicylic acid or steroids as second-choice antipyretics (P = 0.937) and 6.7% (n = 26) of parents declared to use table- or teaspoons for determining the dose of drug.

CONCLUSIONS

Paediatricians' attitudes greatly influence the parental behaviours and beliefs. Implementation of educational programs regarding the management of the febrile child are needed in our setting.

Efficacy of standard doses of Ibuprofen alone, alternating, and combined with acetaminophen for the treatment of febrile children

BACKGROUND

Many pediatricians recommend, and many parents administer, alternating or combined doses of ibuprofen and acetaminophen for fever. Limited data support this practice with standard US doses.

OBJECTIVE

This study compared the antipyretic effect of 3 different treatment regimens in children, using either ibuprofen alone, ibuprofen combined with acetaminophen, or ibuprofen followed by acetaminophen over a single 6-hour observation period.

METHODS

Febrile episodes from children aged 6 to 84 months were randomized into the 3 treatment groups: a single dose of ibuprofen at the beginning of the observation period; a single dose of ibuprofen plus a single dose of acetaminophen at the beginning of the observation period; or ibuprofen followed by acetaminophen 3 hours later. Ibuprofen was administered at 10 mg/kg; acetaminophen at 15 mg/kg. Temperatures were measured hourly for 6 hours using a temporal artery thermometer. The primary outcome was temperature difference between treatment groups. Adverse-event data were not collected in this single treatment period study.

RESULTS

Sixty febrile episodes in 46 children were assessed. The mean (SD) age of the children was 3.4 (2.2) years, and 31 (51.7%) were girls. Differences among temperature curves were significant (P < 0.001; the combined and alternating arms had significantly better antipyresis compared with the ibuprofen-alone group at hours 4 to 6 (hour 4, P < 0.005; hours 5 and 6, P < 0.001). All but one of the children in the combined and alternating groups were afebrile at hours 4, 5, and 6. In contrast, for those receiving ibuprofen alone, 30%, 40%, and 50% had temperatures >38.0 °C at hours 4, 5, and 6, respectively (hour 4, P = 0.002; hours 5 and 6, P < 0.001).

CONCLUSION

During a single 6-hour observation period for these participating children, combined and alternating doses of ibuprofen and acetaminophen provided greater antipyresis than ibuprofen alone at 4 to 6 hours. ClinicalTrials.gov identifier: NCT00267293.

Fever and antipyretic use in children

Fever in a child is one of the most common clinical symptoms managed by pediatricians and other health care providers and a frequent cause of parental concern. Many parents administer antipyretics even when there is minimal or no fever, because they are concerned that the child must maintain a "normal" temperature. Fever, however, is not the primary illness but is a physiologic mechanism that has beneficial effects in fighting infection. There is no evidence that fever itself worsens the course of an illness or that it causes long-term neurologic complications. Thus, the primary goal of treating the febrile child should be to improve the child's overall comfort rather than focus on the normalization of body temperature. When counseling the parents or caregivers of a febrile child, the general well-being of the child, the importance of monitoring activity, observing for signs of serious illness, encouraging appropriate fluid intake, and the safe storage of antipyretics should be emphasized. Current evidence suggests that there is no substantial difference in the safety and effectiveness of acetaminophen and ibuprofen in the care of a generally healthy child with fever. There is evidence that combining these 2 products is more effective than the use of a single agent alone; however, there are concerns that combined treatment may be more complicated and contribute to the unsafe use of these drugs. Pediatricians should also promote patient safety by advocating for simplified formulations, dosing instructions, and dosing devices.

Fever phobia: a survey of caregivers of children seen in a pediatric emergency department

BACKGROUND

Fever continues to be the most common complaint of children seen in a Pediatric Emergency Department (PED). Previous studies have assessed the prevalence of fever phobia in various populations. This study aims to document the incidence of fever phobia in a PED.

METHODS

Through convenience sampling, caregivers of children seen in a PED were surveyed using a research-assistant-administered questionnaire. The survey contained 28 questions pertaining to caregivers' perceptions, attitudes, and behaviors regarding fever in children.

