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Parental Perceptions of Fever in Children

Article  in  Annals of Saudi medicine · May 2000

DOI: 10.5144/0256-4947.2000.202

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 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 immediate
medical care. The objective of this study was to survey parents about their knowledge and attitude concerning
fever in their children.
Patients and Methods: The study involved the random selection of Saudi parents who brought their febrile
children to the emergency rooms or walk-in clinics of four hospitals in Riyadh. Parents of 560 febrile children
were interviewed using a standard questionnaire to obtain sociodemographic information and current knowledge
of fever. Approximately 70% of the respondents were female, and the ages of the most were in the range of 20-40
years. 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% of
parents 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 high
fever. Another 23% believed that if left untreated, temperatures could rise to 42.0oC or higher, but 37% could not
provide 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, including
convulsion, 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 its
consequences, 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 have
been shown to have unrealistic fears of the harmful effects
of fever in their children, and they generally see it as the
main component of an illness.1,2 Parents are unable to
define fever accurately, tend to overestimate its dangers,
and make inappropriate telephone calls and unnecessary
clinic visits, leading to excessive utilization of healthcare
services.3 Anecdotal experiences suggest that physicians
contribute to parental misconceptions about fever, although
it is unclear which part of the patient-doctor interaction
promotes this fear.4 Our clinical experience suggests that
pediatric health providers may impart mixed messages to
parents about the dangers of fever. For example, although
From the Departments of Pediatrics, College of Medicine, King Saud
University (Drs. Al-Eissa and Al-Sanie), King Fahad National Guard
Hospital (Drs. Al-Alola, Al-Shaalan, Al-Harbi, and Al-Wakeel), and
Sulaimania Children’s Hospital (Dr. Ghazal), Riyadh, Saudi Arabia.
Address reprint requests and correspondence to Prof. Al-Eissa:
Department of Pediatrics (39), College of Medicine, King Saud
University, 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 is
mostly for the comfort of the child, during consultations
many tend to prescribe antipyretic medication for any child
with a fever. Furthermore, physicians frequently differ in
their definition and management of fever.
The purpose of the study was to determine the status of
knowledge and attitude of parents about fever in their
children. The study was undertaken in the pediatric
practices at four different hospitals in Riyadh.
Patients and Methods
Parents bringing their febrile children to hospital-based
emergency departments or walk-in clinics between 8:00
a.m. and 8:00 p.m. (when research assistants were
available) were recruited at random, on the basis of
generated odd registration numbers. Febrile children who
were judged to be critically ill were excluded from the
study. Eligible parents were interviewed in the waiting
rooms as they awaited appointments with their physicians.
The study was carried out in four hospitals in different
areas of Riyadh, namely, the King Khalid University

