Fever: pathological or physiological, injurious or beneficial?

Survey of knowledge, practice, and associated factors toward home management of childhood fever among parents visiting Gondar health facilities in 2022

Background

Fever is a typical symptom of many sicknesses, but for children under the age of five, fever can have devastating consequences and represents a source of worry for parents. To the best of our knowledge, no research on home management of fever in children has been conducted in Ethiopia. We aimed to assess knowledge, practices, and associated factors towards home management of childhood fever among parents visiting Gondar Town health facilities in 2022.

Method

This multicenter institutional-based cross-sectional study was conducted in Gondar public health facilities from June 1st-June 30th, 2022. Participants were fathers and mothers of children aged 0-5 years. A stratified random sampling technique was used. Data were collected through face-to-face interviews using a pretested structured questionnaire.

Results

Approximately, 40.2% (95% CI: 35.5%, 45.2%) of parents had good knowledge and only 12.8% (95% CI: 9.7-15.8) of parents practiced home fever management. Being married [Adjusted odds ratio [(AOR) = 2.1 (1.2, 3.2)], having a primary or higher level of education [AOR = 2.4 (1.17, 4.9)] [AOR = 2.0 (1.02-4.6)], respectively, and number of children [AOR = 1.8 (1.63, 2.03)] were factors associated with parental knowledge. Likewise, being married [AOR = 3.05 (2.27.50-3.83)], receiving counseling from health care providers [AOR = 2.12 (1.53-3.32)], and being male [AOR = 2.03 (1.50-3.00)] were significant predictors of practice.

Conclusion

Inadequate levels of knowledge and numerous irrational practices related to home fever management were predominant among parents, which needs to be addressed. Evidence-based health education is essential for parents to enhance their level of knowledge and practice to effectively treat fever at home.

Association between Acute and Chronic Inflammatory States: A Case-Control Study

BACKGROUND

 Fever is the hallmark of efficient acute inflammatory response, which may be disrupted in chronic inflammatory conditions. The "continuum theory" proposes that the return of acute inflammatory states with high fever predicts improvement in chronic diseases during treatment. Our objective was to investigate the observation made, during classical homeopathic treatment, that such an association exists between chronic inflammation and efficient acute inflammation.

METHODS

 In a case-control study, the reports of patients diagnosed with chronic inflammatory conditions with at least 6 months of follow-up under homeopathic treatment were retrospectively sampled from homeopathic medical practices from Greece, India, Romania and Russia. Twenty patients who improved under homeopathic treatment and 20 age-matched controls of those who did not improve were selected. The occurrence of common acute infectious diseases with fever during the follow-up period was investigated.

RESULTS

 The average age of the cases and controls was 28.4 (SD: 16.64) and 27.9 (SD: 17.19) years respectively. 18/20 cases and 4/20 controls developed common infectious diseases with fever. Cramer's V co-efficient value was found to be 0.551 (p < 0.01), indicating that improvement was more in patients with fever than without. Odds ratio of improving with respect to development of acute infectious diseases was 36.0 (95% CI: 5.8 to 223.5). The binary logistic regression model indicated significant contribution of occurrence of acute infections with fever as a predictor for improvement in chronic inflammatory disease.

CONCLUSIONS

 Classical homeopathic clinical observations indicate an association between chronic inflammatory status in the body and the ability to mount efficient acute inflammation. In this case-control study, the occurrence of common infections with fever during treatment heralded improvement in chronic inflammatory disease. Further powered studies are necessary to substantiate this finding.

Potential for Further Mismanagement of Fever During COVID-19 Pandemic: Possible Causes and Impacts

Fever remains an integral part of acute infectious diseases management, especially for those without effective therapeutics, but the widespread myths about "fevers" and the presence of confusing guidelines from different agencies, which have heightened during the coronavirus disease 2019 (COVID-19) pandemic and are open to alternate interpretation, could deny whole populations the benefits of fever. Guidelines suggesting antipyresis for 37.8-39°C fever are concerning as 39°C boosts the protective heat-shock and immune response (humoral, cell-mediated, and nutritional) whereas ≥40°C initiates/enhances the antiviral responses and restricts high-temperature adapted pathogens, e.g., severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), strains of influenza, and measles. Urgent attention is accordingly needed to address the situation because of the potential public health consequences of the existence of conflicting guidelines in the public domain. We have in this article attempted to restate the benefits of fever in disease resolution, dispel myths, and underline the need for alignment of national treatment guidelines with that of the WHO, to promote appropriate practices and reduce the morbidity and mortality from infectious diseases, such as COVID-19.

Metabolic trade-offs favor regulated hypothermia and inhibit fever in immune-challenged chicks

The febrile response to resist a pathogen is energetically expensive while regulated hypothermia seems to preserve energy for vital functions. We hypothesized here that immune challenged birds under metabolic trade-offs (reduced energy supply / increased energy demand) favor a regulated hypothermic response at the expense of fever. To test this hypothesis, we compared 5-days old broiler chicks exposed to fasting, cold (25oC), and fasting combined with cold to a control group fed at thermoneutral condition (30oC). The chicks were injected with saline or with a high dose of endotoxin known to induce a biphasic thermal response composed of body temperature (Tb) drop followed by fever. Then Tb, oxygen consumption (metabolic rate), peripheral vasomotion (cutaneous heat exchange), breathing frequency (respiratory heat exchange), and huddling behavior (heat conservation indicator) were analyzed. Irrespective of metabolic trade-offs, chicks presented a transient regulated hypothermia in the first hour, which relied on a suppressed metabolic rate for all groups, increased breathing frequency for chicks fed/fasted at 30oC, and peripheral vasodilation in fed/fasted chicks at 25oC. Fever was observed only in chicks kept at thermoneutrality and was supported by peripheral vasoconstriction and huddling behavior. Fed and fasted chicks at 25oC completely eliminated fever despite the ability to increase metabolic rate for thermogenesis in the phase correspondent to fever when it was pharmacologically induced by 2.4-Dinitrophenol. Our data suggest that increased competing demands affect chicks’ response to an immune challenge favoring regulated hypothermia to preserve energy while the high costs of fever to resist a pathogen are avoided.

Beneficial Effects of Receiving Johrei on General Health or Hypothermia Tendency

OBJECTIVES

Johrei is a type of biofield therapy that is said to bring physical and mental well-being to the recipient. This study sought to measure changes in body temperature and circulation resulting from Johrei treatment, for generally healthy subjects and for individuals with a tendency toward hypothermia.

