Int J Clin Pharm
DOI 10.1007/s11096-016-0333-2
REVIEW ARTICLE
Drivers for inappropriate fever management in children:
a systematic review
M. Kelly1 • S. McCarthy1,2 • R. O’Sullivan3,4 • F. Shiely5 • P. Larkin6
M. Brenner6 • L. J. Sahm1,7
Received: 16 February 2016 / Accepted: 6 June 2016
 Springer International Publishing 2016
Abstract Background Fever is one of the most common
childhood symptoms and accounts for numerous consul-
tations with healthcare practitioners. It causes much anxi-
ety amongst parents as many struggle with managing a
feverish child and find it difficult to assess fever severity.
Over- and under-dosing of antipyretics has been reported.
Aim of the review The aim of this review was to synthesise
qualitative and quantitative evidence on the knowledge,
attitudes and beliefs of parents regarding fever and febrile
illness in children. Method A systematic search was con-
ducted in ten bibliographic databases from database
inception to June 2014. Citation lists of studies and con-
sultation with experts were used as secondary sources to
identify further relevant studies. Titles and abstracts were
screened for inclusion according to pre-defined inclusion
and exclusion criteria. Quantitative studies using a
Electronic supplementary material The online version of this
article (doi:10.1007/s11096-016-0333-2) contains supplementary
material, which is available to authorized users.
& M. Kelly
113223823@umail.ucc.ie
1
Pharmaceutical Care Research Group, School of Pharmacy,
University College Cork, Cork, Ireland
2
Department of Pharmacy, Cork University Hospital, Cork,
Ireland
3
School of Medicine, University College Cork, Cork, Ireland
4
National Children’s Research Centre, Dublin 12, Ireland
5
HRB Clinical Research Facility & Department of
Epidemiology and Public Health, University College Cork,
Cork, Ireland
6
School of Nursing, Midwifery and Health Systems,
University College Dublin, Dublin, Ireland
7
Mercy University Hospital, Cork, Ireland
•
questionnaire were analysed using narrative synthesis.
Qualitative studies with a semi-structured interview or
focus group methodology were analysed thematically.
Results Of the 1565 studies which were screened for
inclusion in the review, the final review comprised of 14
studies (three qualitative and 11 quantitative). Three cate-
gories emerged from the narrative synthesis of quantitative
studies: (i) parental practices; (ii) knowledge; (iii) expec-
tations and information seeking. A further three analytical
themes emerged from the qualitative studies: (i) control;
(ii) impact on family; (iii) experiences. Conclusion Our
review identifies the multifaceted nature of the factors
which impact on how parents manage fever and febrile
illness in children. A coherent approach to the management
of fever and febrile illness needs to be implemented so a
consistent message is communicated to parents. Healthcare
professionals including pharmacists regularly advise par-
ents on fever management. Information given to parents
needs to be timely, consistent and accurate so that inap-
propriate fever management is reduced or eliminated. This
review is a necessary foundation for further research in this
area.
Keywords Attitudes
Children
Fever
Fever
management
Knowledge
Parents
Impact of findings on practice
• For the management of fever, caregivers seek reassur-
ance from a variety of sources including healthcare
practitioners.
• Further initiatives and safety netting advice are required
to provide trustworthy, accessible information to
123

