Physicians' attitudes toward the diagnosis and management of fever in children 3 months to 2 years of age

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.

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 Unpublished literature, grey literature and consultation with experts in the area will be used to supplement database searching.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.

Population-level effects of suppressing fever

Fever is commonly attenuated with antipyretic medication as a means to treat unpleasant symptoms of infectious diseases. We highlight a potentially important negative effect of fever suppression that becomes evident at the population level: reducing fever may increase transmission of associated infections. A higher transmission rate implies that a larger proportion of the population will be infected, so widespread antipyretic drug use is likely to lead to more illness and death than would be expected in a population that was not exposed to antipyretic pharmacotherapies. We assembled the published data available for estimating the magnitudes of these individual effects for seasonal influenza. While the data are incomplete and heterogeneous, they suggest that, overall, fever suppression increases the expected number of influenza cases and deaths in the US: for pandemic influenza with reproduction number , the estimated increase is 1% (95% CI: 0.0-2.7%), whereas for seasonal influenza with , the estimated increase is 5% (95% CI: 0.2-12.1%).

Comparison of cold water sponging and acetaminophen in control of Fever among children attending a tertiary hospital in South Nigeria

Background:

A wide range of childhood illnesses are accompanied by fever, leading to varied attempts at treatment by caregivers at home before coming to a hospital. Common modalities of treatment include use of antipyretics and physical methods such as cold water sponging, fanning and removal of clothing. These treatment modalities have been received with varied attitudes among physicians and the scientific community. This study was to assess the efficacy of both modalities in first-line management of fever in our area.

Objectives:

The main aim of the study is to compare the effectiveness of cold water sponging with that of oral paracetamol in the treatment of fever in children attending the University of Calabar Teaching Hospital, Calabar.

Subjects and Methods:

This is a randomized clinical trial. Eighty-eight children aged 12-120 months who presented to the Children Outpatient Clinic (CHOP) and the Children Emergency Room (CHER) of University of Calabar Teaching Hospital, Calabar, with acute febrile illness and axillary temperatures spanning ≥ 38.0-40.0°C. All children within the age limit whose caregivers gave consent were recruited into the study and were randomized to receive either cold water sponging or oral paracetamol. Axillary temperature, pulse rate, respiratory rate and assessment of discomforts (crying, shivering, goose pimples and convulsions) were recorded every 30 min for 2 h. The results were analyzed using the SPSS statistical software and have been presented in the tables.

Results:

Cold water sponging was very effective in temperature reduction within the first 30 min, with 29 (70.73%) having their temperature reduced to within normal limits. This declined to 12 (29.26%) at 60 min and 4 (10.53%) at 120 min, with the mean temperature differences from the baseline value following the same trends (1.63°C by 30 min, 0.91°C by 60 min and 0.39°C by 120 min). When compared with paracetamol, cold water sponging was more effective in temperature reduction within the first 30 min (P = 0.000), with the difference in effect at 60 min less significant between these two groups (P = 0.229). Paracetamol demonstrated a gradual and sustained reduction in temperature with the proportions of afebrile children in this group increasing from 7 (16.27%) at 30 min to 33 (78.57%) at 120 min. The mean temperature differences from the baseline value also showed the same trend. Children who received cold water sponging had more discomforts compared with those who received only oral paracetamol.

Conclusions:

It is concluded that cold water sponging, although producing rapid reduction in temperature compared with paracetamol, has effects that last only for a short time. Paracetamol on the other hand produces a gradual but sustained effect. The discomforts experienced should not be a limiting factor to the use of cold water sponging in reducing the body temperature of febrile children. Cold water sponging is safe and its use by mothers and primary caregivers should be encouraged while preparing to take the child to the nearest health facility for definitive treatment of the underlying cause of the fever.

