202 Annals of Saudi Medicine, Vol 20, Nos 3-4, 2000

PARENTAL PERCEPTIONS OF FEVER IN CHILDREN

Youssef A. Al-Eissa, MD, FAAP, FRCPC; Abdullah M. Al-Sanie, MD, MRCP;Suleiman A. Al-Alola, MD, CABP; Mohammed A. Al-Shaalan, MD, FAAP, MRCP;

Sameeh S. Ghazal, MD, MRCP; Amal H. Al-Harbi, MD, CABP;Anwar S. Al-Wakeel, MD, CABP

Background: Fever is a common medical problem in children which often prompts parents to seek immediatemedical care. The objective of this study was to survey parents about their knowledge and attitude concerningfever in their children.Patients and Methods: The study involved the random selection of Saudi parents who brought their febrilechildren to the emergency rooms or walk-in clinics of four hospitals in Riyadh. Parents of 560 febrile childrenwere interviewed using a standard questionnaire to obtain sociodemographic information and current knowledgeof fever. Approximately 70% of the respondents were female, and the ages of the most were in the range of 20-40years. More than 80% of the parents had two or more children.Results: More than 70% of parents demonstrated a poor understanding of the definition of fever, high fever,maximum temperature of untreated fever, and threshold temperature warranting antipyresis. About 25% ofparents considered temperatures less than 38.0oC to be fever, another 25% did not know the definition of fever,64% felt that temperatures of less than 40.0oC could be dangerous to a child, and 25% could not define highfever. Another 23% believed that if left untreated, temperatures could rise to 42.0oC or higher, but 37% could notprovide an answer, and 62% did not know the minimum temperature for administering antipyretics.Approximately 95% of parents demonstrated undue fear of consequent body damage from fever, includingconvulsion, brain damage or stroke, coma, serious vague illness, blindness, and even death.Conclusion: Parental misconceptions about fever reflect the lack of active health education in our community.Health professionals have apparently not done enough to educate parents on the condition of fever and itsconsequences, a common problem.Ann Saudi Med 2000;20(3-4):202-205.

Key Words: Convulsion, fever, heat stroke, hyperpyrexia.

Fever is extremely common in childhood. Parents havebeen shown to have unrealistic fears of the harmful effectsof fever in their children, and they generally see it as themain component of an illness.1,2 Parents are unable todefine fever accurately, tend to overestimate its dangers,and make inappropriate telephone calls and unnecessaryclinic visits, leading to excessive utilization of healthcareservices.3 Anecdotal experiences suggest that physicianscontribute to parental misconceptions about fever, althoughit is unclear which part of the patient-doctor interactionpromotes this fear.4 Our clinical experience suggests thatpediatric health providers may impart mixed messages toparents about the dangers of fever. For example, although

From the Departments of Pediatrics, College of Medicine, King SaudUniversity (Drs. Al-Eissa and Al-Sanie), King Fahad National GuardHospital (Drs. Al-Alola, Al-Shaalan, Al-Harbi, and Al-Wakeel), andSulaimania Childrens Hospital (Dr. Ghazal), Riyadh, Saudi Arabia.

Address reprint requests and correspondence to Prof. Al-Eissa:Department of Pediatrics (39), College of Medicine, King SaudUniversity, P.O. Box 2925, Riyadh 11461, Saudi Arabia.

Accepted for publication 4 March 2000. Received 6 July 1999.

many physicians agree that treatment to reduce fever ismostly for the comfort of the child, during consultationsmany tend to prescribe antipyretic medication for any childwith a fever. Furthermore, physicians frequently differ intheir definition and management of fever.

The purpose of the study was to determine the status ofknowledge and attitude of parents about fever in theirchildren. The study was undertaken in the pediatricpractices at four different hospitals in Riyadh.

Patients and Methods

Parents bringing their febrile children to hospital-basedemergency departments or walk-in clinics between 8:00a.m. and 8:00 p.m. (when research assistants wereavailable) were recruited at random, on the basis ofgenerated odd registration numbers. Febrile children whowere judged to be critically ill were excluded from thestudy. Eligible parents were interviewed in the waitingrooms as they awaited appointments with their physicians.The study was carried out in four hospitals in differentareas of Riyadh, namely, the King Khalid University

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Annals of Saudi Medicine, Vol 20, Nos 3-4, 2000 203

Hospital, King Fahad National Guard Hospital, SulaimaniaChildrens Hospital, and Childrens Hospital of RiyadhMedical Complex. These hospitals were selected to ensureenrolment of a truly representative Saudi population sampleof all socioeconomic strata. Each eligible male or femaleparent was interviewed in Arabic by a male or femaleresearch assistant, using a standard questionnaire designedto obtain background sociodemographic information andcurrent knowledge of fever.