parents on the management of fever and febrile illness
in children.
• Healthcare practitioners should encourage parents to
manage the general condition of child rather than
focussing on the fever alone.
Introduction
Fever is one of the most common childhood symptoms
treated by parents [1–4]. Despite its prevalence, manage-
ment of fever and febrile illness causes concern [5] and
anxiety [6] in parents. Fever is often a self-limiting
symptom [3], causing little more than discomfort to the
child [2, 7]. Nevertheless, parents often consider fever a
disease in itself [8].
Many parents find the task of managing fever in a child
overwhelming [9], resulting in over-engagement with
health services [3, 7]. Consequently, it is one of the main
reasons for paediatric consultations at emergency depart-
ments (EDs) [7]. In the USA 60 million clinic visits per
year are due to fever in children, costing an estimated $10
billion in 2010 [10–12]. Parents also seek reassurance from
a variety of other sources including the internet, family,
friends, books and magazines and other healthcare practi-
tioners [3, 4, 7]. Guidelines recommend that safety netting
advice, including written or verbal information on warning
symptoms along with when and how to access further
healthcare services, should be provided to parents when
presenting with a sick child [13].
Some parents find it difficult to assess the severity of
fever [14]. This often leads to over- and under-dosing with
antipyretics [2, 15]. It can also contribute to administration
of antipyretics when there is either insignificant fever or a
lack of fever [16]. Furthermore, parents often feel that they
are not caring for a child if they are not controlling the
fever to maintain a ‘‘normal’’ temperature and this further
compounds the over-use of antipyretics [15, 16]. However,
the use of antipyretics to manage fever shows minimal
evidence of clinical benefit [15].
The American Academy of Pediatrics recommends that
the purpose of antipyretics should be to improve the overall
comfort of the child [10, 16]. The use of antipyretics does
not reduce mortality or morbidity (if a child is not critically
ill) [16]. Furthermore, the ability of viruses and bacteria to
replicate in a febrile child may be lessened and, therefore,
outcomes may be improved if fever is left untreated
[10, 17, 18].
Parental knowledge of definition and management of
fever has been shown to be deficient [10, 19]. Studies have
shown that parents rarely define fever correctly [10], are
unaware of the correct frequency to administer antipyretics
123
Int J Clin Pharm
[19] and hold many misconceptions regarding fever [20].
Similarly, physician understanding of the nature, conse-
quences and treatments for fever are lacking in some cases
[21, 22]. Information from several physicians was found to
be lacking regarding the nature, dangers and management
of childhood fever [21] and misunderstandings regarding
complications of fever were observed in another study [22].
Some nurses exhibited a corresponding lack of knowledge
concerning fever [23, 24]. Inconsistent treatment approa-
ches [24] along with fever phobia [24] and a lack of
knowledge [23] were exhibited in certain studies. Over-
diagnosis of fever is also apparent within the healthcare
professions [25, 26].
There is a clear knowledge gap between the recom-
mendations of guidelines and national organisations [27]
and what parents and other caregivers understand and
implement [10, 19, 20]. Acknowledging this gap and tar-
geting interventions to close it will improve health out-
comes for children.
Aim of the review
The aim of this review was to synthesise qualitative and
quantitative evidence on the knowledge, attitudes and
beliefs of parents regarding fever, febrile illness and anti-
pyretic use.
Methods
A systematic literature search was conducted in the ten
bibliographic databases listed in Table 1.
Searching was conducted from database inception to
June 2014. The primary researcher (MK) undertook the
search with the assistance of a medical librarian. A search
strategy was devised comprising of four blocks of terms
relating to: (i) antipyretics; (ii) children; (iii) fever; and (iv)
Table 1 Databases searched
Cumulative Index to Nursing & Allied Health Literature
(CINAHL)
Cochrane systematic reviews
Cochrane trials
Embase
Google scholar
Index to theses
PsychINFO
PubMed
Turning research into practice (TRIP)
Web of science
Int J Clin Pharm

Fig. 1 Flow chart of study

selection Records identified through database Additional records identified through
searching other sources (hand searching (n = 6)
(n = 1,565) and consultation with experts in the
field (n = 1))

Records after duplicates removed

(n = 1,070)

Records screened Records excluded

(n = 1,070) (n = 951)

Full-text articles assessed for

eligibility Full-text articles excluded
(n = 119) (n = 105)

Studies removed as they did

not focus on parents, were
not available in full-text in
Studies included in the English, or due to age of
review included children.
(n = 14)

Table 2 Inclusion and exclusion criteria for studies

Inclusion criteria Exclusion criteria

Original research in the English language Reviews, meta-analyses, editorials, commentary or conference abstracts
Qualitative studies including interviews or focus groups with Studies with a focus on children aged 6 years of age or older so as to
parents regarding management of fever or febrile illness in conform to current guidelines. These guidelines refer to children aged
children 5 years of age and under [27]
Quantitative studies using questionnaire design with parents
regarding management of fever or febrile illness in children
Parents of any age