Fever following immunization

Fever is a frequent systemic adverse event following immunization, especially in infants and young children. Any fever after immunization may be caused by immunization or may coincide temporally as an indication of underlying disease, usually an infectious one. The time pattern of fever attributable to immunization has characteristic features depending on the vaccine used. Comparability of fever rates associated with different vaccines, or the same vaccines in different studies, is frequently hampered by the use of different definitions and/or assessment techniques for fever. A recent analysis by the Brighton Collaboration has provided a standardized case definition for fever, the use of which should be strongly encouraged.

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.

Non-pharmacological Management of Fever in Otherwise Healthy Children

BACKGROUND

Fever is a common childhood problem faced in both hospital and community settings. In many cases the fever is associated with mild to moderate self-limiting illnesses. There has been a rapid increase in antipyretic use as the means of managing or treating this adaptive physiological response to infection. The use of alternative means of caring for a febrile child could minimise the amount of antipyretics administered to children and thereby reduce the potential risks.

OBJECTIVE

The objective of this systematic review was to establish what non-pharmacological practices are effective in managing fever in children, three months to 12 years of age, who are otherwise healthy.

INCLUSION CRITERIA

Interventions for inclusion were physiological e.g. maintenance of hydration and rest, and external cooling, either direct e.g. sponging, clothing, or environmental e.g. fans, ambient temperature. Outcomes of interest were effect on fever, increase in comfort, decrease in parental anxiety and reduction in unnecessary use of health services.

SEARCH STRATEGY

The search sought English, Spanish, Portuguese, Mandarin and Italian language studies, published 2001-2011 in 12 major databases.

CRITICAL APPRAISAL, DATA EXTRACTION AND DATA SYNTHESIS

Critical appraisal of and data extraction from eligible studies were undertaken using standardised tools developed by the Joanna Briggs Institute. As statistical pooling of data was precluded, the findings are presented in narrative form.

RESULTS

Twelve randomised controlled trials were included, involving 986 children in total. Only one intervention identified in the review protocol - direct external cooling measures - was addressed by the studies. Eleven studies included sponging as an intervention while one also included clothing (unwrapping). No studies investigated physiological interventions, (e.g. hydration or rest), or environmental cooling measures, (e.g. fans or ambient temperature) as separate interventions. Three of these interventions (encouragement of fluid intake, rest and fans) were reported as part of the standard care provided to participants in several studies or were controlled in the study (ambient temperature). Only two of the four outcomes identified in the review protocol were examined (effect on fever (all 12 studies) and patient comfort). Although tepid sponging alone resulted in an immediate decrease in temperature, this response was of short duration, with antipyretics or antipyretics plus sponging having a more lasting effect. In addition, the observed levels of discomfort of the sponged children were higher than the other groups. For both measures, this effect was not statistically significant in every case.

CONCLUSION

The care of a febrile child needs to be individualised, based on current knowledge of the effectiveness and risks of interventions. The administration of antipyretics should be minimised, used selectively and with caution, even in otherwise healthy children. The results of this systematic review support previous findings that routine tepid sponging does not have an overall beneficial effect. However measures such as encouraging fluid intake and unwrapping the child should be encouraged.

IMPLICATIONS FOR PRACTICE

The two foci of care should be the child and the parents/primary caregiver. For the child, care should aim to support the body's physiological responses i.e. maintain hydration, minimise use of antipyretics. Support the parents to reduce anxiety e.g. by involving them in care and providing appropriate education, particularly in respect to correct dosages of antipyretics.

IMPLICATIONS FOR RESEARCH

Given the now well demonstrated discomfort engendered by tepid sponging, its use in treating febrile children is no longer advocated and does not warrant further research. However aspects of other non-pharmacological interventions have not been so well researched e.g. parental response to advice on fluid intake and appropriate clothing.

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.