PARTICIPANTS

A total of 199 qualified Johrei practitioners and 144 non-qualified operators provided Johrei and placebo treatments, respectively. Volunteer subjects -186 in general health and 39 with a hypothermia tendency - participated in this study to receive either or both of these treatments.

METHODS

Each subject was given a 10 min treatment daily by either a qualified practitioner or a non-qualified operator. The effects on subjects of receiving each treatment were compared by observing quantitative changes in blood flow and surface body temperature after a course of treatment.

RESULTS

A total of 107 healthy subjects were randomly assigned to the qualified-practitioner group or the non-qualified operator group. Treatment by qualified practitioners significantly enhanced blood flow and surface body temperature in the subjects' designated neck area compared to that in treatment by non-qualified operators. This finding was further corroborated by a comparative experiment in which each healthy subject was treated by both a qualified practitioner and a non-qualified operator. These results indicate that only the qualified-practitioner treatment increased the subject's-blood flow and surface body temperature. Similarly, in a comparative study of qualified-practitioner treatment against non-qualified-operator treatment, subjects tending toward hypothermia showed increased blood flow and elevated body temperature with only the authentic Johrei treatment.

Efficacy of Scenario Simulation-Based Education in Relieving Parental Anxiety about Fever in Children

PURPOSE

This study was designed to evaluate the short- and long-term effects of a scenario simulation-based education intervention on parental anxiety about fever in their children.

DESIGN AND METHODS

This experimental research was conducted using a two-group pretest-posttest design. One hundred and sixty parents of 3-month to 5-year-old children enrolled in preschools and kindergartens with childcare services were recruited as participants using cluster random sampling. The participants were divided randomly into an experimental group (80) and a control group (80). The former participated in a scenario simulation-based education intervention and received a fever education booklet. The latter received the booklet only. Data were collected using the Children's Fever Anxiety Inventory at three time points: before the intervention (pretest, T1) and at six-month (T2) and 12-month (T3) posttests.

RESULTS

Significant intergroup differences in fever anxiety were found at both T2 and T3 (p < .001). For both groups, the scores at T2 and T3 were significantly lower than at T1 (p < .001) and the difference between T2 and T3 did not attain statistical significance (p > .05). Although both groups experienced reduced fever anxiety over time, this reduction was significantly greater in the experimental group than in the control group (p < .001).

CONCLUSION

Simulation-based education may be used in conjunction with the traditional fever education booklet to further reduce parent fever anxiety over time.

PRACTICE IMPLICATIONS

This simulation-based education approach significantly and positively impacts parental anxiety about fever in their children. Furthermore, the approach may be generalizable to other childhood healthcare settings.

Modelling the Efficacy of Febrile Heating in Infected Endotherms

Fever is a response to infection characterised by an increase in body temperature. The adaptive value of this body temperature increase for endotherms is unclear, given the relatively small absolute temperature increases associated with endotherm fever, its substantial metabolic costs, and the plausibility for pathogens to adapt to higher temperatures. We consider three thermal mechanisms for fever's antimicrobial effect: (1) direct growth inhibition by elevating temperature above the pathogens optimal growth temperature; (2) further differentiating the host body from the wider environment; and (3) through increasing thermal instability of the pathogen environment. We assess these by modelling their effects pathogen on temperature dependent growth, finding thermal effects can vary from highly to minimally effective depending on pathogen species. We also find, depending on the specification of a simple physical model, intermittent heating can inhibit pathogen growth more effectively than continuous heating with an energy constraint.

Regulated hypothermia in response to endotoxin in birds

KEY POINTS

The costs associated with immune and thermal responses may exceed the benefits to the host during severe inflammation. In this case, regulated hypothermia instead of fever can occur in rodents as a beneficial strategy to conserve energy for vital functions with consequent tissue protection and hypoxia prevention. We tested the hypothesis that this phenomenon is not exclusive to mammals, but extends to the other endothermic group, birds. A decrease in metabolic rate without any failure in mitochondrial respiration, nor oxygen delivery, is the main evidence supporting the regulated nature of endotoxin-induced hypothermia in chicks. Thermolytic mechanisms such as tachypnea and cutaneous vasodilatation can also be recruited to facilitate body temperature decrease under lipopolysaccharide treatment, especially in the cold. Our findings bring a new perspective for evolutionary medicine studies on energy trade-off in host defence because regulated hypothermia may be a phenomenon spread among vertebrates facing a severe immune challenge.

ABSTRACT

A switch from fever to regulated hypothermia can occur in mammals under circumstances of reduced physiological fitness (e.g. sepsis) to direct energy to defend vital systems. Birds in which the cost to resist a pathogen is additive to the highest metabolic rate and body temperature (T_b ) among vertebrates may also benefit from regulated hypothermia during systemic inflammation. Here, we show that the decrease in T_b observed during an immune challenge in birds is a regulated hypothermia, and not a result of metabolic failure. We investigated O₂ consumption (thermogenesis index), ventilation (respiratory heat loss), skin temperature (sensible heat loss) and muscle mitochondrial respiration (thermogenic tissue) during T_b fall in chicken chicks challenged with endotoxin [lipopolysaccharide (LPS)]. Chicks injected with LPS were also tested regarding the capacity to raise O₂ consumption to meet an increased demand driven by 2,4-dinitrophenol. LPS decreased T_b and the metabolic rate of chicks without affecting muscle uncoupled, coupled and non-coupled mitochondrial respiration. LPS-challenged chicks were indeed capable of increasing metabolic rate in response to 2,4-dinitrophenol, indicating no O₂ delivery limitation. Additionally, chicks did not attempt to prevent T_b from falling during hypothermia but, instead, activated cutaneous and respiratory thermolytic mechanisms, providing an additional cooling force. These data provide the first evidence of the regulated nature of the hypothermic response to endotoxin in birds. Therefore, it changes the current understanding of bird's thermoregulation during severe inflammation, indicating that regulated hypothermia is either a convergent trait for endotherms or a conserved response among vertebrates, which adds a new perspective for evolutionary medicine research.