knowledge or attitude or belief (supplementary material).
The search strategy was pre-tested prior to use to maximise
sensitivity and specificity and to optimise the difference
between both. Citation lists of studies and consultation with
experts in the field were used as secondary sources to
identify further relevant studies. MK and ROS undertook
screening of titles and abstracts of studies for inclusion in
the review. A third party (LS) was consulted when ambi-
guity arose. LS was consulted regarding one paper which
was subsequently included in the review. Full text papers
were obtained for all potential studies. Second screening of
full text studies was undertaken by MK and ROS. Selection
of the final studies (Fig. 1) was undertaken in accordance
with a priori inclusion and exclusion criteria (Table 2).
Children aged 6 years of age and over were excluded as
current guidelines refer to children aged 5 years of age and
younger [27].
A data extraction form was designed by MK based on
examples used in the literature [28]. Relevant data from the
included studies were extracted into the data extraction
form by MB, SM and LS.
The selected studies were independently verified by all
researchers. All included studies were assessed for quality
by MB, PL and FS using appropriate study design
checklists from the Critical Appraisal Skills Programme
[29].
Narrative synthesis was used to synthesise data from the
quantitative studies with guidance from Centre for Reviews

123

and Dissemination’s Guidance for Undertaking Reviews in
Health Care [30].
Thematic synthesis was used to synthesise data from
studies using a semi-structured interview or focus group
methodology [31]. Thematic synthesis was selected as it
compares themes across studies, examines study charac-
teristics to rationalise differences in results and generates
analytical themes [31]. Data from results sections were
analysed to develop free line-by-line codes (primary
codes). Descriptive themes were generated from categori-
sation of the primary codes. Analytical themes were con-
structed from the descriptive themes. The analytical themes
(presented in this paper) explore the descriptive themes in
the context of the research question. Discussion between
the authors throughout the analysis process facilitated the
development of themes and interpretation of the data. The
data were stored in QSR International’s NVivo 10 software
[32]. Data in the form of quotes from the primary research
is presented in this paper to illustrate various themes. The
selected excerpts provide the best illustration of the
themes.
Results
Study characteristics
Fourteen studies were eligible for inclusion in the review.
Eleven studies were quantitative in nature [33–43], using
questionnaires to gather information, the characteristics of
which are represented in Table 3. Two of these studies
reported results from the same study cohort [42, 43]. Three
studies were qualitative [44–46] using semi-structured
interviews to gather information, the characteristics of
which are represented in Table 4. One of these studies used
a mixed methods approach.
The results of quality assessment, based on CASP cri-
teria, indicated that all studies were of medium to high
quality [29].
Three themes emerged from the quantitative studies:
(i) parental practices, (ii) knowledge; (iii) expectations and
information seeking. Knowledge was common to both the
qualitative and quantitative studies. A further three themes
also emerged from the qualitative studies: (i) control; (ii)
impact on family; (iii) experiences.
Narrative synthesis
Three themes emerged from the studies using a question-
naire-based approach: (i) parental practices; (ii) knowl-
edge; (ii) expectations and information seeking.
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Int J Clin Pharm
Summary of narrative synthesis
Parents regularly consulted General Practitioners (GPs;
family doctors) because of feverish children. However,
referrals and multiple contacts within the system often
resulted in dissatisfaction [37]. Parents indicated that
antipyretics were used regularly to control fever symp-
toms [34, 35, 40, 43, 46]. Parents perceived that they
knew how best to manage fever, yet non-evidence based
practice was observed in the included studies. Parents’
knowledge of fever varied widely [42]. Parents demon-
strated a fear of fever, directly related to negative out-
comes associated with fever such as febrile convulsions
[34, 43]. Parents who received safety netting advice were
less likely to re-present to urgent and emergency care
services [37].
Parental practices
The majority of parents had visited the GP with a feverish
child [33, 34, 43]. More than two in five parents (43.7 %)
had visited an out-of-hours GP because of fever [34].
Multiple contacts during the same fever episode were made
for children, primarily due to repeated referrals within the
system [37]. Almost two-thirds (63 %) of repeat contacts
were initiated by a service provider [37].
Some parents used tepid or cool sponging to cool chil-
dren [40, 43]. Administration of over-the-counter medica-
tions was the first approach used to treat fever, however it
was based on individual beliefs and experiences (e.g.
choice of antipyretic, dose, route, temperature at which
antipyretic was administered) [34, 35, 40, 43, 46]. Over
half of parents (51.8 %) in one study practiced alternating
paracetamol and ibuprofen [42]. Decisions to alternate
were influenced by information from doctors/hospitals
(49.5 %) and children remaining febrile post-antipyretic
use (41.7 %) [42].
Knowledge
Both the qualitative and quantitative studies indicate that
parents’ knowledge regarding fever varied widely, with
some parents feeling helpless as they were not aware of, or
were unsure about, when or how to give sufficient care
[44–46]. Participants from the included studies indicated a
fear of fever [38, 40, 41]. Febrile convulsions, brain
damage, and dehydration were listed as harmful outcomes
considered by parents [34, 43]. Parents who reported
receiving safety netting advice (81 %) were less likely to
re-present to urgent and emergency care services than those
who did not recall receiving such advice [37].
 Table 3 Summary of study characteristics included in narrative synthesis
Study authors, Study title Sample size Study population characteristics Characteristics of children Study setting Study design
year, country