Approach to the febrile patient in the ICU

Fever is a normal adaptive brain response to infectious and noninfectious causes involving a cytokine-mediated response, the generation of acute phase reactants, and the activation of numerous physiologic, endocrinologic and immunologic systems. Ninety percent of patients with severe sepsis in the intensive care unit (ICU) will experience fever during their hospitalization, while the half of the new detected febrile episodes are of noninfectious origin. In the ICU, fever should be treated in cardiorespiratory and neurosurgical patients and in those in whom temperature exceeds 40 degrees C (104 degrees F). Antipyretic therapy must be justified regardless of the metabolic cost (if fever exceeds its physiologic benefit), the result (if the symptomatic relief adversely affects the course of the febrile illness) and the side effects.

???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.

Clinical and consumer guidelines related to the management of childhood fever

Background: The majority of childhood fever episodes are considered part of normal childhood development. However, febrile children frequently present to hospital and general practitioners. Health providers and parents therefore require knowledge on how to manage childhood fever, how to recognise which febrile children are likely to become seriously ill and when to seek urgent medical advice. This information is frequently provided in the form of clinical and/or consumer guidelines.

Aim: The aim of this systematic review was to identify and assess clinical and consumer guidelines related to the management of childhood fever.

Methods: A comprehensive search strategy included searching electronic clinical databases, guideline databases, Internet searching, contacting paediatric hospitals across the UK, and experts and researchers. Application of inclusion criteria, quality assessment and data extraction were independently conducted by two reviewers. Data is presented in tabular format with narrative discussion.

Results: A total of 22 guidelines were identified and included in the review. Five were clinical guidelines and 17 guidelines designed for parents/carers. The results highlight that key markers cannot be identified to help predict which febrile children might become seriously ill. Because childhood fever guidelines also lack comprehensive evidence and offer conflicting recommendations, parents and carers are unlikely to be able to identify such markers.

Conclusions: Current clinical and consumer guidelines related to childhood fever are not evidence-based and appear to be produced as consensus statements summarising current care provision. Healthcare workers need to ensure when undertaking the development and dissemination of patient information that they follow appropriate processes to incorporate the most appropriate evidence.

Current guidelines fail to provide information on key markers to enable early recognition of seriously ill children. This review also demonstrates that alternative search strategies can prove effective in identifying guidelines for care.

Fever after Immunization: Current Concepts and Improved Future Scientific Understanding

Fever is a common clinical complaint in adults and children with a variety of infectious illnesses, as well as a frequently reported adverse event following immunization. Although the level of measured temperature indicative of a "fever" was first defined in 1868, it remains unclear what role fever has as a physiologic reaction to invading substances, how best to measure body temperature and compare measurements from different body sites, and, consequently, how to interpret fever data derived from vaccine safety trials or immunization safety surveillance. However, even with many aspects of the societal, medical, economic, and epidemiologic meanings of fever as an adverse event following immunization (AEFI) still elusive, it is a generally benign--albeit common--clinical sign. By standardizing the definition and means of assessment of fever in vaccine safety studies, thereby permitting comparability of data, we hope to arrive at an improved understanding of its importance as an AEFI.

Clinical review: fever in intensive care unit patients

Fever is a common response to sepsis in critically ill patients. Fever occurs when either exogenous or endogenous pyrogens affect the synthesis of prostaglandin E2 in the pre-optic nucleus. Prostaglandin E2 slows the rate of firing of warm sensitive neurons and results in increased body temperature. The febrile response is well preserved across the animal kingdom, and experimental evidence suggests it may be a beneficial response to infection. Fever, however, is commonly treated in critically ill patients, usually with antipyretics, without good data to support such a practice. Fever induces the production of heat shock proteins (HSPs), a class of proteins critical for cellular survival during stress. HSPs act as molecular chaperones, and new data suggest they may also have an anti-inflammatory role. HSPs and the heat shock response appear to inhibit the activation of NF-kappabeta, thus decreasing the levels of proinflammatory cytokines. The anti-inflammatory effects of HSPs, coupled with improved survival of animal models with fever and infection, call into question the routine practice of treating fever in critically ill patients.