RESULTS

In all, 230 caregivers were surveyed. The median temperature considered to be a fever was 37.8 degrees C (100.0 degrees F), with a range of 36.1 degrees C (97 degrees F) to 40.6 degrees C (105 degrees F), whereas the median temperature considered to result in harmful consequences was 40.6 degrees C (105 degrees F), with a range of 37.8 degrees C (100 degrees F) to 43.3 degrees C (110 degrees F). The median temperature at which antipyretics would be administered was 37.8 degrees C (100 degrees F), with a range of 36.1 degrees C (97 degrees F) to 39.4 degrees C (103 degrees F). More than one third of caregivers reported that they would administer antipyretics inappropriately. The median temperature at which a child would be taken to the PED was 39.4 degrees C (103 degrees F), with a range of 36.7 degrees C (98 degrees F) to 40.8 degrees C (105.4 degrees F). There was also a relationship between level of education and level of fever concern.

CONCLUSION

Fever phobia and inappropriate treatment for febrile children is present among caregivers of patients seen in a PED. Level of education may be a factor in fever knowledge and practices. Overly zealous, potentially harmful home practices and unnecessary PED visits for the assessment and treatment of fever in children is widespread among caregivers surveyed in the PED.

Paracetamol and fever management

Paracetamol is one of the most commonly used legal drugs in the western world. Its availability is good, cost is low, and its uses include `over-the-counter' (OTC) distribution, primary care prescribed therapy, secondary care `post-operative' application and emergency treatment. Stated benefits of paracetamol include: the drug's analgesic effects, preference to aspirin in avoidance of Reye's syndrome, good patient tolerance, and iatrogenic complications are infrequent and minor. Stated cautions include hepatotoxic effect following minor doses and short duration use and users may incur compromised immune integrity. This paper is concerned with paracetamol's role in fever management. Public concern regarding, in particular, childhood fever and febrile convulsions is largely unwarranted. Despite paracetamol's reputation as a popular fever-reducing agent the drug is poorly effective in the control of febrility and febrile convulsions showing no important advantage compared with placebo. Paracetamol is probably grossly over-prescribed for fever management and its value more perceived than real. Greater efforts are needed to inform patients of the natural benefits of the biological strategy of fever and of the highly limited and in some cases contraindicated use of paracetamol in fever management.

Evaluation and treatment of fever in intensive care unit patients

Fever is a common complaint in hospitalized patients, with estimates that more than 30% of ward patients and as much as 90% of critically ill patients will experience fever. Much of the treatment of fever, however, is based on tradition and the belief the fever is harmful to the patient rather than on scientific evidence. There is a need to determine via analysis of the literature the best evidence-based approach to the identification and treatment of fever with attention to appropriate measurement of body temperature, diagnostic evaluation, changing of indwelling catheters, administration of antipyretics, and alteration in antimicrobial therapy. The advanced practice nurse is uniquely capable of gathering this evidence and implementing a plan of care that meets the individual needs of the patient, family, nursing staff, and healthcare system.

Promoting evidence-based childhood fever management through a peer education programme based on the theory of planned behaviour

AIMS AND OBJECTIVES

This study examined effectiveness of a theoretically based education programme in reducing inappropriate antipyretic use in fever management.

BACKGROUND

Paediatric nurses' inconsistent, ritualistic antipyretic use in fever management is influenced by many factors including inconsistent beliefs and parental requests. Determinants of antipyretic administration, identified by the theory of planned behaviour, were belief-based attitudes and subjective norms.

DESIGN

A quasi-experiment explored group effects of a peer education programme, based on the theory of planned behaviour, on factors influencing paediatric nurses' antipyretic administration. Surveys and chart audits collected data from medical wards at experimental and control hospitals one month pre and one and four months postpeer education programme.

