C O N C E PT A N A LY SIS

Fever in children – a concept analysis

Edward Purssell

Aims and objectives. To undertake a concept analysis to clarify the meaning of the term ‘fever’ in children and to identify
models of fever-related belief that may help in understanding the response of parents and professionals to fever in children.
Background. This concept analysis was undertaken because the approach to the treatment of fever varies widely and in par-
ticular that there is often a difference between what parents want for their children, official guidelines and what profession-
als do in practice.
Design. Concept analysis.
Methods. The study used a modified evolutionary method of concept analysis. The analysis was based on data from medi-
cal, nursing, popular and biological literature and used an iterative process to clarify the term.
Results. Fever has a number of distinct uses based on its meaning and history; these include its use to indicate an illness
itself, as a beneficial symptom associated with disease, and a diagnostic sign. Three models of fever-related practice emerged
from the analysis, these being a phobic-fearful approach that drives routine treatment, a scientific approach that sees fever
as a potentially adaptive and beneficial response and a scientific but pragmatic approach that recognises potential benefit but
results in treatment anyway. These different uses, which are often not clarified, go some way to explaining the different
approaches to its treatment.
Conclusions. When parents, clinicians, physiologists and guideline writers discuss fever, they attribute different meanings to
it, which may go some way to explaining the dissonance between theory and practice. In the absence of new knowledge, the
emphasis of practitioners should therefore be on their safe use.
Relevance to practice. When discussing the meaning and treatment of fever, it is important to understand what is meant in
different circumstances. The models of fever-related beliefs outlined here may go some way to helping this process.

Key words: antipyretic medication, children, fever, pyrexia, temperature

Accepted for publication: 5 March 2013

rather than normalise temperature (NICE 2007, Sullivan

Introduction
Fever is a common symptom of a number of medical con-
ditions, most notably infectious diseases. Despite not being
inherently dangerous, it is known to cause anxiety in par-
ents and professionals alike, and it is one of the leading
reasons why parents seek healthcare advice. Evidence-based
guidelines consistently state that the symptom of fever does
not need treating and that the aim should be to identify
those children with severe disease and to increase comfort
& Farrar 2011). Furthermore, there is evidence that as
part of the acute phase response, fever may actually be
beneficial in promoting recovery from a number of condi-
tions (Romanovsky & Szekely 1998). Despite this, there is
substantial evidence from many countries that anxiety
around fever and the routine use of antipyretics remains
high (Schmitt 1980, Al-Eissa et al. 2000, Crocetti et al.
2001, Walsh et al. 2008, Chiappini et al. 2012, Sakai
et al. 2012).

Author: Edward Purssell, PhD, RGN, RSCN, Senior Lecturer, Correspondence: Edward Purssell, Senor Lecturer, King’s College
King’s College London, London, UK London, James Clerk Maxwell Building, 57 Waterloo Road,
London SE1 8WA, UK. Telephone: +44 (0)20 7848 3021.
E-mail: edward.purssell@kcl.ac.uk

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 3575–3582, doi: 10.1111/jocn.12347 3575
E Purssell
One reason for the lack of compliance with these
evidence-based guidelines may be that the term ‘fever’
means different things in different contexts: that it has a
different meaning to the guideline writer to that understood
by the clinician, physiologist or parent. Thus, a simple
dictionary definition may be insufficient to understand the
meaning of the term in these different contexts. This makes
this a suitable subject for concept analysis to identify the
attributes, properties and dimensions of the concept of fever
(Fawcett 2012). A previous concept analysis of the general
use of term has been undertaken (Thompson 2005); this
analysis builds upon that by investigating the term in a
specific population, that is, children, and by investigating
the different uses of the term in a variety of professional,
lay and popular settings.
Aim
This analysis therefore aims to clarify the meaning of the
concept of fever in children.