Antipyretic Therapy's future

There is little doubt that clinicians will continue to seek new and, one hopes, more intelligent ways to suppress fever. In the process, new agents will be developed, new uses will be identified for existing antipyretic agents, new measures will be designed to maximize the benefits of antipyretic therapy while minimizing its adverse effects, and a concerted effort will be made to define more clearly and to promote appropriate indications for such therapy.

Benefits and risks of antipyretic therapy

Physicians have used various forms of antipyretic therapy since antiquity to lower the temperature of febrile patients. Nevertheless, it has yet to be determined whether the benefits of antipyretic therapy outweigh its risks. It is not known, for example, if core temperatures encountered during the febrile state ever reach levels that are intrinsically noxious (and therefore merit antipyretic intervention) or when, if ever, fever's metabolic costs exceed its physiologic benefits, or if the benefits of symptomatic relief afforded by antipyretic drugs consistently exceed their toxicologic cost. Whereas preliminary experimental and clinical observations suggest that antipyretic therapy has the potential to increase the duration and/or severity of certain infections, such data are as yet too fragmentary to draw firm conclusions regarding their validity. Finally, although clinicians have long suspected that bacteremia and other severe infections might induce fevers that are less responsive to antipyretic therapy than are those associated with self-limited infections, this concept has not held up under scientific scrutiny. Thus, despite over 2.5 millennia of clinical experience, important questions regarding the risks and benefits of antipyretic therapy remain to be answered.

Childhood fever: is practice scientific?

Diagnosis of fever is not necessarily simple. A variety of factors influence the decision to administer medication. The action of the antipyretic paracetamol is discussed in relation to practice issues. The importance of monitoring and recording fever is examined. The rationales for use of paracetamol are explored.

Case management by physician assistants and primary care physicians vs emergency physicians

OBJECTIVES

To determine whether physician assistants' (PAs') and primary care physicians' (PCPs') case management for 5 common primary care medical problems is similar to that of emergency physicians (EPs).

METHODS

An anonymous survey was used to compare PAs, PCPs, and EPs regarding intended diagnostic and treatment options for hypothetical cases of asthma, pharyngitis, cystitis, back strain, and febrile child. Published national practice guidelines were used as a comparison criterion standard where available. The participants stated that they treated all of the patients and responded to all of the cases to be included in the survey. The responses of the PA and PCP groups were compared with those of the EP group, and financial charges for care by each group were analyzed.

RESULTS

The EPs tended to follow treatment guidelines closer than did other primary care specialists. The management of PCPs and PAs differed from that of EPs, as follows: [table: see text]

CONCLUSION

The EPs more closely followed clinical guidelines than did the PAs and PCPs for these standardized clinical scenarios. Although the relationship of such theoretical practice to actual practice remains unknown, use of these clinical scenarios may identify intended practice patterns warranting attention.

Tepid sponging to reduce temperature in febrile children in a tropical climate

The effectiveness of tepid sponging, in addition to antipyretic medication, in the reduction of temperature in febrile children living in a tropical environment, was assessed in a prospective, randomized, open trial. Seventy-five children aged between 6 and 53 months who attended the casualty department of the Children's Hospital, Bangkok, Thailand, with fever (rectal temperature > or = 38.5 degrees C) of presumed viral origin were randomized to received either tepid sponging and oral paracetamol (sponged group) or paracetamol alone (control group). Rectal temperature and the occurrence of crying, irritability, and shivering were recorded over the following 2 hours. A greater and more rapid fall in mean rectal temperature occurred in the sponged group than in the control group. Temperature fell below 38.5 degrees C sooner in children in the sponged group than in control children (P < 0.001). At 60 minutes, 38 (95.0%) of the controls still had a temperature of 38.5 degrees C or greater, compared with only 15 children (42.9%) in the sponged group (P < 1 x 10(-5). Crying was associated with sponging, but shivering and irritability occurred in only one child who was being sponged. It is concluded that tepid sponging, in addition to antipyretic medication, is clearly more effective than antipyretic medication alone in reducing temperature in febrile children living in a tropical climate.