Cinar et al., Turkish parents’ management 205 91.2 % mothers, 100 % were 6 months–5 years of age State of Sakarya in Turkey. Interview using the
Int J Clin Pharm

2014, Turkey of childhood fever: A cross- participants married. Age range: 57.6 % Participants recruited from one Parents Fever
sectional survey using the were less than 30 years of age, paediatric hospital and two Management
PFMS-TR 37.1 % were between 31 and family health centres Scale—Turkish
45 years of age, 5.4 % were Version (PFMS-
over 46 years of age TR)
De Bont et al., Parents’ knowledge, attitudes, 625 Age range 19–55 years, mean age At least one child aged Stratified sample for province to Internet based
2014, The and practice in childhood participants 34.9 years. 51 % had 1 child, 5 years of age or under. ensure an accurate survey
Netherlands fever: An internet based 29 % had more than 1 child 29 (4.6 %) children had representation of parents with
survey an underlying chronic children aged 5 years of age or
condition, 81 (13 %) had under from the Dutch
severe illness in medical population
history
Kelly et al., Improving caretakers’ 86 90 % were mothers. Age range 2 months–5 years of age. Convenience sample from a Guided interview
1996, United knowledge of fever participants 17–60 years, with a mean of Children attending the suburban private paediatrician’s format using a
States of management in preschool 26.9 years centre for routine health office, a suburban primary questionnaire
America children: is it possible? maintenance or acute health centre and three inner-
minor illness city health centres
Lagerløv et al., Severity of illness and the use 159 77.3 % of participants were Children up to 5 years of Participants recruited from a Self-completed
2006, of paracetamol in febrile participants mothers. Mean age of parents age public health centre and a questionnaire
Norway children; a case simulation of was 33.5 years of age. Mean kindergarten
parents’ assessments number of children was 1.8. 36
(38 %) parents had experience
with chronic disease
Maguire et al., Which urgent care services do Dataset 1: Demography was similar to that Children up to 5 years of Sampling conducted across three Mixed methods
2011, United febrile children use and why? 220 of England as a whole. age areas in the United Kingdom. using telephone
Kingdom participants Participants were from urban Participants were selected from questionnaire,
Dataset 2: (52 %), rural (24 %) and inner all services providing urgent case note review
194 medical city (24 %) areas. Ethnicity: and emergency care services; and telephone
notes were white British (59 %), non-white this included ambulance semi-structured
reviewed. British (41 %) services, children’s assessment interviews
units, primary care out of hours
Dataset 3: 29
services, walk in centres and
participants
other services such as
were
pharmacists, midwives, health
interviewed
visitors and community nurses
Nijman et al., Parental fever attitude and 211 55 % of included children were Children up to two years of Paediatric emergency department Questionnaire
2010, The management: influence of participants boys. 42 % of included children age in Rotterdam
Netherlands parental ethnicity and child’s were younger than 12 months,
age median age 1.2 years