Methods
This study uses a modification of the evolutionary method
of concept analysis (Rodgers 1989), which uses a seven-step
approach consisting of concept identification; terms and rel-
evant uses; the selection of data from the literature and
elsewhere; identification of the attributes, antecedents and
consequences of the concept; related concepts; and finally a
model case. The last step is controversial, as casuistry,
while useful in some circumstances, may also mislead or
confuse and so was not undertaken in this analysis, which
is too complex to summarise in a single model case (Beck-
with et al. 2008). The other area where the process was
modified was that random sampling of the literature was
not undertaken; instead, the literature was purposefully
sampled to ensure that all aspects of the concept were
investigated.
The literature search comprised a search of MEDLINE
and EMBASE (all years) using the terms fever, pyrexia and
high temperature as index and free-text terms. Subse-
quently, a hand search of reference lists and Google was
undertaken, and a search was made for papers describing
the physiology of fever, the aim being to retrieve literature
from as wide a variety of sources as possible, including
those from medical, nursing, physiological and popular
backgrounds. In addition, experts in specific areas of fever
research, primarily in physiology, were contacted. The
resulting literature was purposefully sampled to find data
that explained the concept of fever, beginning with the
3576
three model of fever belief identified by Leiser (Leiser et al.
1996), and through an iterative process, to identify others.
Following the initial literature search, further searches were
undertaken in an iterative process perusing additional liter-
ature as question arose, making decisions based on the need
to achieve maximum clarity regarding the concept. This
process continued until no new themes emerged.
A number of surrogate terms were identified; synonyms
from EMBASE were body temperature elevation, febrile dis-
ease, febrile reaction, febrile response, pyrexia and sweating
sickness. Fever is also a MeSH heading on MEDLINE, to
which pyrexia also maps. Roget’s Thesaurus (http://
thesaurus.com/Roget-Alpha-Index.html; accessed 5 January
2013) gives the following synonyms: burning up, delirium,
ecstasy, excitement, febrile disease, ferment, fervour, fire,
flush, frenzy, heat, intensity, passion, pyrexia, restlessness,
running a temperature, the shakes, turmoil and unrest, not
all of which refer to its medical use. The main surrogates
therefore appear to be body temperature elevation, burning
up, febrile disease/reaction/response and pyrexia. No further
significant surrogate terms emerged from detailed reading of
the literature.
Attributes
The attributes are the real characteristics of the concept
(Tofthagen & Fagerstrøm 2010), which may or may not be
reflected in the dictionary definition (Rogers 1993). In this
case, the main attribute is the maintenance of body temper-
ature and particularly its elevation in fever. The mainte-
nance of a relatively stable internal body temperature in a
range of different thermal environments is characteristic of
homoeothermic organisms such as humans, and this allows
them to survive in many different climatic conditions.
Temperature regulation is complex and not completely
understood; however, definitions that use the concept of a
single unified ‘set-point’, which is set and controlled by a
putative integrative structure within the hypothalamus, are
not supported by current models. Instead, regulation is
likely to be simply the result of a balance between multiple
heat gain and heat loss mechanisms. Under normal circum-
stances, the body is required to lose heat; thus, heat promo-
tion mechanisms are inhibited. If the body is cooled or if
pyrogens stimulate the febrile response, disinhibition of
heat promotion effectors such as vasoconstriction, shivering
and nonshivering thermogenesis occurs and body tempera-
ture increases. The difference between this model and the
‘set-point’ model is that there is no coordinating structure;
each effector has its own activation point; any coordination
simply resulting from the fact that they are all responding
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 3575–3582
Concept analysis
to the same stimulus (Mekjavic & Eiken 2006). Thus, each
effector forms part of an individual ‘loop’ from thermosen-
sory neurones, through the nervous system to the hypothala-
mus at the sensory end, and then onto the effector neurones
of the autonomic nervous system at the effector end, which
affects what sensory neurones are sensing, thus completing
the loop (Romanovsky 2004).