Changing mindsets about side effects

Given research showing that the very act of communicating side effects can increase their likelihood, how can providers inform patients about side effects while upholding their oath to do no unnecessary harm? An emerging approach provides a potential solution: truthfully describe certain minor side effects as a sign the treatment is active and working in the body. This approach focuses on instilling adaptive mindsets about the meaning of side effects while still keeping patients informed. This article describes existing research suggesting that this approach can be helpful in improving experience and outcomes in treatments for pain, hypertension and allergy. Compared with control groups given a standard, empathetic message about side effects, patients who were informed that side effects are a sign treatment is working were less anxious about side effects and rated them as less threatening and intense. A longitudinal, randomised controlled trial of this approach in patients receiving oral immunotherapy for food allergies found that describing side effects as a sign treatment was working reduced the rate at which patients contacted providers with concerns about side effects and led to greater increases in a biomarker of allergic tolerance from pretreatment to post-treatment (peanut-specific blood IgG4). In unveiling this approach, this article also raises important issues regarding which treatments and symptoms this approach should be applied to. Finally, we outline questions future research should address to further understand and leverage this approach.

Perinatal Infection: A Major Contributor to Efficacy of Cooling in Newborns Following Birth Asphyxia

Neonatal encephalopathy (NE) is a global burden, as more than 90% of NE occurs in low- and middle-income countries (LMICs). Perinatal infection seems to limit the neuroprotective efficacy of therapeutic hypothermia. Efforts made to use therapeutic hypothermia in LMICs treating NE has led to increased neonatal mortality rates. The heat shock and cold shock protein responses are essential for survival against a wide range of stressors during which organisms raise their core body temperature and temporarily subject themselves to thermal and cold stress in the face of infection. The characteristic increase and decrease in core body temperature activates and utilizes elements of the heat shock and cold shock response pathways to modify cytokine and chemokine gene expression, cellular signaling, and immune cell mobilization to sites of inflammation, infection, and injury. Hypothermia stimulates microglia to secret cold-inducible RNA-binding protein (CIRP), which triggers NF-κB, controlling multiple inflammatory pathways, including nod-like receptor family pyrin domain containing 3 (NLRP3) inflammasomes and cyclooxygenase-2 (COX-2) signaling. Brain responses through changes in heat shock protein and cold shock protein transcription and gene-expression following fever range and hyperthermia may be new promising potential therapeutic targets.

Let fever do its job: The meaning of fever in the pandemic era

Although fever is one of the main presenting symptoms of COVID-19 infection, little public attention has been given to fever as an evolved defense. Fever, the regulated increase in the body temperature, is part of the evolved systemic reaction to infection known as the acute phase response. The heat of fever augments the performance of immune cells, induces stress on pathogens and infected cells directly, and combines with other stressors to provide a nonspecific immune defense. Observational trials in humans suggest a survival benefit from fever, and randomized trials published before COVID-19 do not support fever reduction in patients with infection. Like public health measures that seem burdensome and excessive, fevers involve costly trade-offs but they can prevent infection from getting out of control. For infections with novel SARS-CoV-2, the precautionary principle applies: unless evidence suggests otherwise, we advise that fever should be allowed to run its course. Lay summary: For COVID-19, many public health organizations have advised treating fever with medicines such as acetaminophen or ibuprofen. Even though this is a common practice, lowering body temperature has not improved survival in laboratory animals or in patients with infections. Blocking fever can be harmful because fever, along with other sickness symptoms, evolved as a defense against infection. Fever works by causing more damage to pathogens and infected cells than it does to healthy cells in the body. During pandemic COVID-19, the benefits of allowing fever to occur probably outweigh its harms, for individuals and for the public at large.

Characterization of fever and sickness behavior regulated by cytokines during infection

In response to invasion of pathogens, hosts present fever and a series of behavioural changes including reduced grooming, reduction of foraging, decreased locomotion, withdrawing from social activities and reproductive process, which are collectively termed sickness behaviour. Fever as well as sickness behaviour are adaptive and benefit the host to reduce pathology caused by infections and opportunity costs for time away from foraging, reproduction and predator avoidance. Antipathogenic fever and sickness behaviour are mediated proximately by cytokines including pro- and anti-inflammatory cytokines. Pro-inflammation cytokines trigger these sickness responses, while anti-inflammatory cytokines constrain these responses and prevent damage to host from exaggerated responses. The present study reviews the characterization of fever and sickness behaviour regulated by cytokines during infection.

Effects of Fever on 18F-FDG Distribution In Vivo: a Preliminary Study

PURPOSE

Elevated body temperature might change glucose metabolism in human organs. The purpose of this study is to explore ¹⁸F-FDG distribution in febrile patients on the day of ¹⁸F-FDG PET/CT scanning and compare it with patients with a normal temperature.

PROCEDURES

¹⁸F-FDG PET/CT was performed on 69 febrile patients and 82 patients with a normal temperature. Patient sociodemographic data, blood glucose levels before PET/CT, body temperature on the day of the exam, and laboratory test results were collected. Maximal standard uptake values (SUV_max) in the brain, mediastinal blood pool, liver, spleen, and the bone marrow were compared.

RESULTS

Compared with the controls, SUV_max of the febrile patients was significantly lower in the brain, mediastinal blood pool, and the liver (p < 0.01), and higher in the spleen and bone marrow (p < 0.01). In the febrile group, SUV_max was not significantly different between the FDG burden and non-FDG burden patients (p > 0.05). Body temperature was found negatively correlated with SUV_max in the brain (r = - 0.646), mediastinal blood pool (r = - 0.530), and the liver (r = - 0.384), and positively correlated with the SUV_max in the spleen (r = 0.592) and bone marrow (r = 0.651). Multivariate linear regression established body temperature on the day of PET/CT as an independent affecting factor (p < 0.01) for the SUV_max in the brain, mediastinal blood pool, liver, spleen, and bone marrow. The SUV in the brain, liver, and mediastinal blood pool remained different (p < 0.05) after corrected with the SUV_max in the blood pool or liver.

CONCLUSIONS

Fever influences ¹⁸F-FDG distribution in multiple human tissues and organs. Altered ¹⁸F-FDG distribution in vivo might affect results of disease lesion detection and tumor therapy response assessment. Correction with blood pool or liver SUV fails to cancel the effects of fever. The day of fever should be avoided for PET/CT scan, especially in assessing tumor therapy response.