123
 Table 3 continued
Study authors, Study title
year, country
123
Sakai et al., Parental knowledge and
2009, Japan perceptions of fever in
children and fever
management practices:
differences between parents
of children with and without a
history of febrile seizures
Tessler et al., Unrealistic concerns about
2008, Israel fever in children: the
influence of cultural-ethnic
and sociodemographic factors
Van Parents’ fear regarding fever
Stuijvenberg and febrile seizures
et al., 1999,
The
Netherlands
Walsh et al., Over-the-counter medication
2007, use for childhood fever: A
Australia cross-sectional study of
Australian Parents
Walsh et al., Parents’ childhood fever
2008, management: community
Australia survey and instrument
development
Sample size Study population characteristics
386 100 % mothers
participants
201 101 Jews and 100 Bedouin
participants participants. Average age of
Jewish mothers was 30.7 years,
average age of Bedouin mothers
was 27.7 years. Average age of
Jewish fathers was 34.1 years,
average age of Bedouin fathers
was 31.9 years
181 Average age 32.6 years, range
participants 29–37 years. Non-west
European origin 25 %, low
educational lever 43 %, low
professional level 55 %
401 Age range 20–52 years, mean age
participants 34.58 years. 97.5 % female
401 Age range 20–52 years, mean age
participants 34.58 years. 97.5 % female
Characteristics of children Study setting Study design
Children attending their Health department in Tokyo Self-completed
18 month check-up. 44 questionnaire
children had a history of
febrile seizures
Children up to 5 years of Paediatric emergency unit of the Researcher
age Soroka University Medical administered
Centre, Israel questionnaire to
parents
1–4 years of age. Children Sophia Children’s Hospital, Questionnaire
had a history of febrile Rotterdam and Juliana
seizures Children’s Hospital, The Hague
6 months–5 years of age. Parents recruited through Questionnaire
401 (11.2 %) had a advertisements in parenting
chronic illness magazines (48.4 %), childcare
centres, kindergartens and pre-
schools (26.4 %), snowball
technique (24.4 %)
6 months–5 years of age. Parents recruited through Questionnaire
41 (10.2 %) had advertisements in parenting
previously had a febrile magazines (48.4 %), childcare
convulsion, 9 (2.3 %) had centres, kindergartens and pre-
epilepsy schools (26.4 %), snowball
technique (24.4 %)
Int J Clin Pharm
Int J Clin Pharm

Experiences
Expectations and information seeking

Knowledge

Knowledge

Knowledge
Themes

Control

Control

Control
Parents had expectations of services and were frustrated if
they had to wait for a long period of time for their child to
be assessed [37]. The most important aspect of a consul-

mothers attended

Six interviews and

10 focus groups
tation with a GP was a physical examination of the child
participated in

interviews, 63

three group
Study design

discussions
individual [34]. The least important aspect was obtaining a prescrip-
32 mothers

Interviews
tion for medication [34].

Thematic synthesis: analytical themes

Norwegian town and two

public health centres in a
Four public health centres
Disadvantaged inner city

A further three themes emerged from the studies using a

Queensland, Australia
nearby rural district
semi-structured interview or focus group approach:

Metropolitan area in
community setting

in a middle-sized

(i) control; (ii) impact on family; (iii) experiences.

Study setting

Summary of thematic synthesis

Our findings show that the reported lack of confidence

among parents in managing fever and febrile illness in
asthma, epilepsy). 2 children had

children appears to originate, at least in part, from their

children had cronic illness (e.g.
Children up to 5 years of age. 4

syndrome, tuberous sclerosis)

difficulty in acquiring the necessary knowledge to effec-

Children up to 5 years of age
special needs (e.g. Down;s

tively assess and manage fever severity in children. Parents

6 months–5 years of age

acknowledged that caring for a child with fever impacted

on family life as well as professional responsibilities [45].
Parents attempted to control their children’s symptoms,
Age of children

however, if these attempts proved futile, concern increased

[44].

Control
household. 31 lived in

23 mothers and 1 father

range; 25–42 years of

16–41 years. 29 were

15 mothers. Age range

of children less than
from a single parent

a household with 1

29–42 years of age

Parents used constant monitoring and relentless observa-

5 years old. Age
Study population

tion as a means of exercising personal control to ensure the

characteristics
Table 4 Summary of study characteristics included in thematic synthesis

safety of the child: ‘‘I always keep an eye on the temper-

Age range;

ature, I like to get their temperature down’’ [44]. Parents’

child

main aim was to decrease discomfort and minimise the

age

threat of harm. The feeling of threat experienced by parents

increased when strategies used to reduce fever failed:
mothers

parents

parents

‘‘When she’s got a bug…I’m worried that it’s something

Sample

else, and I’m missing something… it could be something

size

95

24

15

nasty… I don’t know’’ [44]. Fear of not recognising a

ill, and why: a qualitative study
What worries parents when their

of common childhood illnesses

(acetaminophen): a qualitative
study of parents’ management
preschool children are acutely