The dictionary definition of fever is that it is ‘an
abnormally high body temperature’ or ‘a state of nervous
excitement or agitation’ (Oxford Dictionary, http://
oxforddictionaries.com/definition/english/fever?q=fever; acc-
essed 27 March 2013). A more precise definition is that it
is a state of elevated core temperature that is actively estab-
lished and defended by thermoeffectors (IUPS Thermal
Commission 2001), the important distinction being that the
latter definition makes it clear that fever is a regulated rise
in temperature, differentiating it from hyperthermia which
is unregulated. There is also a clear distinction in this defi-
nition between the thermal core, that is, inner tissues whose
temperature is stable with regard to each other and heat
loss to the environment; and the thermal shell, which is
comprised of those parts of the body which exchange heat
with the environment and which are affected by changes in
the rate and nature of blood flow to and from the skin.
However, because in most clinical situations it is not possi-
ble to measure the temperature of the core tissues, those
parts of the shell that are most practical or thought to be
most reflective of the core are usually used as a surrogate
for this. It is also notable that this physiological definition
does not contain a particular temperature to define fever.
The National Institute for Health and Clinical Excellence
defined fever as an elevation of body temperature above the
normal daily variation; however, recognising the limitations
of this for clinical practice, they also noted that many
studies have used a temperature of  38 °C or higher as a
cut-off point (NICE 2007), while the American Academy of
Pediatrics Guidelines do not attempt to define a figure
(Sullivan & Farrar 2011). The concept of a normal temper-
ature is complicated because as with most physiological
measures, temperature varies both between individuals and
over time. There are wide variations in the normal tempera-
ture of children (Purssell et al. 2009) and adults (Mack-
owiak et al. 1992), further variation being introduced by
time of day, route of measurement and the skill and consis-
tency of those taking the measurement (Jackson Barton
et al. 2003, Eyelade et al. 2011).
The origin of our modern understanding of normal
temperature is widely attributed to the work of Carl Wun-
derlich who conducted a major investigation of temperature
in Germany in the 19th century (Wunderlich 1871). How-
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 3575–3582
Fever in children – a concept analysis
ever, he did not provide single numbers, but rather ranges
for subnormal temperature (36–36
5 °C), really normal
(36
6–37
4 °C), subfebrile (37
5–38 °C); slightly febrile
(38–38
4 °C), moderate fever (38
5–39 °C in the morning
and 39
5 °C in the evening); considerable fever (about
39
5 °C in the morning and 40
5 °C in the evening) and
high fever (above 39
5 °C in the morning and 40
5 °C in
the evening). Thus, the idea of a single normal temperature
has no historical or physiological support.
Antecedents
Antecedents are the situations, events or phenomena that
precede the concept (Rogers 1993); in the case of fever,
there are two aspects to this: the physiological events that
cause fever and historical belief models associated with
fever; the latter will be considered as a consequence as it
linked to treatment that occurs as a result of the concept.
Fever results from the action of prostaglandin E2 (PGE2)
upon cells in the anterior hypothalamus. The mechanism
that precedes this is well described: pyrogenic cytokines and
other substances activate phospholipase A2 enzymes (PLA2)
to release arachidonic acid (AA) from lipid membranes
within the cell. Cyclooxygenase enzymes 1 and 2 (COX-1
and COX-2) then convert the AA to a range of prostaglan-
dins including PGE2 resulting in a range of physiological
and behavioural changes often referred to as the acute
phase response, which includes fever (Romanovsky & Szek-
ely 1998, Hirabayashi & Shimizu 2000). Antipyretic drugs
work by inhibiting the action of these COX enzymes.
In experimental models, it is possible to identify two dis-
tinct phases of the febrile response: the early phase consisting
of elevated temperature alongside hyperalgesia and motor
hyperexcitability and the late phase that is characterised by
motor depression and hypoalgesia. It is suggested that the
early phase constitutes a preparatory response to an impend-
ing infection and the latter a systemic response to disease
progression (Romanovsky & Szekely 1998). The range and
nature of the physiological and behavioural changes, along-
side the evolutionary conserved nature of fever and both
theoretical and experimental evidence suggesting it has
immunological and survival benefits, lead many to conclude
that fever and its associated symptoms are usually beneficial.