Faster recovery and reduced paracetamol use - a meta-analysis of EPs 7630 in children with acute respiratory tract infections

OBJECTIVE

Fever is a very common adaptive immune response in acute respiratory tract disorders during infancy. Antipyretic / analgesic drugs such as paracetamol (acetaminophen) are widely used to improve the comfort of the child but may cause medically unneeded antipyresis and rare but potentially serious side effects. We assess whether treatment with Pelargonium sidoides extract EPs 7630 reduces the administration of paracetamol in children with acute tonsillopharyngitis (ATP) or acute bronchitis (AB).

DESIGN

Meta-analysis of randomised, placebo-controlled clinical trials.

METHODS

We searched clinical trial registries (ISRCTN, ClinicalTrials.gov ) and medical literature (MEDLINE, EMBASE), for randomised, placebo-controlled trials investigating the administration of EPs 7630 to children with ATP or AB and reporting the co-administration of paracetamol. Based on the individual participant data of the eligible trials, study populations were characterized according to sex and age, and meta-analyses were performed for cumulative paracetamol use and ability to attend school at treatment end.

RESULTS

Six trials including a total of 523 children aged 6-10 years (EPs 7630: 265; placebo: 258) and suffering from non-β-hemolytic streptococcal ATP (3 trials) or from AB (3 trials) were identified and eligible. Children received EPs 7630 or placebo for 6 (ATP) or 7 days (AB). Compared to placebo, EPs 7630 reduced the cumulative dose of paracetamol in 5 out of the 6 trials, by an average of 244 mg (Hedges' g; - 0.28; 95% confidence interval: [- 0.53; - 0.02]; p < 0.03). At treatment end, 30.2% (EPs 7630) and 74.4% (placebo) of the children were still unable to attend school (risk ratio: 0.43; 95% confidence interval: [0.29; 0.65]; p < 0.001).

CONCLUSIONS

In children aged 6-10 years with AB or ATP, EPs 7630 alleviated the symptom burden and accelerated recovery. Although EPs 7630 has no known antipyretic effect, concomitant use of paracetamol was reduced.

Emergency Department Triage Early Warning Score (TREWS) predicts in-hospital mortality in the emergency department

AIM

The purpose is to assess the adequacy of the National Early Warning Score (NEWS) in the emergency department (ED) and the usefulness of the Triage in Emergency Department Early Warning Score (TREWS) that has been developed using the NEWS in the ED.

METHODS

In this retrospective observational cohort study, we performed univariable and multivariable regression analyses with 81,520 consecutive ED patients to develop a new scoring system, the TREWS. The primary outcome was in-hospital mortality within 24 h, and secondary outcomes were in-hospital mortality within 48 h, 7 days, and 30 days. The prognostic properties of the TREWS were compared with those of the NEWS, Modified Early Warning Score (MEWS), and Rapid Emergency Medicine Score (REMS) using the area under the receiver operating characteristic curve (AUC) technique.

RESULTS

The AUC of the TREWS for in-hospital mortality within 24 h was 0.906 (95% CI, 0.903-0.908), those of the NEWS, MEWS, and REMS were 0.878 (95% CI, 0.875-0.881), 0.857 (95% CI, 0.854-0.860), and 0.834 (95% CI, 0.831-0.837), respectively. Differences in the AUC between the TREWS and NEWS, the TREWS and MEWS, and the TREWS and REMS were 0.028 (95% CI, 0.022-0.033; p < .001), 0.049 (95% CI, 0.041-0.057; p < .001), and 0.072 (95% CI, 0.063-0.080; p < .001), respectively. The TREWS showed significantly superior performance in predicting secondary outcomes.

CONCLUSION

The TREWS predicts in-hospital mortality within 24 h, 48 h, 7 days, and 30 days better than the NEWS, MEWS, and REMS for patients arriving at the ED.

Changing Patient Mindsets about Non-Life-Threatening Symptoms During Oral Immunotherapy: A Randomized Clinical Trial

BACKGROUND

Oral immunotherapy (OIT) can lead to desensitization to food allergens, but patients can experience treatment-related symptoms of allergic reactions that cause anxiety and treatment dropout. Interventions to improve OIT for patients are needed.

OBJECTIVE

To determine whether fostering the mindset that non-life-threatening symptoms during OIT can signal desensitization improves treatment experience and outcomes.

METHODS

In a randomized, blinded, controlled phase II study, 50 children/adolescents (28% girls, aged 7-17 years, M = 10.82, standard deviation = 3.01) completed 6-month OIT for peanut allergies. Patients and their parent(s) had monthly clinic visits at the Sean N. Parker Center for Allergy and Asthma Research between January 5, 2017, and August 3, 2017. All families received identical symptom management training. In a 1:1 approach, 24 patients and their families were informed that non-life-threatening symptoms during OIT were unfortunate side effects of treatment, and 26 patients and their families were informed that non-life-threatening symptoms could signal desensitization. Families participated in activities to reinforce these symptom mindsets.

RESULTS

Compared with families informed that symptoms are side effects, families informed that symptoms can signal desensitization were less anxious (B = -0.46, 95% confidence interval [CI]: -0.76 to -0.16; P = .003), less likely to contact staff about symptoms (5/24 [9.4%] vs 27/154 [17.5%] instances; P = .036), experienced fewer non-life-threatening symptoms as doses increased (B_Interaction = -0.54, 95% CI: -0.83 to -0.27; P < .001), less likely to skip/reduce doses (1/26 [4%] vs 5/24 [21%] patients; P = .065), and showed a greater increase in patient peanut-specific blood IgG4 levels (B_Interaction = 0.76, 95% CI: 0.36 to 1.17; P < .001).

CONCLUSIONS

Fostering the mindset that symptoms can signal desensitization improves OIT experience and outcomes. Changing how providers inform patients about non-life-threatening symptoms is a promising avenue for improving treatment.

Temperature-driven changes in viral loads in the honey bee Apis mellifera

Many of the physiological traits in insects are shaped by environmental temperatures, which can influence their interactions with pathogens. Therefore, quantifying the thermal responses of the host-pathogen system is crucial for better understanding and predicting their dynamics due to environmental changes. This is particularly important in honey bees, which are experiencing severe colony losses around the world, notably due to infection with the Deformed wing virus (DWV). To investigate the influence of temperature on the honey bee/DWV relationship we exposed adult bees to low or high temperatures and determined the effects on viral titers and bee survival. Emerging bees naturally infected with DWV were reared in vitro at different temperatures ranging from 15 °C to 37 °C. In addition, some bees reared at 37 °C were exposed daily to acute heat treatments (40 and 43 °C). High temperatures significantly decreased DWV titers close to the initial viral load at emergence but increased bee mortality. The lowest temperature resulted in higher mortality, but virus load was not significantly impacted. In conclusion, our results indicate that temperature could contribute to seasonal variations in viral loads but do not suggest temperature to be used as a tool to eliminate viruses, even given that high temperatures limit viral multiplication.