METHODS

All nurses employed in targeted wards were eligible to participate in surveys and all eligible charts were audited. The peer education programme consisted of four one-hour sessions targeting evidence-based knowledge, myths and misconceptions, normative, attitudinal and control influences over and rehearsal of evidence-based fever management. All nurses in experimental hospital targeted wards were eligible to attend. Peer education and support facilitated session information reaching those unable to attend sessions.

RESULTS

Two-way univariate anovas explored between subject, experimental and control group and within subject factors, pre, post and latency data. Significant interactions in normative influence (p = 0.01) and intentions (p = 0.01), a significant main group effect in control influence (p = 0.01) and a significant main effect between audit data across time points (p = 0.03) highlight peer education programme effectiveness in behaviour change. Normative, control and intention changes postpeer education programme were maintained in latency data; mean temperature was not.

CONCLUSION

The peer education programme, based on a behaviour change theory, initiated and maintained evidence-based intentions for antipyretics use in fever management.

RELEVANCE TO CLINICAL PRACTICE

The promotion of evidence-based change in organizational unit intentions and behaviour highlights the crucial role peer support and education can play in continuing educational programmes.

Effect of an evidence-based education programme on ED discharge advice for febrile children

AIMS

This study aimed to examine the effect of an educational intervention on discharge advice given to parents leaving the emergency department with a febrile child.

BACKGROUND

Childhood fever is a common reason to seek emergency care. Many children are discharged from the emergency department with fever as a significant component of their illness; therefore, it is vital that emergency department medical and nursing staff provide accurate and reliable information about childhood fever management.

DESIGN

A pre/post-test design was used. The outcome measure was parental advice regarding paediatric fever management and the intervention for the study was an educational intervention for emergency department nursing staff that consisted of two tutorials. Data were collected using structured telephone interviews.

RESULTS

Data were collected from 22 families during the pretest period and 18 families during the post-test period. The number of parents leaving the emergency department with no advice decreased by 48% (p = 0.002). Reports of written advice increased by 69.7% (p < 0.001) and there was a 38.4% increase in reports of verbal advice (p = 0.014). Parents leaving the emergency department with both written and verbal advice increased from 0 to 55.6% (p < 0.001). Reports of advice by nursing staff increased by 52% (p < 0.001) and there were significant increases in specific instructions related to oral fluid administration (22.7 vs. 77.8, p = 0.001) and use of antipyretic medications (27.2 vs. 77.8, p = 0.001).

CONCLUSION

Evidence-based education of emergency nurses improved both the amount and quality of discharge advice for parents of febrile children.

RELEVANCE TO CLINICAL PRACTICE

Parents and health care professionals alike need to better understand the physiological benefits of fever and the potential harmful effects of aggressive and often unwarranted treatment of fever.

Managing childhood fever and pain--the comfort loop

Parents can transmit their anxiety to their child, and just as children can pick up on parental anxiety, they can also respond to a parent's ability to stay calm in stressful situations. Therefore, when treating children, it is important to address parental anxiety and to improve their understanding of their child's ailment. Parental understanding and management of both pain and fever - common occurrences in childhood - is of utmost importance, not just in terms of children's health and welfare, but also in terms of reducing the economic burden of unnecessary visits to paediatric emergency departments. Allaying parental anxiety reduces the child's anxiety and creates a positive feedback loop, which ultimately affects both the child and parentIn this review, the integral role of parental perception of the child's condition and the efficacy of treatment in the management of childhood fever and pain will be discussed.

Intramuscular Dipyrone versus Oral Ibuprofen or Nimesulide for Reduction of Fever in the Outpatient Setting

OBJECTIVE

To compare the effectiveness and rate of temperature reduction of three antipyretic medications in febrile children.

DESIGN

A single-dose, randomised, prospective, modified double-blind, parallel clinical trial.

SETTING

The paediatric emergency department of a university hospital that has 13 000 annual visits.

STUDY PARTICIPANTS

252 otherwise healthy children aged 6 months to 14 years with acute, intercurrent, febrile illness.