However, there may be situations in which it is not, for
example, if the increased energy costs associated with fever
are not able to be met (Romanovsky & Szekely 1998). There
are limited data regarding the effect upon recovery of treating
fever with antipyretic drugs, suggesting that it does not make
a significant difference (Doran et al. 1989, Kramer et al.
1991); however, one study did show that the prophylactic
3577
E Purssell
use of paracetamol reduced the antibody response to some
vaccine antigens (Prymula et al. 2009).
Consequences
These are the events or phenomena that follow an episode
of the concept (Rogers 1993). In the case of fever, the
actions that are taken depend upon the interpretation that
is put upon the febrile episode.
Models of fever-related belief
The reason for the dissonance between evidence and prac-
tice may be due to different models of fever-related beliefs,
a number of which have been identified. One classification
recognises three such models, namely the ancient, which
reflects ancient and medieval historical views of fever; mod-
ern folk, which considers fever to be either ‘wet’ or ‘dry’
depending upon the nature of the underlying illness, this
recognises the germ theory of causation but believes that
the body is a passive battlefield between antibiotics and
germs; and the modern medical approach (Leiser et al.
1996). A second divides fever-related beliefs into two: fear-
ful and functional depending upon a score calculated from
six fever-related statements (Langer et al. 2011). The
unwarranted fears that many parents have towards fever
were named ‘fever phobia’ by Schmitt in 1980, (Schmitt
1980), and since then, similar studies from countries as var-
ied as Australia (Walsh et al. 2008), Italy (Chiappini et al.
2012), Japan (Sakai et al. 2012), Saudi Arabia (Al-Eissa
et al. 2000), the United States (Crocetti et al. 2001) and the
United Kingdom (Purssell 2009) have all shown similar
anxieties that have persisted despite evidence that fever is
not harmful to otherwise healthy children.
However, such classifications of parental beliefs are com-
plicated by two main factors. First that the role of fever in
illness and recovery is poorly understood, for example, the
modern folk model was typified by the phrase ‘feed a cold,
starve a fever’ (Helman 1978). However, it appears that
this may have some basis in physiology as calorie intake
has been shown to modify the immune response towards a
cell-mediated (antiviral) response, while anorexia promotes
a humoral (antibody) response. Furthermore, anorexia often
forms part of the acute phase response, perhaps to deprive
infecting organisms of nutrition (Bazar et al. 2005). The
second difficulty with differentiating folk from medial
approaches is that many healthcare professionals practise
the fearful or phobic responses to fever shown by parents
(Demir & Sekreter 2012, Lava et al. 2012). For profession-
als, this response may be at least partly a pragmatic one of
3578
responding to parental concerns; thus, there may be three
models of fever belief, these being scientific; scientific but
pragmatic; and the fearful.
Fever as an illness
Fever is seen in three main ways: as a disease; as a single
symptom of an underlying condition; or as part of a col-
lection of symptoms that is a part of a syndrome often
referred to as the ‘acute phase response’. The term ‘fever’
has been attached to at least 67 different diseases, some
of which are true febrile diseases; others of which are not
and have gained the suffix for other reasons and which
vary widely in prevalence and severity (Ogoina 2011).
Depending upon which view is taken, the approach to a
febrile illness may differ: if it is seen as an illness, it is
entirely logical to treat it; if it is seen as a symptom, the
emphasis may be upon its use as a sign of serious illness,
while the latter view may lead to an emphasis upon its
immunological and evolutionary importance. While
researchers and physiologists appear to take this view,
many parents and medical practitioners subscribe to the
former approaches, perhaps explaining their often aggres-
sive treatment of fever.
However, even in the absence of evidence of harm from
fever, there is a rationale for its treatment to promote com-
fort, particularly as it is often accompanied by inflamma-
tion and pain. Furthermore, as anxiety may be conducted
from child to parent (or vice versa) in what has been
referred to as ‘the comfort loop’, treatment of distressing
symptoms such as fever and pain in the child may reduce
anxiety in the parent leading to a virtuous circle of reduced
symptoms leading to reduced distress and anxiety, which
may also extend to healthcare professionals (Clinch & Dale
2007).