Parents were given no assistance with answering thequestions and none refused to be interviewed. In an attemptto obtain unbiased data that truly reflected parentsperceptions about fever, the questionnaire relied principallyupon open-ended questions (i.e., no suggestions of theright answer).

Demographic data obtained included age of bothparents, accompanying parent, level of education attained,current occupation of parents, and number of children caredfor by the parent. The questionnaire items were designed toascertain parents knowledge, attitudes and fearsconcerning fever in their child. The questions asked were asfollows: how do you know if your child has a fever?; whatis the temperature reading that constitutes a fever in achild?; what do you consider a high fever?; how high couldthe fever go if it is not treated?; what is the greatest harmthat high fever can cause to a child? The questions wereframed in a way as to enable the average lay person tounderstand and respond, yet an attempt was also made toobtain definitive data. Fever was defined as a documentedtemperature of 38.0C or higher per rectum (or rectalequivalent). A rectal equivalent temperature wascalculated by adding 0.5C to the oral temperature and0.8C to the axillary temperature. The appropriateness ofresponses to questions was determined on the basis ofcurrent medical literature.

Results

A total of 560 parents of febrile children wereinterviewed. A description of the sociodemographiccharacteristics of the study parents is presented in Table 1.The majority of the parents surveyed were living in Riyadhcity. A wide range in parental age, educational level,occupation and family size was noted. Most parentsparticipating in the study were housewives in their latetwenties or early thirties, with at least a primary schooleducation. Only one-third of fathers brought their febrilechildren to the hospital. Roughly one-half of respondentscared for four children or more.

The majority of parents believed that they could tellwhether their child had a fever by the appearance orpalpation of the child. Only 24% of parents had theirchilds temperature measured at home.

Data concerning parental knowledge and attitudes aboutfever are shown in Table 2. In this study, the quoted body

TABLE 1. Sociodemographic characteristics of 560 study parents.Characteristic Number %

Accompanying parent

Mother 397 70.9

Father 84 15Both parents 79 14.1

Residence

Riyadh city 424 75.7Outside Riyadh city 136 24.3

Age of father (range 19-70, mean 37 years)

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204 Annals of Saudi Medicine, Vol 20, Nos 3-4, 2000

TABLE 2. Parental knowledge and attitudes about fever.Variable Number %

Minimum temperature considered as fever (range, 30.0-41.0C)39.0C 13 2.3Unknown 143 25.5

Temperature considered as high fever (range, 35.0-50C)

41.0C 20 3.6Unknown 142 25.3

How high could temperature go without treatment (range, 37.0-100.0C)44.0C 33 5.9

Unknown 206 36.8Threshold temperature for giving an antipyretic

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Annals of Saudi Medicine, Vol 20, Nos 3-4, 2000 205

occur between 5 and 7 p.m., and the minimum temperaturesoccur between the hours of 2 and 6 a.m. Hence, it is notunusual for an active normal childs temperature to be ashigh as 38.0C rectally in the late afternoon. A rise intemperature above 38.0C may also be caused by physicalexercise, warm clothing, hot or humid weather, or warmfood/drinks.2 Such external factors should be eliminatedbefore measuring the temperature.

Fever is defined as a temperature above the normalrange. A rectal temperature of 38.0C or more, an oraltemperature of 37.5C or more, and an axillary temperatureof 37.2C or more, are all considered fever.2,8 About 25% ofthe study parents identified fever as a temperature of 37.9Cor less, and another 25% did not know the temperaturelevel that constituted a fever.