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

 PARENTAL PERCEPTIONS OF FEVER

Hospital, King Fahad National Guard Hospital, Sulaimania TABLE 1. Sociodemographic characteristics of 560 study parents.
Children’s Hospital, and Children’s Hospital of Riyadh Characteristic Number %
Medical Complex. These hospitals were selected to ensure Accompanying parent
enrolment of a truly representative Saudi population sample Mother 397 70.9
of all socioeconomic strata. Each eligible male or female Father 84 15
parent was interviewed in Arabic by a male or female Both parents 79 14.1
research assistant, using a standard questionnaire designed Residence
to obtain background sociodemographic information and Riyadh city 424 75.7
Outside Riyadh city 136 24.3
current knowledge of fever.
Age of father (range 19-70, mean 37 years)
Parents were given no assistance with answering the
<30 122 21.8
questions and none refused to be interviewed. In an attempt
30-39 247 44.1
to obtain unbiased data that truly reflected parents’
≥40 191 34.1
perceptions about fever, the questionnaire relied principally
Age of mother (range 15-55, mean 29.6 years)
upon open-ended questions (i.e., no suggestions of the
<30 305 54.5
“right” answer).
30-39 193 34.4
Demographic data obtained included age of both
≥40 62 11.1
parents, accompanying parent, level of education attained,
Father’s education
current occupation of parents, and number of children cared
Illiterate 71 12.7
for by the parent. The questionnaire items were designed to
Primary/secondary school 176 31.4
ascertain parents’ knowledge, attitudes and fears
High school/some university 172 30.7
concerning fever in their child. The questions asked were as University graduate and above 141 25.2
follows: how do you know if your child has a fever?; what Mother’s education
is the temperature reading that constitutes a fever in a Illiterate 142 25.4
child?; what do you consider a high fever?; how high could Primary/secondary school 217 38.7
the fever go if it is not treated?; what is the greatest harm High school/some university 151 27
that high fever can cause to a child? The questions were University graduate and above 50 8.9
framed in a way as to enable the average lay person to Father’s occupation
understand and respond, yet an attempt was also made to Skilled 187 33.4
obtain definitive data. Fever was defined as a documented Semiskilled 217 38.7
temperature of 38.0ºC or higher per rectum (or “rectal Unskilled 126 22.5
equivalent”). A rectal equivalent temperature was Retired 14 2.5
calculated by adding 0.5ºC to the oral temperature and Student 16 2.9
0.8ºC to the axillary temperature. The appropriateness of Mother’s occupation
responses to questions was determined on the basis of Skilled 29 5.2
current medical literature. Semiskilled 54 9.6
Unskilled 2 0.4
Results Housewife 436 77.9
Student 39 6.9
A total of 560 parents of febrile children were Number of children(range 1-15, mean 4)
interviewed. A description of the sociodemographic 1 99 17.7
characteristics of the study parents is presented in Table 1. 2-3 195 34.8
The majority of the parents surveyed were living in Riyadh 4-5 126 22.5
city. A wide range in parental age, educational level, ≥6 140 25
occupation and family size was noted. Most parents
participating in the study were housewives in their late temperatures refer either to the true rectal measurement or
twenties or early thirties, with at least a primary school its “rectal equivalent.” Twenty-six percent of the parents
education. Only one-third of fathers brought their febrile considered body temperatures of less than 38.0ºC to be
children to the hospital. Roughly one-half of respondents fever, 30% considered 38.0ºC to be fever, and 26% did not
cared for four children or more. know the definition of fever. A dangerous fever was said to
The majority of parents believed that they could tell be a temperature of 40.0ºC or less by 67% of parents, and
whether their child had a fever by the appearance or 39.0ºC or less by 33%. Approximately 23% of all parents
palpation of the child. Only 24% of parents had their thought an untreated fever could keep rising to 42.0ºC or
child’s temperature measured at home. higher, 2% responded that the body temperature could
Data concerning parental knowledge and attitudes about climb to 50.0ºC and 0.4% believed that untreated fever
fever are shown in Table 2. In this study, the quoted body could soar to 100.0ºC.