Historical significance
The historical importance of fever should not be underesti-
mated; it has been noted that fever is particularly salient in
the lives of most people throughout history as it is ubiqui-
tous and its consequences often dramatic (Bates 1981); and
this may be at least partly responsible for the anxiety that
many people display towards fever in children. The associa-
tion between fever and morbidity is emphasised by one of
the more commonly cited quotations of Sir William Osler
that ‘humanity has but three great enemies: fever, famine
and war; of these by far the greatest, the most terrible, is
fever’. However, the following comment is less commonly
cited, which is that ‘three of the greatest benefits conferred
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 3575–3582
Concept analysis
on mankind….have been in connection with the fevers’
(these being the introduction of cinchona as a treatment for
malaria, vaccination and asepsis) (Osler 1896).
The improvement in medical treatments, social conditions
and supportive care has significantly reduced morbidity and
mortality resulting from febrile illness; however, it may be
that a mismatch remains between the perception of fever
and its modern reality. Another alternative or possible
complementary view is that fever remains an important
indicator of possible serious illness, and a lack of specificity
is the price of this vigilance.
Fever as a diagnostic sign
Because fever is associated with disease, particularly but
not exclusively infectious disease, it is often used as an indi-
cator of infection. Other causes of fever include surgery,
trauma, chemicals, and other thermal insult (Roth et al.
2006). The assessment of diagnostic indicators has tradi-
tionally been carried out through calculating sensitivity and
specificity; however, these are population indicators that
have limited application to individual patients, while posi-
tive and negative predictive values provide better patient-
specific data but these are prevalence specific. More
recently, likelihood ratios have been promoted as a better
way of both ruling-in and ruling-out disease as the result of
the presence or absence of a symptom or test result; these
give information that is applicable to individual patient
results and is not prevalence specific.
However, the ubiquity of febrile illness in the paediatric
population and the common association with minor self-
limiting infections means that its diagnostic use on its own
is limited. A systematic review of the diagnostic value of
Table 1 Models of fever
Model of belief Characteristic
Phobic-fearful Fever is dangerous and must be treated
Scientific Fever is not dangerous but may indicate an underlying
condition that is potentially dangerous
Fever is one part of the acute phase response that has
adaptive benefits and should not routinely be treated
Pragmatic- Fever is not dangerous but may indicate an underlying
scientific condition that is potentially dangerous
Fever probably has some adaptive benefit but may be
distressing
Fever is upsetting to parents and so should be treated
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 3575–3582
Fever in children – a concept analysis
fever as an indicator of serious infection did not show that
the presence of absence of any level of fever had predict-
able rule-in or rule-out values. The highest rule-in level was
seen in one study where a fever of 40 °C or more increased
the likelihood of serious infection from 0
8 to 5%, but this
was not consistent across studies, lack of fever had
virtually no rule-out value, and the low prevalence of 0
8%
is typical only of a community-based study. As prevalence
becomes higher, as might be expected in hospital, the rule-
in value of fever diminished (Van den Bruel et al. 2010).
Therefore, fever is a good sign of an infection, but not to
differentiate between those children with minor and serious
infections.
Fever in popular use
In addition to its use to describe high temperature, fever is
also defined and commonly used to refer to ‘a state of nervous
excitement or agitation’ (Oxford Dictionary, http://
oxforddictionaries.com/definition/english/fever?q=fever; acc-
essed 27 March 2013), for example, the atmosphere sur-
rounding elections and similar events are often described as
being ‘febrile’. While this is not necessarily negative, its con-
notations are of something abnormal that requires treatment
or resolution.