Although the definition of high fever is arbitrary (i.e.,>40.0C), 67% of the parents defined high fever as 40.0Cor less. Also of great concern is the misconception on thepart of 25% of study parents who indicated that untreatedfever could reach 42.0C and above, and those parents whodid not know the effects of untreated fever. With thesemisconceptions of fever, it is not surprising that parentswould treat fever aggressively. An analysis of temperaturecharts during febrile illnesses before the advent ofantimicrobial therapy showed that peak temperaturesalmost never exceeded 41.1C.7

Hyperpyrexia is defined as a temperature of 41.0C orgreater. Fevers of this magnitude are rare. Tomlinsonreported temperatures of higher than 41.1C in only twochildren in his study on high fevers in ambulatory patientsduring 13 years of private pediatric practice.9 McCarthyand Dolan found only 100 children with temperatures of41.1C or higher among 210,000 consecutive patients overan eight-year span,10 an incidence of only 0.05%.

The body temperature is controlled by a thermo-regulatory center in the hypothalmus via a complexfeedback system.11 This hypothalmic thermostat, ifuninfluenced by complicating circumstance (e.g., heatstroke or drugs), seems to exert a shutoff valvephenomenon so that high temperatures are generally keptbelow a level that would seriously damage body tissues.Most temperatures above 41.1C in children are due tohuman errors from excessive heat load or from interferencewith heat loss. Examples are wrapping a febrile child in toomuch clothing or blankets, placing a baby near a heatradiator, or placing a child in a car in direct sunlight.1 Toomuch clothing is more dangerous during a heat wave intropical countries.12 Children uncommonly develophyperpyrexia (temperatures of 41.1C or greater) because ofcentral nervous system infections, namely meningitis,9,13

and cerebral malaria,14 underlying structural brain defectssuch as Down syndrome or hydrocephalus, and braintumor.13

Our study showed that parents were overly concernedabout the harmful effects of fever. The type of harm that

parents thought their children would suffer from fever werevaried, and included convulsions, brain damage or stroke,coma, dehydration, blindness and death. The same fearswere found among parents in other previous studies.1,3 Theadverse effects of fever include discomfort, milddehydration, febrile delirium and uncomplicated seizures.Heat stroke, a catastrophic circulatory failure characterizedby hyperpyrexia, delirium, coma and anhidrosis, rarelyoccurs in children, and is mostly caused by environmentalfactors such as overheating or too much clothing.2,15

Although febrile convulsions are terrifying to parents, theycarry no risk to subsequent neurologic or developmentaldisabilities.16

This study indicates that child health care providershave apparently not done enough in educating parentsabout fever and its consequences, and considerable effortswill be required to correct such parental misconceptions.Health education is all too often given short shrift in thebusy ambulatory care setting. The harried clinician isfrequently so pressed that the delivery of health informationis abbreviated and perfunctory. When these cursoryinstructions fall on the ears of an anxious mother distractedby a screaming child, the efforts become almost futile. Useof well-designed health education aids that presentinformation in a clear, consistent and entertaining mannerwould be more effective. Hence, an audio-visual healtheducation message on fever would be superior to thewritten material containing the same information.

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3. Kramer MS, Maimark L, Leduc DG. Parental fever phobia and itscorrelates. Pediatrics 1985;75:1110-3.

4. May A, Bauchner H. Fever phobia: the pediatrician contribution.Pediatrics 1992;90:851-4.

5. Casey R, McMahon F, McCormick MC, Pasquariello PS, Zavod W,King FH. Fever therapy: an educational intervention for parents.Pediatrics 1984;73:600-5.

6. ONeill MB. Fever in children. Can J Pediatr 1994;1:48-9.7. DuBois EF. Fever and the regulation of body temperature.

Springfield, Illinois: Charles C. Thomas, 1948.8. Schmitt BD. Fever in childhood. Pediatrics 1984;74(Suppl):929-36.9. Tomlinson WA. High fever. Am J Dis Child 1975;129:693-6.10. McCarthy PL, Dolan TF. Hyperpyrexia in children: eight-year

emergency room experience. Am J Dis Child 1976;130:849-51.11. Dinarello CA, Wolff SM. Pathogenesis of fever in man. N Engl J

Med 1978;298:607-12.12. Stanfield JP. Fever in children in the tropics. BMJ 1969;1:61-5.13. DuBois EF. Why are fever temperatures over 106oF rare? Am J Med

Sci 1949;217:361-8.14. Stern RC. Pathophysiologic basis for symptomatic treatment of

fever. Pediatrics 1977;59:92-8.15. Knochel JP. Environmental heat illness. Arch Intern Med 1974;133:

841-64.16. Al-Eissa YA. Febrile seizures: rate and risk factors of recurrence. J

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