Childhood illnesses and the use

serious illness was one of the main concerns of parents.

experiences and information

There was a desire to share the responsibility of protecting

Influences on parents fever

the child by contacting medical professionals: ‘‘when the

management: beliefs,

children were really ill and we had nothing more to offer.’’

[45].
of paracetamol
Study title

Impact on family
sources

Managing fever in one child impacted on family life. The

extent of this impact was found to be dependent upon
Kingdom

Australia
Kai, 1996,

Norway

variables such as experience and family situation. Other

Lagerløv
United
authors,

country

et al.,

et al.,
2003,

2007,
Walsh
Study

duties, professional responsibilities and healthy siblings

year,

were seen as less important than caring for the sick child.

123

When one child had a fever or febrile illness, it impacted
on the care and attention which other children received:
‘‘I’m aware that the other child needs attention too,
sometimes he needs to pretend he’s ill to get special
attention’’ [45]. Furthermore, conflicts within the family
arose due to opinions around the correct management of
fever.
Experiences
Previous positive febrile illness experiences, along with
increased experience with the child, reduced concern about
fever: ‘‘You don’t realise this with the first child, but when
it occurs again you become familiar with it and learn to
handle it without getting anxious or nervous.’’ [45].
Negative experiences, including media reports of harm and
receiving conflicting information, increased concerns:
‘‘…one doctor will tell you something different to the nurse
or tell you something different to the chemist. That sort of
does make it a bit hard sometimes’’ [46].
Discussion
This is the first study that we are aware of to systematically
review both qualitative and quantitative literature on the
knowledge, attitudes and beliefs of parents on managing
fever and febrile illness in children. Lack of knowledge
emerged from the literature as a barrier to parents’ effec-
tively assessing and managing fever in their children. An
obvious discordance exists between the beliefs and per-
ceptions of the participants from the included studies and
clinical evidence. When this is coupled with a historical
fear of fever [47] and inconsistent information from
numerous sources, [42] it clearly compounds parents’
unease with managing fever.
The review demonstrated that parental attitudes to the
administration of antipyretics were subjective, based on
individual beliefs and experiences. A desire for accurate
and coherent guidance and reassurance on management of
fever was expressed by parents. This information is
required to provide adequate instruction to deal with the
perceived threat of fever and to address the negative per-
ception of the illness. Parents attempted to exert personal
control over the symptoms of fever. If attempts to control
the illness failed, this increased the perceived threat and
negative perception of the illness. Our results clearly
indicate that parents’ first preference for advice is to con-
sult their GP when their child is ill, which has resource
implications with regard to staffing levels for GPs and ED
practitioners. However, if parents are encouraged to use the
services of other healthcare professionals such as phar-
macists, waiting times and workload pressures on GPs and
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Int J Clin Pharm
ED practitioners may be alleviated. The review also indi-
cates that referral between services can contribute to par-
ental dissatisfaction and can lead to inefficiencies in
healthcare systems. Safety netting advice including written
and verbal information on when and where to re-consult
decreased the likelihood that parents would re-present to
emergency care services.
It is widely acknowledged in clinical guidelines that
alternating antipyretics is not recommended practice for the
management of fever [27]. However, this review illustrates
that such practice is prevalent, often on the recommenda-
tions of healthcare professionals. The presence of non-ev-
idence-based management practices such as alternating
antipyretics is possibly due to a lack of communication
with parents and a lack of up-to-date accurate information
on the part of some healthcare professionals. An alternative
explanation is that advising parents to medicate is less time
consuming and an easier option than trying to reassure
parents [48]. The short-term time investment by healthcare
professionals in reassuring and educating a parent will
provide long-term benefits for the stakeholders involved.
Management of fever should be a core concept in health-
care professionals’ education. A greater understanding of
where and why the gap between education and practice
exists needs to be explored.
This review illustrates that safety netting initiatives and
reassuring information assist parents when managing a
febrile child and decrease levels of re-presentation at
healthcare facilities. As suggested by previous studies,
opportunities within practice need to be exploited to
empower patients [49]. Opportunities are being lost to