INTERVENTIONS

Enrolled children were assigned to receive a single dose of oral ibuprofen 10 mg/kg, oral nimesulide 2.5 mg/kg, or parenteral dipyrone 10 mg/kg.

MAIN OUTCOME MEASURES AND RESULTS

Axillary temperature was measured at the time of antipyretic administration and at 30, 45, 60 and 120 minutes thereafter. All three medications were effective in reducing the axillary temperature during the 2-hour testing period. The rates of axillary temperature change between the three medications were significantly different for the ibuprofen and dipyrone groups (p = 0.023). In addition, the axillary temperature in the dipyrone group was significantly lower than that in the ibuprofen group (p = 0.036) at 120 minutes. There was no significant difference in antipyretic effect between the nimesulide group and the other two groups during the testing period. Within each group the difference between initial temperature and the temperature at the end of the testing period was statistically significant (p = 0.036) for the dipyrone group only.

CONCLUSIONS

All three antipyretic medications were effective in reducing the axillary temperature in febrile children. Although administration of intramuscular dipyrone seemed to be more effective than ibuprofen, this relationship was not significant when nimesulide was considered. In addition, in view of its known side effects and the problems associated with intramuscular administration in children, the preference for orally administered nimesulide or ibuprofen over dipyrone in the setting of the emergency department seems more logical provided that the child accepts oral therapy.

What Greek mothers know about evaluation and treatment of fever in children: an interview study

BACKGROUND

Fever is one of the most common symptoms in childhood. Mothers' insufficient knowledge about its evaluation and treatment frequently leads to excessive fear and anxiety.

OBJECTIVES

To explore mothers' knowledge concerning management of fever in their children, at home.

DESIGN

Descriptive, correlational.

SETTINGS

An emergency department of a pediatric hospital.

PARTICIPANTS

A total of 327 mothers with febrile children randomly selected in the waiting room.

METHODS

Data collection was based on interviews by using a questionnaire which was specifically developed for this study.

RESULTS

Almost one out of three mothers (32.4%) evaluated fever as a temperature between 37-38 degrees C and the 38.1% of them considered that side effects could be a result of these temperatures. The majority of the mothers (73.7%) administered antipyretics at body temperatures of 37-38.5 degrees C, usually without a medical instruction (49.2%). Younger mothers with lower education levels and those who admitted to hospital for the first time with children less than 12 months of age showed the poorest level of Knowledge about fever evaluation and treatment.

CONCLUSIONS

Educational interventions by health care professionals aiming at educating young mothers with a low educational level and those with a child younger than 12 months old who seek medical attention at hospital, for the first time, are needed to dispel misconceptions about fever and to promote the appropriate management of the febrile child.

Improving paediatric nurses' knowledge and attitudes in childhood fever management

AIM

This paper reports an evaluation of the effectiveness of a peer education programme in developing paediatric nurses' evidence-based knowledge and attitudes towards fever management and the sustainability of these changes.

BACKGROUND

In general, paediatric nurses' fever management knowledge seems to be mediocre. They believe fever to be harmful, causing febrile convulsions and brain damage. Antipyretics are administered to prevent febrile convulsions and alternate antipyretics are given when temperatures are not reduced.

METHOD

A quasi-experiment was conducted from August 2002 to March 2003. An experimental group of Registered Nurses received the peer education programme and peer support and education were promoted for those unable to attend the sessions. A control group continued its normal practices. Seventy-seven nurses were eligible to attend the programme; 74.0% attended at least one session, 52% two or more. Questionnaire data were collected 1 month before and 1 and 4 months after the peer education programme from 56.3% to 77.8% of eligible experimental and 40.9% to 51.6% of eligible control group nurses.

FINDINGS

Interaction effects between group and time were found in overall knowledge (P = 0.01), specifically knowledge of the physiology of fever (P = 0.001), and attitudes towards evidence-based fever management (P = 0.05). In addition, experimental group nurses demonstrated statistically significantly more knowledge of general fever management principles at 4 months after the intervention than control group nurses (P = 0.01), and compared with their own knowledge at baseline (P < 0.001).