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

AL-EISSA ET AL

TABLE 2. Parental knowledge and attitudes about fever. sponge their child if the temperature reached 38.0 or
Variable Number % 38.9ºC, and an additional 13% would do the same if it
Minimum temperature considered as fever (range, 30.0-41.0°C) reached 39.0 to 39.9ºC. Only 10% of respondents indicated
<37.0°C 14 2.5 their readiness to bathe or sponge their child if the body
37.0-37.9°C 132 23.6 temperature reached 40.0ºC or more. About 61% of parents
38.0°C 166 29.6 did not know the threshold body temperature for bathing or
38.1-39.0°C 92 16.4 sponging their febrile child.
>39.0°C 13 2.3 Table 2 shows that 95% of parents believed fever can
Unknown 143 25.5 cause harm, and 18% believed it could cause death.
Temperature considered as high fever (range, 35.0-50°C) Specific types of damage feared included convulsions
<38.0°C 47 8.4 (69%), brain damage and stroke (36%), coma (35%),
38.0-39.0°C 144 25.7 serious illness (28%) and blindness (3%).
39.1-40.0°C 168 30 No significant differences in patterns of response to
40.1-41.0°C 39 7 questions were found among parents with regard to their
>41.0°C 20 3.6 sociodemographic features such as educational level,
Unknown 142 25.3 occupation or family size.
How high could temperature go without treatment (range, 37.0-100.0°C)
<40.0°C 22 3.9 Discussion
40.0-40.9°C 134 23.9
41.0-41.9°C 69 12.3 The randomly selected survey parents represented a
42.0-43.9°C 96 17.1 broad demographic, cultural and socioeconomic spectrum.
>44.0°C 33 5.9 They were surveyed at the time when their children were
Unknown 206 36.8 febrile, and not when they were well. It might be argued
Threshold temperature for giving an antipyretic that parents’ anxiety and misunderstanding would be
<38.0°C 26 4.6 exaggerated by the development of fever in their children,
38.0-39.0°C 141 25.2 and that their real fears and misconceptions would be
≥39.0°C 47 8.4 overestimated. However, our concern was with the
Unknown 346 61.8 potential consequences of parents’ attitude when their
Threshold temperature for bathing/sponging children actually developed a fever. Hence, it is more
<38.0°C 17 3 relevant, in our view, to survey parents of febrile children
38.0-38.9°C 72 12.9 rather than a general poll of parents of well children,
39.0-39.9°C 71 12.7 because the opinion of the latter is of little practical
≥40.0°C 56 10 importance, as shown in a previous study.3 The results of
Unknown 344 61.4 this study can be applied to all parents in our Saudi
community and are in agreement with the findings of other
TABLE 3. Parental conceptions of principal complications of fever. studies in the developed countries.1,5 These findings
Complication Number % confirm the fact that parental misconceptions about fever
Death 103 18.4 are common worldwide.6 Such misconceptions can lead to
Brain damage/stroke 201 35.9 inappropriate treatment and potential overutilization of
Convulsions 388 69.3 healthcare services.
Loss of consciousness 194 34.6 In this study, parents showed little understanding of the
Dehydration 105 18.8 normal range of body temperature and individual diurnal
Weight loss 86 15.4 variation, and as well demonstrated inadequate knowledge
Blindness 18 3.2 of what actually constitutes a fever or high fever. We were
Serious illness 157 28.1 also surprised that parents of high socioeconomic status and
No response 26 4.6 those with many children and, therefore, with previous
experience with fever, were not different in terms of
Table 2 shows that less than 5% of all parents would knowledge of fever from parents of lower socioeconomic
give antipyretic medications for body temperatures less background and limited previous experience. It seems that
than 38.0ºC (i.e., possibly normal body temperature). About healthcare providers have not done enough in educating
25% advocated treatment for body temperatures of 38.0 to parents in this basic information.
39.0ºC, and less than 10% felt that body temperatures of The definition of normal body temperature is complex.
39.0ºC and more should be treated. Surprisingly, 67% of DuBois found the normal ranges of body temperature for
the surveyed parents could not determine the minimum children to be from a low of 36.2ºC to a high of 38.0ºC
body temperature for initiation of antipyretic medications. when measured rectally, and from 36.0ºC to 37.4ºC when
Approximately 13% of parents stated they would bathe or taken orally.7 The maximum body temperatures for children