Ability of Pharmacy Students, Pharmacists and Pharmacy Support Staff to Manage Childhood Fever via Simulation

Objective. To ascertain how pharmacy students (novices) and pharmacy staff (experts) respond to a childhood fever scenario. Methods. Data were collected from 65 second year students and 51 fourth (final) year students in an over-the-counter fever scenario during assessment tasks. Data from pharmacy staff were collected via mystery shopping conducted over nine weeks between March and October 2015. All encounters were immediately scored by the trained simulated client, and immediate feedback was provided for pharmacy staff and fourth year students. Questioning scores and proportions of competent participants were collected in all groups. Statistical comparative analyses were made between fourth year students and pharmacy staff. Pharmacy staff scores were also tracked over time. Results. Second year students performed well, achieving a median questioning score of 100%. Conversely, pharmacy staff scored 22%. A large proportion of the fourth year students and pharmacy staff achieved appropriate outcomes (92% and 65%, respectively); however, a smaller proportion of second year students performed well (52%). The pharmacy staff achieved statistical improvements over time for median questioning scores. Conclusion. Protocol compliant questioning appears to decline with experience. However, experienced counselors are more likely to provide appropriate patient advice. Further improvements in outcomes can also occur when staff are provided feedback and coaching. Mystery shopping simulations can be used as a valuable educational tool.

Reverse Engineering the Febrile System

Fever, the elevation of core body temperature by behavioral or physiological means, is one of the most salient aspects of human sickness, yet there is debate regarding its functional role. In this paper, we demonstrate that the febrile system is an evolved adaptation shaped by natural selection to coordinate the immune system to fight pathogens. First, we show that previous arguments in favor of fever being an adaptation are epistemologically inadequate, and we describe how an adaptationist strategy addresses this issue more effectively. Second, we argue that the mechanisms producing fever provide clear indications of adaptation. Third, we demonstrate that there are many beneficial immune system responses activated during fever and that these responses are not mere byproducts of heat on chemical reactions. Rather, we show that natural selection appears to have modified several immune system effects to be coordinated by fever. Fourth, we argue that there are some adaptations that coordinate the febrile system with other important fitness components, particularly growth and reproduction. Finally, we discuss evidence that the febrile system may also have evolved an antitumor function, providing suggestions for future research into this area. This research informs the debate on the functional value of fever and antipyretic use.

Beneficial effects of Houttuynia cordata polysaccharides on "two-hit" acute lung injury and endotoxic fever in rats associated with anti-complementary activities

Houttuynia cordata Thunb. is a traditional herb used for clearing heat and eliminating toxins, and has also been used for the treatment of severe acute respiratory syndrome (SARS). In vitro, the crude H. cordata polysaccharides (CHCP) exhibited potent anti-complementary activity through both the classical and alternative pathways by acting on components C3 and C4 of the complement system without interfering with the coagulation system. This study was to investigate the preventive effects of CHCP on acute lung injury (ALI) induced by hemorrhagic shock plus lipopolysaccharide (LPS) instillation (two-hit) and LPS-induced fever in rats. CHCP significantly attenuated pulmonary injury in the “two-hit” ALI model by reducing pulmonary edema and protein exudation in bronchoalveolar lavage fluid (BALF). In addition, it reduced the deposit of complement activation products in the lung and improved oxidant-antioxidant imbalance. Moreover, CHCP administration inhibited fever in rats, reduced the number of leukocytes and restored serum complement levels. The inhibition on the inappropriate activation of complement system by CHCP may play an important role in its beneficial effects on inflammatory diseases. The anti-complementary polysaccharides are likely to be among the key substances for the heat-clearing function of H. cordata.

Polysaccharides from Arnebia euchroma Ameliorated Endotoxic Fever and Acute Lung Injury in Rats Through Inhibiting Complement System

Arnebiaeuchroma (Royle) Johnst (Ruanzicao) is a traditional Chinese herbal medicine (TCM). It is extensively used in China and other countries for treatment of inflammatory diseases. It is known that hyper-activated complement system involves in the fever and acute lung injury (ALI) in rats. In our preliminary studies, anti-complementary activity of crude Arnebiaeuchroma polysaccharides (CAEP) had been demonstrated in vitro. This study aimed to investigate the role and mechanism of crude Arnebiaeuchroma polysaccharides (CAEP) using two animal models, which relate with inappropriate activation of complement system. In lipopolysaccharide (LPS)-induced fever model, the body temperature and leukocytes of peripheral blood in rats were significantly increased, while the complement levels of serum were remarkably decreased. CAEP administration alleviated the LPS-induced fever, reduced the number of leukocytes, and improved the levels of complement. Histological assay showed that there were severe damages and complement depositions in lung of the ALI rats. Further detection displayed that the oxidant stress was enhanced, and total hemolytic activity and C3/C4 levels in serum were decreased significantly in the ALI model group. Remarkably, CAEP not only attenuated the morphological injury, edema, and permeability in the lung but also significantly weakened the oxidant stress in bronchoalveolar lavage fluid (BALF) in the ALI rats. The levels of complement and complement depositions were improved by the CAEP treatment. In conclusion, the CAEP treatment ameliorated febrile response induced by LPS and acute lung injury induced by LPS plus ischemia-reperfusion. CAEP exerted beneficial effects on inflammatory disease potentially via inhibiting the inappropriate activation of complement system.

Identification of secreted and membrane-bound bat immunoglobulin using a Microchiropteran-specific mouse monoclonal antibody

Bat immunity has received increasing attention because some bat species are being decimated by the fungal disease, White Nose Syndrome, while other species are potential reservoirs of zoonotic viruses. Identifying specific immune processes requires new specific tools and reagents. In this study, we describe a new mouse monoclonal antibody (mAb) reactive with Eptesicus fuscus immunoglobulins. The epitope recognized by mAb BT1-4F10 was localized to immunoglobulin light (lambda) chains; hence, the mAb recognized serum immunoglobulins and B lymphocytes. The BT1-4F10 epitope appeared to be restricted to Microchiropteran immunoglobulins and absent from Megachiropteran immunoglobulins. Analyses of sera and other E. fuscus fluids showed that most, if not all, secreted immunoglobulins utilized lambda light chains. Finally, mAb BT1-4F10 permitted the identification of B cell follicles in splenic white pulp. This Microchiropteran-specific mAb has potential utility in seroassays; hence, this reagent may have both basic and practical applications for studying immune process.