CONCLUSIONS

Educational programmes targeting practice change must be theoretically based and target knowledge, attitudes and barriers to change. The programme tested here, which incorporated peer education and support and facilitated group change, is adaptable to other practices, groups and settings.

Effect of an evidence-based paediatric fever education program on emergency nurses’ knowledge

INTRODUCTION

This study examined the effect of an educational intervention of factual knowledge on emergency nurses' knowledge and clinical decisions related to paediatric fever.

METHOD

A prospective pre-test/post-test design was used. Emergency nurses' factual knowledge was measured by parallel multiple choice questions and the intervention for the study was an educational intervention consisting of two tutorials. Pre-test data were collected in early June 2005 and post-test data were collected during August 2005.

RESULTS

Thirty-one emergency nurses completed the pre and post-test multiple choice questions. Emergency nurses' knowledge increased following the tutorials. Pre-test score was positively correlated with knowledge acquisition. Self-reports of independent decisions related to fever management were influenced by experience, hours of employment, level of appointment, postgraduate qualifications and pre-test score.

DISCUSSION

High levels of variability in knowledge and knowledge acquisition suggest a review of undergraduate and postgraduate curricula is warranted. Although this study identified associations between independent fever management decisions and participant characteristics, further research is pivotal to better understanding these relationships.

???Fever phobia??? in the emergency department: a survey of children??s caregivers

OBJECTIVES

To investigate children's caregivers' attitudes towards fever in an emergency department setting.

METHODS

A 25-item questionnaire was formulated, on the basis of similar previous published surveys, for administration to a convenience sample of caregivers. It was administered by a medical translator after triage, before assessment by a physician. Most questions were multiple choice, a few open-ended.

RESULTS

Three hundred questionnaires were administered to caregivers and 264 were analyzed. A high proportion (82%) of caregivers professed to be 'very worried' about fever. Temperatures that were felt to require treatment were relatively low (one-third treating <37.9 degrees C), but many respondents measured body temperature at the axilla. Similar to previously published studies, the main specific concerns were possible central nervous system damage (24%), seizures (19%) and death (5%), although worries about discomfort and signs of serious illness were also expressed by a significant number of respondents (11%). Similar to older surveys, home treatment of fever was worrisome, with too-frequent dosing (acetaminophen <q4h, 27%; ibuprofen <q6h, 50%) and possibly inappropriate topical treatments (76%) being used. The presence of both parents in the emergency department was associated with lower levels of worry.

CONCLUSIONS

We found high levels of anxiety among caregivers presenting to a hospital emergency department with a complaint of fever in a child. Many caregivers appear to confuse effects of fever with the harmful effects of hyperthermia. Aggressive and potentially dangerous home therapy and monitoring of fever is common among the caregivers surveyed.

Management of childhood fever by parents: literature review

AIM

This paper reports a review which draws together findings from studies targeting parents' temperature-taking, antipyretic administration, attitudes, practices and information-seeking behaviours.

BACKGROUND

Parents' concerns about the harmful effects of fever have been reported for more than two decades. These concerns remain despite successful educational interventions.

METHOD

Medline, CINAHL, PsycINFO, PsycARTICLES and Web of Science databases were searched from 1980 to 2004 during November 2004. The search terms were fever, child, parent, education, knowledge, belief, concern, temperature, antipyretic and information, and combinations of these.