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


occur between 5 and 7 p.m., and the minimum temperatures
occur between the hours of 2 and 6 a.m. Hence, it is not
unusual for an active normal child’s temperature to be as
high as 38.0ºC rectally in the late afternoon. A rise in
temperature above 38.0ºC may also be caused by physical
exercise, warm clothing, hot or humid weather, or warm
food/drinks.2 Such external factors should be eliminated
before measuring the temperature.
Fever is defined as a temperature above the normal
range. A rectal temperature of 38.0ºC or more, an oral
temperature of 37.5ºC or more, and an axillary temperature
of 37.2ºC or more, are all considered fever.2,8 About 25% of
the study parents identified fever as a temperature of 37.9ºC
or less, and another 25% did not know the temperature
level that constituted a fever.
Although the definition of high fever is arbitrary (i.e.,
>40.0ºC), 67% of the parents defined high fever as 40.0ºC
or less. Also of great concern is the misconception on the
part of 25% of study parents who indicated that untreated
fever could reach 42.0ºC and above, and those parents who
did not know the effects of untreated fever. With these
misconceptions of fever, it is not surprising that parents
would treat fever aggressively. An analysis of temperature
charts during febrile illnesses before the advent of
antimicrobial therapy showed that peak temperatures
almost never exceeded 41.1ºC.7
Hyperpyrexia is defined as a temperature of 41.0ºC or
greater. Fevers of this magnitude are rare. Tomlinson
reported temperatures of higher than 41.1ºC in only two
children in his study on high fevers in ambulatory patients
during 13 years of private pediatric practice.9 McCarthy
and Dolan found only 100 children with temperatures of
41.1ºC or higher among 210,000 consecutive patients over
an 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 complex
feedback system.11 This hypothalmic “thermostat,” if
uninfluenced by complicating circumstance (e.g., heat
stroke or drugs), seems to exert a shutoff valve
phenomenon so that high temperatures are generally kept
below a level that would seriously damage body tissues.
Most temperatures above 41.1ºC in children are due to
human errors from excessive heat load or from interference
with heat loss. Examples are wrapping a febrile child in too
much clothing or blankets, placing a baby near a heat
radiator, or placing a child in a car in direct sunlight.1 Too
much clothing is more dangerous during a heat wave in
tropical countries.12 Children uncommonly develop
hyperpyrexia (temperatures of 41.1ºC or greater) because of
central nervous system infections, namely meningitis,9,13
and cerebral malaria,14 underlying structural brain defects
such as Down syndrome or hydrocephalus, and brain
tumor.13
Our study showed that parents were overly concerned
about the harmful effects of fever. The type of harm that
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PARENTAL PERCEPTIONS OF FEVER
parents thought their children would suffer from fever were
varied, and included convulsions, brain damage or stroke,
coma, dehydration, blindness and death. The same fears
were found among parents in other previous studies.1,3 The
adverse effects of fever include discomfort, mild
dehydration, febrile delirium and uncomplicated seizures.
Heat stroke, a catastrophic circulatory failure characterized
by hyperpyrexia, delirium, coma and anhidrosis, rarely
occurs in children, and is mostly caused by environmental
factors such as overheating or too much clothing.2,15
Although febrile convulsions are terrifying to parents, they
carry no risk to subsequent neurologic or developmental
disabilities.16
This study indicates that child health care providers
have apparently not done enough in educating parents
about fever and its consequences, and considerable efforts
will be required to correct such parental misconceptions.
Health education is all too often given short shrift in the
busy ambulatory care setting. The harried clinician is
frequently so pressed that the delivery of health information
is abbreviated and perfunctory. When these cursory
instructions fall on the ears of an anxious mother distracted
by a screaming child, the efforts become almost futile. Use
of well-designed health education aids that present
information in a clear, consistent and entertaining manner
would be more effective. Hence, an audio-visual health
education message on fever would be superior to the
written material containing the same information.
References
1. Schmitt BD. Fever phobia: misconceptions of parents about fevers.
Am J Dis Child 1980;134:176-81.
2. Adam D, Stankov G. Treatment of fever in childhood. Eur J Pediatr
1994;153:394-402.
3. Kramer MS, Maimark L, Leduc DG. Parental fever phobia and its
correlates. 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. O’Neill 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.
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14. Stern RC. Pathophysiologic basis for symptomatic treatment of
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Annals of Saudi Medicine, Vol 20, Nos 3-4, 2000 205