Revised models of fever beliefs
Five main models of fever beliefs were found in the litera-
ture; however, analysis of the concept suggests that there
are three common approaches to fever and its treatment in
children; these are outlined in Table 1. The first is the pho-
bic or fearful and can be seen in both professionals and lay
Effects
High levels of anxiety
Routine treatment of fever may lead to polypharmacy or
overdosage
High sensitivity to serious illness, but low specificity leads to
overuse of health services
Fever is not routinely treated, may cause conflict with parents
and other professionals who are phobic-fearful
Heightened awareness of parental anxiety
Routine treatment of fever may lead to polypharmacy or
overdosage
High sensitivity to serious illness but able to differentiate
from less serious illness
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E Purssell
persons; this is typified by high levels of anxiety about both
the underlying causes of fever and fever itself and routine
treatment. The second is the scientific model, which
acknowledges that fever may be a sign of serious illness,
but that fever itself may also have benefits either alone or
as part of the acute phase response and so should not be
treated. Finally, there is what might be called the
pragmatic-scientific, which acknowledges aspects of both of
the above models, but errs towards routine treatment as a
pragmatic solution to parental or professional anxiety.
Depending upon which model is followed, different treat-
ment decisions may be made.
Conclusion
The term ‘fever’ has two main dictionary definitions; how-
ever, within medicine and nursing, there are many different
interpretations of what constitutes fever and what it means,
suggesting that the term is poorly delineated. It appears
from the literature that there are three main practice-belief
models surrounding fever in children, these being: the
phobic-fearful, characterised by high levels of anxiety and
routine treatment; the scientific that sees fever as an
adaptive and possibly beneficial response that does not
require treatment but may indicate more serious disease;
and the pragmatic-scientific practised by many profession-
als, who while acknowledging the scientific model usually
actively treat fever in a way similar to that seen in the
phobic-fearful model.
This reflects the state of knowledge surrounding many
aspects of fever, in particular how to define fever in an
individual child, and its importance in the immune
response, facts that should be acknowledged by practitio-
ners both among themselves and when discussing febrile
illness with parents and carers. The analysis undertaken
here identified a number of different uses and implications
of the term, the lack of clarity about what is meant by
fever and its implications leads to, among other things, a
dichotomy between what practitioners and researchers say,
which is that fever does not in itself require treatment;
and what they often do, which is to treat it routinely. In
addition to the uncertainty surrounding the relative costs
and benefits of fever, this may also be the result of
perceived or real pressure to administer antipyretics from
parents and many professionals, leading to socialisation
into a pragmatic-scientific approach. While such behaviour
is not ‘evidence based’, in the absence of evidence of
harm, which as much as can be said for these practices;
and acknowledging that absence of evidence is not
3580
evidence of absence, it may be that such an approach is
reasonable as long as practitioners remain ever vigilant
and that both the potential costs and the benefits are
understood and explained.
The practice implications for this are that while any
direct benefit from fever is unclear, it does have a purpose
as a nonspecific sign of infection. However, there is no
evidence that treating it with antipyretics is deleterious,
particularly when the analgesic properties of antipyretics
are also considered. The main disadvantages of treating
fever, particularly aggressively, are the anxiety it provokes
and the possibility of drug-related toxicity, and it is
perhaps upon these that healthcare professionals should
concentrate, particularly as decades of education have
failed to reduce ‘fever phobia’ around the world, even
among healthcare professionals. Demonstration of harm
from treating fever would require a reappraisal of this
stance, but until such evidence is found, the emphasis
should be on safety.
Large-scale randomised controlled trials comparing
recovery times between children with a variety of infections
receiving different antipyretics and a placebo would help
illuminate this aspect, although recruitment to such a trial
might be difficult based on the popularity of antipyretics.
Other areas that might benefit from greater investigation
include how parental anxiety can be reduced, factors that
predispose to toxicity and how these drugs can be most
safely packaged and used.
From a historical perspective, the anxiety surrounding
fever is understandable, as febrile illness has been a major
cause of morbidity and mortality. However, many of the
symptoms that occur alongside fever constitute part of
the acute phase response and so may themselves provide
some benefit. To reduce the confusion surrounding the
various uses and responses to fever, it is recommended
that practitioners are clear about the definition and
meaning of the term in the context in which they are
using it: Is it seen as a symptom, a diagnostic sign or a
disease itself?
Contributions
Study design: EP; data collection and analysis: EP and
manuscript preparation: EP.
Conflict of interest
EP has spoken at educational meetings sponsored by Berlin-
Chemi and Abbott.
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 3575–3582
Concept analysis
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