FINDINGS

In the 1980s, studies were mainly descriptive of small single site samples of parents with a febrile child seeking assistance from healthcare professionals. From 1990, sample sizes increased and multi-site studies were reported. Educational interventions were designed to increase knowledge and reduce unnecessary use of health services. One 2003 study targeted knowledge and attitudes. Parental knowledge about normal body temperature and the temperature that indicates fever is poor. Mild fever is misclassified by many as high, and they actively reduce mild fever with incorrect doses of antipyretics. Although some parents acknowledge the benefits of mild fever, concerns about brain damage, febrile convulsions and death from mild to moderate fever persist irrespective of parental education or socio-economic status. Many base their fever management practices on inaccurate temperature readings. Increased use of antipyretics to reduce fever and waking sleeping febrile children for antipyretics or sponging reflects heightened concern about harmful effects of fever. Educational interventions have reduced unnecessary use of healthcare services, improved knowledge about fever and when to implement management strategies, and reduced incorrect parental accuracy of antipyretic dosing. Information-seeking behaviours in fever management differ according to country of origin.

CONCLUSION

Despite successful educational interventions, little has changed in parents' fever management knowledge, attitudes and practices. There is a need for interventions based on behaviour change theories to target the precursors of behaviour, namely knowledge, attitudes, normative influences and parents' perceptions of control.

Paediatric fever management: continuing education for clinical nurses

PURPOSE

This study examined the influence of level of practice, additional paediatric education and length of paediatric and current experience on nurses' knowledge of and beliefs about fever and fever management.

METHOD

Fifty-one nurses from medical wards in an Australian metropolitan paediatric hospital completed a self-report descriptive survey.

RESULTS

Knowledge of fever management was mediocre (Mean 12.4, SD 2.18 on 20 items). Nurses practicing at a higher level and those with between one and four years paediatric or current experience were more knowledgeable than novices or more experienced nurses. Negative beliefs that would impact nursing practice were identified. Interestingly, beliefs about fever, antipyretic use in fever management and febrile seizures were similar; they were not influenced by nurses' knowledge, experience, education or level of practice.

CONCLUSIONS

Paediatric nurses are not expert fever managers. Knowledge deficits and negative attitudes influence their practice irrespective of additional paediatric education, paediatric or current experience or level of practice. Continuing education is therefore needed for all paediatric nurses to ensure the latest clear evidence available in the literature for best practice in fever management is applied.

Fever management: paediatric nurses' knowledge, attitudes and influencing factors

AIMS

This paper describes Australian paediatric nurses' knowledge of and attitudes toward fever and its management and the predictors of their intentions to administer paracetamol to a febrile child.

BACKGROUND

Despite evidence-based support for the beneficial effects of fever over the past three decades, health professionals' negative attitudes toward fever and their reliance on antipyretics to reduce it have persisted and continue to be reported in the literature.

METHODS

A self-report questionnaire was used. An instrument was developed, piloted by test-retest and revised prior to data collection. Fifty-one paediatric nurses working in medical wards of a metropolitan paediatric hospital in Australia participated.

RESULTS

Nurses' mean knowledge score about the physiology of fever, general fever management and antipyretics was 62%, which was not as high as expected. Participants reported positive attitudes toward the benefits of fever, the necessity for its reduction in children with pre-existing cardiac or respiratory conditions and towards regular antipyretic administration masking the infective process. Negative attitudes included disbelief that temperature is often unrelated to illness severity. Conflicting attitudes toward febrile convulsions were highlighted by beliefs that antipyretic therapy prevents these and that antipyretics do not prevent initial febrile convulsions. Predictors of intentions to administer paracetamol were beliefs about the effectiveness of paracetamol and nurses' beliefs about the expectations of others in relation to paracetamol administration. Nurses reported strong intentions to administer paracetamol to the next febrile child they cared for. Limitations of the study include the use of a nurse manager for recruitment and collecting the data at only one site.

CONCLUSIONS

Fever management is an integral aspect of paediatric nursing. For its consistent rational management, nurses must have appropriate knowledge and positive attitudes. This highlights the need for continuing education in fever management.

When Fever, Paracetamol? Theory and Practice in a Paediatric Outpatient Clinic

OBJECTIVE

To determine how medical and nursing staff treat feverish children and compare the findings with their theoretical knowledge, evaluating how they might contribute to fever phobia in parents.

SETTING

Paediatric Emergency Department.