Fever as an important resource for infectious diseases research

Fever or pyrexia is a process where normal body temperature is raised over homeostasis conditions. Although many effects of fever over the immune system have been known for a long time, it has not been until recent studies when these effects have been evaluated in several infection processes. Results have been promising, as they have reported new ways of regulation, especially in RNA molecules. In light of these new studies, it seems important to start to evaluate the effects of pyrexia in current research efforts in host-pathogen interactions. Viruses and bacteria are responsible for different types of infectious diseases, and while it is of paramount importance to understand the mechanisms of infection, potential effects of fever on this process may have been overlooked. This is especially relevant because during the course of many infectious diseases the organism develops fever. Due to the lack of specific treatments for many of those afflictions, experimental evaluation in fever-like conditions can potentially bring new insights into the infection process and can ultimately help to develop treatments. The aim of this review is to present evidence that the temperature increase during fever affects the way the infection takes place, for both the pathogen and the host.

Fever and sickness behavior: Friend or foe?

Fever has been recognized as an important symptom of disease since ancient times. For many years, fever was treated as a putative life-threatening phenomenon. More recently, it has been recognized as an important part of the body's defense mechanisms; indeed at times it has even been used as a therapeutic agent. The knowledge of the functional role of the central nervous system in the genesis of fever has greatly improved over the last decade. It is clear that the febrile process, which develops in the sick individual, is just one of many brain-controlled sickness symptoms. Not only will the sick individual appear "feverish" but they may also display a range of behavioral changes, such as anorexia, fatigue, loss of interest in usual daily activities, social withdrawal, listlessness or malaise, hyperalgesia, sleep disturbances and cognitive dysfunction, collectively termed "sickness behavior". In this review we consider the issue of whether fever and sickness behaviors are friend or foe during: a critical illness, the common cold or influenza, in pregnancy and in the newborn. Deciding whether these sickness responses are beneficial or harmful will very much shape our approach to the use of antipyretics during illness.

Body temperature changes during simulated bacterial infection in a songbird: fever at night and hypothermia during the day

Although fever (a closely regulated increase in body temperature in response to infection) typically is beneficial, it is energetically costly and may induce detrimentally high body temperatures. This can increase the susceptibility to energetic bottlenecks and risks of overheating in some organisms. Accordingly, it could be particularly interesting to study fever in small birds, which have comparatively high metabolic rates and high, variable body temperatures. We therefore investigated two aspects of fever and other sickness behaviours (circadian variation, dose dependence) in a small songbird, the zebra finch. We injected lipopolysaccharide (LPS) at the beginning of either the day or the night, and subsequently monitored body temperature, body mass change and food intake for the duration of the response. We found pronounced circadian variation in the body temperature response to LPS injection, manifested by (dose-dependent) hypothermia during the day but fever at night. This resulted in body temperature during the peak response being relatively similar during the day and night. Day-to-night differences might be explained in the context of circadian variation in body temperature: songbirds have a high daytime body temperature that is augmented by substantial heat production peaks during activity. This might require a trade-off between the benefit of fever and the risk of overheating. In contrast, at night, when body temperature is typically lower and less variable, fever can be used to mitigate infection. We suggest that the change in body temperature during infection in small songbirds is context dependent and regulated to promote survival according to individual demands at the time of infection.

Mechanisms of fever production and lysis: lessons from experimental LPS fever

Fever is a cardinal symptom of infectious or inflammatory insults, but it can also arise from noninfectious causes. The fever-inducing agent that has been used most frequently in experimental studies designed to characterize the physiological, immunological and neuroendocrine processes and to identify the neuronal circuits that underlie the manifestation of the febrile response is lipopolysaccharide (LPS). Our knowledge of the mechanisms of fever production and lysis is largely based on this model. Fever is usually initiated in the periphery of the challenged host by the immediate activation of the innate immune system by LPS, specifically of the complement (C) cascade and Toll-like receptors. The first results in the immediate generation of the C component C5a and the subsequent rapid production of prostaglandin E2 (PGE2). The second, occurring after some delay, induces the further production of PGE2 by induction of its synthesizing enzymes and transcription and translation of proinflammatory cytokines. The Kupffer cells (Kc) of the liver seem to be essential for these initial processes. The subsequent transfer of the pyrogenic message from the periphery to the brain is achieved by neuronal and humoral mechanisms. These pathways subserve the genesis of early (neuronal signals) and late (humoral signals) phases of the characteristically biphasic febrile response to LPS. During the course of fever, counterinflammatory factors, "endogenous antipyretics," are elaborated peripherally and centrally to limit fever in strength and duration. The multiple interacting pro- and antipyretic signals and their mechanistic effects that underlie endotoxic fever are the subjects of this review.

Distribution of Plasmodium falciparum gametocytes and malaria-attributable fraction of fever episodes along an altitudinal transect in Western Cameroon

BACKGROUND

Highland areas are hypoendemic zones of malaria and are therefore prone to epidemics, due to lack of protective immunity. So far, Cameroon has not succeeded in implementing a convenient and effective method to detect, prevent and forecast malaria epidemic in these peculiar zones. This monitoring and evaluation study aims to assess the operational feasibility of using the human malaria infectious reservoir (HMIR) and the malaria-attributable fraction of fever episodes (MAFE) as indicators, in designing a malaria epidemic early warning system (MEWS).

METHODS

Longitudinal parasitological surveys were conducted in sentinel health centres installed in three localities, located along an altitudinal transect in Western Cameroon: Santchou (750 m), Dschang (1,400 m) and Djuttitsa (1,965 m). The syndromes of outpatients with malaria-like complaints were recorded and their blood samples examined. The HMIR and the MAFE were estimated and their spatial-temporal variations described.