inform parents about symptomatic care and when to re-
consult. This offers a role for healthcare professionals to
tailor diagnostic explanations to parental expectations and
concerns [50]. Precise safety netting advice should be
provided and inconsistencies within and between organi-
sations must be eliminated [51]. Helping parents, espe-
cially less experienced parents, to understand when to
consult a doctor may initiate small changes in the number
of parents presenting unnecessarily to doctors.
A coherent approach to fever management is required
across all areas of healthcare so that incorrect management
of fever can be reduced or eliminated along with inap-
propriate presentation at EDs and out-of-hours GP services.
Community pharmacists have a major role to play in pro-
viding information and educating parents about correct
fever management strategies. As one of the most accessible
healthcare providers with convenient locations, long
opening hours, no appointment necessary and free con-
sultation, pharmacists are an ideal option for offering
guidance. Previous research has shown that parents value
pharmacists as providers of medical information [52].
Published research has demonstrated that non-pharmacist
Int J Clin Pharm
staff also have a large role to play when providing con-
sultations for non-prescription medications, however
pharmacists tended to perform better than non-pharmacist
staff in these consultations [53]. Training and education of
the entire pharmacy team is necessary so that consultation
both with and without the presence of a pharmacist are
optimised, thereby ensuring parents are getting evidence-
based information on fever management. Furthermore,
studies suggest that non-prescription medicines are often
provided for sale in pharmacies without any counselling
[53]. Provision of information and advice are crucial ele-
ments of pharmacy service provision. It should be
encouraged for all medications sales, particularly medica-
tions used in the management of fever and febrile illness.
Every opportunity to impart evidence-based information to
parents must be utilised by all healthcare professionals to
empower parents so that they can manage their children’s
fever appropriately. Contact and interactions with parents
when children are well (e.g. developmental checks) must
be utilised as often as contacts when children are ill so that
parents fever management knowledge and practices can
become effective and evidence-based.
The significance of this review is the finding that unless
healthcare providers understand and acknowledge the risks
of misinformation or consequences of lack of information
for parents, they cannot develop and implement useful
strategies to combat the problem. Furthermore, unless
healthcare systems investigate the knowledge and attitudes
of their employees, they cannot measure the extent of the
problem and therefore cannot design strategies to address
the problem.
Strengths and limitations
Two independent participants were involved in each step of
this review, which limits the risk of bias and strengthens
the results of this review. Experts in the field were involved
in the review, which further strengthens the results. The
review examined both quantitative and qualitative studies
to obtain a complete overview of the research question.
The review was restricted to English-language studies,
which is a limitation. The review included studies whose
focus was on children aged 5 years of age or younger. We
excluded older children so as to conform to current evi-
dence-based guidelines [27]. Therefore, the results of this
study may not be generalisable to parents of older children.
Conclusion
This systematic review has synthesised existing evidence on
knowledge, attitudes and beliefs of parents around fever and
febrile illness in children to gain a deeper understanding of
the topic. It has shown that parental practices, knowledge,
expectations and information seeking, control, impact on
family and experiences affect how parents manage fever and
febrile illness and that these issues have been reported by
parents over a twenty-year period. Healthcare professionals
regularly advise parents on the management of fever and the
use of anti-pyretic medication. It is imperative therefore that
strategies are put in place to implement a coherent approach
to the management of fever and febrile illness in children and
bring an end to inappropriate fever management, which will
ultimately reduce the cost to the health service and reassure
anxious parents.
Acknowledgments MK is an Honorary Research Fellow at the
Health Research Board Clinical Research Facility, Cork (CRF-C),
Ireland. We would like to acknowledge the assistance of Professor Joe
Eustace, Director CRF-C, who supplemented training and publication
costs for this study. We would also like to acknowledge the support of
Mr Joe Murphy (Librarian, Mercy University Hospital, Cork, Ireland)
who assisted with search design.
Funding No funding was received to conduct this study.
Conflicts of interest The authors have no relevant competing inter-
ests to declare.
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