METHOD

In the first step, we analysed prospectively the files of all children having consulted the Paediatric Emergency Department with a history of fever or of body temperature above 38 degrees C during a 2-week period. The second step consisted of evaluating knowledge and perception of fever of doctors and nurses using a questionnaire.

MAIN OUTCOME MEASURES

Prospective study: final diagnosis (viral, non- invasive bacterial disorders, invasive bacterial disorders), site of measurement and average temperature. Evaluation of theoretical knowledge: definition of fever, site of measurement, evaluation of the child's clinical state, antipyretic drug choice.

RESULTS

A total of 114 children under 5 years of age were enrolled and 24 caregivers (12 doctors, 12 nurses, 90 of the staff) responded to the questionnaire. The results showed good consistency in theoretical knowledge, but an excessive fear about cerebral damage was also shown by doctors. This belief likely contributes to the transmission of fever phobia to parents. In contrast, analysis of children management showed that fever was often under-treated, especially by nurses and even more so by parents. Paracetamol remained the first-line antipyretic drug yet was often administered in insufficient doses. Non-steroidal anti-inflammatory drugs were seldom used, except by parents (16 of all the children). Contrary to literature, the favourite route of administration was the rectal one. Physical methods like sponging were largely used by nurses, despite the uncertainties in their real effectiveness and their known side-effects.

CONCLUSION

Our study showed that the management of feverish children was globally correct in the Paediatric Emergency Department, but several improvement measures have been taken (e.g. tables of normal and abnormal ranges of temperature, recommended temperature measurement techniques, dosage regimen of antipyretic drugs, guidelines to parents), justifying the implementation of a pharmaceutical follow-up.

Fever in children less than 36 months of age--questions and strategies for management in the emergency department

Fever is a common pediatric complaint in the Emergency Department. Emergency Physicians often must be conservative in their management of febrile children, as patient follow-up is not always available. A unified approach for the management of febrile infants will be discussed in this article.

Fever management practises: what pediatric nurses say

Pediatric nurses manage fevers in hospitalized children daily: a complex practise. The present study identified varied decision-making criteria and inconsistent practise influenced by many external variables. Nurses perform comprehensive assessments in order to make informed decisions. However, factors influencing their practise include medical orders, the temperament of the child, a history of febrile convulsions, parental requests, colleagues and ward norms. Nurses have a 'temperature' at which they consider a child febrile (37.2-39.0 degrees C) and many reported a 'temperature' at which they administered antipyretics (37.5-39.0 degrees C). Antipyretics were administered to febrile children for pain relief, irritability, at the request of parents and to settle a child for the night. Administration was reported to be higher during the day and evening shifts, at medication rounds and when the ward was busy. At night, nurses were reluctant to wake a sleeping febrile child, preferring to observe them instead. Recommendations to promote consistent fever management practises are included.

Chronic acetaminophen overdosing in children: risk assessment and management

Acetaminophen is currently the pediatric analgesic and antipyretic of choice. Although children appear to tolerate single, high-dose ingestions well, the literature is replete with reports of significant morbidity and mortality after repeated supra-therapeutic dosing. Proposed risk factors for injury with chronic use include age, total dose, duration, presence of intercurrent febrile illness, starvation, co-administration of cytochrome P450-inducing drugs, underlying hepatic disease, and unique genetic makeup. Evaluation of these children should include serum acetaminophen concentration, prothrombin time, and serum bilirubin and transaminase concentrations. The Rumack-Mathew nomogram should not be used to estimate the risk of hepatotoxicity in cases of chronic ingestion. Based on history, clinical examination, and laboratory findings, patients may be placed in three categories: those without hepatic injury and with no residual acetaminophen to be metabolized, those without injury but with some acetaminophen to be metabolized, and those with hepatotoxicity. Those without injury and no residual acetaminophen need not be treated or followed. Patients with hepatotoxicity or potential for hepatotoxicity based on residual acetaminophen should be treated with N-acetylcysteine. Most importantly, because so many parents are unaware of the potential risk of inappropriate dosing, education is the key to preventing future cases.