RESULTS

The prevalence of asexual Plasmodium infection in outpatients decreased with increasing altitude; meanwhile the HMIR remained fairly constant, indicating that scarcity of malaria disease in highlands is likely due to absence of vectors and not parasites. In lowland, children carried the heaviest malaria burden in the form of febrile episodes, and asexual parasites decreased with age, after an initial peak in the 0-5 year's age group; however, they were similar for all age groups in highland. The HMIR did not show any variation with age in the plain; but some discrepancies were observed in the highland with extreme age groups, and migration of populations between lowland and highland was suspected to be the cause. Plasmodium infection was perennial in the lowland and seasonal uphill, with malaria disease occurring here mostly during the short dry season. The MAFE was high and did not change with altitude.

CONCLUSION

It is obvious that a malaria outbreak will cause the sudden rise of HMIR and MAFE in highland, prior to the malaria season; the discrepancy with lowland would then help detecting an incipient malaria epidemic. It is recommended that in designing the MEWS, the National Malaria Control Programme should include these parameters and put special emphasis on: altitude, age groups and seasons.

Bat flight and zoonotic viruses

High metabolism and body temperatures of flying bats might enable them to host many viruses.

Bats are sources of high viral diversity and high-profile zoonotic viruses worldwide. Although apparently not pathogenic in their reservoir hosts, some viruses from bats severely affect other mammals, including humans. Examples include severe acute respiratory syndrome coronaviruses, Ebola and Marburg viruses, and Nipah and Hendra viruses. Factors underlying high viral diversity in bats are the subject of speculation. We hypothesize that flight, a factor common to all bats but to no other mammals, provides an intensive selective force for coexistence with viral parasites through a daily cycle that elevates metabolism and body temperature analogous to the febrile response in other mammals. On an evolutionary scale, this host–virus interaction might have resulted in the large diversity of zoonotic viruses in bats, possibly through bat viruses adapting to be more tolerant of the fever response and less virulent to their natural hosts.

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%).

Behavioural fever is a synergic signal amplifying the innate immune response

Behavioural fever, defined as an acute change in thermal preference driven by pathogen recognition, has been reported in a variety of invertebrates and ectothermic vertebrates. It has been suggested, but so far not confirmed, that such changes in thermal regime favour the immune response and thus promote survival. Here, we show that zebrafish display behavioural fever that acts to promote extensive and highly specific temperature-dependent changes in the brain transcriptome. The observed coupling of the immune response to fever acts at the gene–environment level to promote a robust, highly specific time-dependent anti-viral response that, under viral infection, increases survival. Fish that are not offered a choice of temperatures and that therefore cannot express behavioural fever show decreased survival under viral challenge. This phenomenon provides an underlying explanation for the varied functional responses observed during systemic fever. Given the effects of behavioural fever on survival and the fact that it exists across considerable phylogenetic space, such immunity–environment interactions are likely to be under strong positive selection.

A physical explanation of the temperature dependence of physiological processes mediated by cilia and flagella

The majority of biological rates are known to exhibit temperature dependence. Here I reveal a direct link between temperature and ecologically relevant rates such as swimming speeds in Archaea, Bacteria, and Eukaryotes as well as fluid-pumping and filtration rates in many metazoans, and show that this relationship is driven by movement rates of cilia and flagella. I develop models of the temperature dependence of cilial and flagellar movement rates and evaluate these with an extensive compilation of data from the literature. The model captures the temperature dependence of viscosity and provides a mechanistic and biologically interpretable explanation for the temperature dependence of a range of ecologically relevant processes; it also reveals a clear dependence on both reaction rate-like processes and the physics of the environment. The incorporation of viscosity allows further insight into the effects of environmental temperature variation and of processes, such as disease, that affect the viscosity of blood or other body fluids.

The inhibitory effect of the fungal toxin, destruxin A, on behavioural fever in the desert locust

During an infection locusts behaviourally fever by seeking out higher environmental temperatures. This behaviour places the pathogen at sub-optimal growth temperatures while improving the efficiency of the immune system, thereby prolonging the lifespan of the host. It is therefore in the interest of the pathogen to either adapt to fever-like temperatures or to evolve mechanisms to interfere with, or inhibit fever. We investigated the behavioural fever response of desert locusts to two fungal pathogens. A prolonged fever was observed in locusts infected with Metarhizium acridum. However, fever was comparatively short-lived during infection with Metarhizium robertsii. In both cases restriction of thermoregulation reduced lifespan. Destruxin A (dtx A) produced by M. robertsii, but not M. acridum has previously been associated with the inhibition of the insect immune system. Injection of dtx A during infection with the fever-causing M. acridum inhibited fever and was particularly effective when administered early on in infection. Furthermore, locusts injected with dtx A were more susceptible to M. acridum infection. Therefore engineering M. acridum isolates currently used for locust biocontrol, to express dtx A may improve efficiency of control by interfering with fever.

Differentiation of CD8+ T cells into effector cells is enhanced by physiological range hyperthermia

In this study, we asked whether exposure to different physiologically relevant temperatures (33°C, 37°C, and 39.5°C) could affect subsequent antigen-specific, activation-related events of naive CD8(+) T cells. We observed that temporary exposure of CD62L(hi)CD44(lo) Pmel-1 CD8(+) cells to 39.5°C prior to their antigen-dependent activation with gp100(25-33) peptide-pulsed C57BL/6 splenocytes resulted in a greater percentage of cells, which eventually differentiated into CD62L(lo)CD44(hi) effector cells compared with cells incubated at 33°C and 37°C. However, the proliferation rate of naive CD8(+) T cells was not affected by mild heating. While exploring these effects further, we observed that mild heating of CD8(+) T cells resulted in the reversible clustering of GM1(+) CD-microdomains in the plasma membrane. This could be attributable to a decrease in line tension in the plasma membrane, as we also observed an increase in membrane fluidity at higher temperatures. Importantly, this same clustering phenomenon was observed in CD8(+) T cells isolated from spleen, LNs, and peripheral blood following mild whole-body heating of mice. Further, we observed that mild heating also resulted in the clustering of TCRβ and the CD8 coreceptor but not CD71R. Finally, we observed an enhanced rate of antigen-specific conjugate formation with APCs following mild heating, which could account for the difference in the extent of differentiation. Overall, these novel findings may help us to further understand the impact of physiologically relevant temperature shifts on the regulation of antigen-specific CD8(+) T cell activation and the subsequent generation of effector cells.

Glucocorticoid and pyrazolone treatment of acute fever is a risk factor for critical and life-threatening human enterovirus 71 infection during an outbreak in China, 2008

BACKGROUND

Human enterovirus 71 (HEV71) causes outbreaks of life-threatening diseases throughout the world. The genesis of these severe diseases is unknown.

METHODS

During an outbreak of HEV71 infection, we investigated risk factors for critical illness. We developed a modified pediatric index of mortality (mPIM) incorporating heart rate, temperature, white blood cell count, respiratory rate, chest infiltrates, skin color, reflexes, responsiveness, and mobility. We calculated the mPIM for 103 patients (22 deaths) using complete scoring criteria in the medical record. In a case-control study, we compared cases (mPIM > or =10 or death) with controls (mPIM = 0-9) by drugs received within 96 hours after onset of fever, initial temperature, age, and nutritional anthropometry.

RESULTS

About 66% (68/103) of the patients with an mPIM score (28 cases and 40 controls) had data on initial exposures. About 50% of the 28 cases and 18% of the 40 controls received an injection to treat fever during the first 96 hours after onset (Odds ratio [OR] = 7.0, 95% confidence interval [CI]: 1.8-28). Injections containing exclusively glucocorticoids (OR = 4.8, 95% CI: 1.2-21) or pyrazolones (OR = 4.1, 95% CI: 0.91-19, P = 0.047) were risk factors for severe HEV71 infection. About 25% of cases and 5% of controls received both drugs parenterally while 7% of cases and 30% of controls received neither (OR = 21, 95% CI: 1.8-305). Conversely, cases and controls had identical average initial temperature, and did not differ significantly by age, sex, nutritional measurements, use of other drugs, or timeliness of medical care received.

CONCLUSION

Fever treatment with glucocorticoids and/or pyrazolones is a risk factor for life-threatening HEV71 infection.

Molecular aspects of fever and hyperthermia

After defining hyperthermia and fever, this article describes the complete chain of events leading to the genesis of fever, starting with the lipopolysaccharide-induced formation of endogenous pyrogens (cytokines), their interactions with relevant targets in the brain, the induction of enzymes responsible for the formation of prostaglandin E2, the activation of descending neuronal pathways via the EP3 receptor, and the stimulation of thermogenesis via this pathway to support the febrile shift of the thermoregulatory set point. This article also summarizes an alternative hypothesis to account for a rapid induction of the early phase of lipopolysaccharide-induced fever before the release of larger amounts of cytokines into the bloodstream. Other topics discussed include malignant hypothermia, drug-induced hypothermia, and the heat stroke syndrome.

Postnatal programming of the innate immune response

A host's defensive response to a pathogen is a phylogenetically ancient reaction that consists of a CNS-mediated series of autonomic, hormonal and behavioral responses that combine to combat infection. The absence of such defense results in greater morbidity and mortality and thus, these responses are essential for survival. The postnatal period represents a malleable phase in which the long-term behavior and physiology of the developing organism, including its immune responses, can be influenced. Postnatal challenge of the immune system by introduction of live replicating infections, or administration of bacterial and viral mimetics, can result in a multidomain alteration to the defenses of the adult host. Findings from our laboratory and others' indicate that the postnatal administration of lipopolysaccharide (LPS) or polyinosinic:polycytidylic acid (PolyI:C), which mimic bacterial and viral infections respectively, can influence the neuroimmune response (generation of fever and production of cytokines) to a second challenge to the immune system in adulthood. This long-lasting alteration in the innate immune response is associated with myriad other effects on the animal's physiology and appears to be primarily mediated by a sensitized hypothalamic-pituitary-adrenal axis. Thus, a transient immunological perturbation to a developing animal may program the organism for subsequent health complications as an adult. In this review we discuss some of the potential mechanisms for these phenomena.

Attitudes and subjective norms: determinants of parents' intentions to reduce childhood fever with medications

Fever is a natural protective response of the host organism. Mild to moderate fevers, up to 40.0 degrees C, have immunological benefits and do not need to be reduced. However, parents regularly reduce fever with medications to prevent perceived harmful outcomes. This study identified the determinants of parents' intentions to reduce childhood fever with medications. A community-based cross-sectional survey was conducted with 391 Australian parents of children aged between 6 months and 5 years. Recruitment was through advertising, face-to-face and snowball methods. The survey targeted constructs of the Theory of Planned Behavior: attitudes, subjective norms, perceived behavioral control, intentions and previously identified background factors. Structural equation modeling identified 69% of the variance in intentions. The strongest influences were from non-scientifically based attitudes (phobic) (beta=0.55) and subjective norms (husband/partner and doctors) (beta=0.36). Attitudes (beta=0.69) and subjective norms (beta=0.52) were strongly determined by child medication behavior (whether the child took medications easily when febrile) which had a total effect on intentions of beta=0.66. Perceived control, education and number of children had minimal influence on intentions. There is an urgent need for (i) the education of both parents in the benefits of fever and (ii) for doctors to consistently provide parents with evidence-based information.

Parents' childhood fever management: community survey and instrument development

AIM

This paper is a report of a study to explore Australian parents' knowledge, beliefs, practices and information sources about fever management and develop a scale to measure parents' fever management practices.

BACKGROUND

Parental fever phobia and overuse of antipyretics to reduce fever continue. No scales to measure parents' fever management practices are available.

METHOD

A community-based, postal survey was carried out in 2005 with 401 Australian parents of well children aged 6 months-5 years. Respondents were recruited through advertising (48.4%), face-to-face (26.4%) and snowball (24.4%) methods. A 33-item instrument was developed; construct and content validity were determined by an expert panel and item reliability by test-retest.

RESULTS

Moderate fever (40.0 +/- 1.0 degrees C) was reported to be harmful (88%), causing febrile convulsions (77.7%). Usual practices targeted temperature reduction, antipyretic administration (87.8%), temperature monitoring (52.5%). Fewer evidence-based practices, such as encouraging fluids (49.0%) and light clothing (43.8%), were reported. Positive changes over time (36.4%) included less concern and delayed or reduced antipyretic use. Negative practice changes (22.7%) included greater concern and increased antipyretic use. Medical advice was sought for illness symptoms (48.7%) and high (37.4%) or persistent (41.5%) fevers. Fever management was learnt from doctors, family and friends and working experience, while receiving conflicting information (41.9%) increased concerns and created uncertainty about best practice.

CONCLUSION

Parents need consistent evidence-based information about childhood fever management. The Parental Fever Management Scale requires further testing with different populations and in different cultures and healthcare systems to evaluate its usefulness in nursing practice and research.