Parents’ Knowledge and Management of Fever: “Parents Versus Fever!”

Abstract

Objective:

Parents’ lack of knowledge about fever causes fear and incorrect practices. This study aims to investigate the fever knowledge level, concerns, and practices of parents of preschool children.

Materials and Methods:

In this descriptive, cross-sectional study, conducted between July 2021 and July 2022, a survey was conducted among parents of children aged 6 months to 5 years who did not have a history of febrile seizure and/or chronic disease, either in themselves or their siblings.

Results:

A total of 386 parents, with a mean age of 33.6 ± 6.38 years and a mean number of children of 1.85 ± 0.9, participated in the study. Approximately one-third of parents started giving antipyretics to their child before the body temperature reached 38°C (32.4%) and/or used them alternately (34.5%). Moreover, approximately two-thirds (67.1%) tended to seek medical help within the first 12 hours. Parents who could not define fever correctly (66.6%) were more likely to start giving antipyretics before the child’s body temperature reached 38°C [odds ratio (OR) 2.83 (1.70-4.71), P < .001] and seek medical help within the first 12 hours [OR 1.81 (1.16-2.82), P = .008]. As the number of children or length of parenting increased, parents started giving antipyretics before the body temperature reached 38°C [OR 1.61 (1.26-2.06), P < .001; OR 1.04 (1.01-1.08), P = .048] and used them alternately [OR 1.07 (1.03-1.11), P = .001; OR 1.28 (1.02-1.62), P = .031].

Conclusion:

This study demonstrates that a substantial proportion of parents still cannot define fever correctly, and inappropriate antipyretic use is more prevalent among experienced parents with multiple children and/or longer lengths of parenting.

What is already known on this topic?

• A substantial proportion of Turkish parents cannot define fever correctly and use antipyretics inappropriately.

What this study adds on this topic?

• Inappropriate antipyretic use is more prevalent among experienced parents with multiple children and/or longer length of parenting.

Introduction

Fever, which is part of the physiological response of the human body to infections, is defined as a body temperature ≥38°C.^1-3 It is regulated by the thermoregulation center in the hypothalamus, not exceeding the upper limit of 41°C, as long as there is no dehydration and an environment that allows heat loss is provided.^3-5 Although it is common in preschool children and rarely indicates a serious illness, it is one of the significant reasons to seek medical help in this age group. However, the vast majority of these well-vaccinated children have self-limiting viral infections.^6-9

Although it is scientifically recognized that fever is beneficial, the lack of knowledge about its cause and effects on the health of their children causes anxiety and fear in parents.^10-12 Because parents often perceive fever as an illness rather than a symptom, they believe that it can rise so high that it might endanger the child’s life.^10,12 In 1980, Dr. Barton Schmitt coined the term “fever phobia” to describe these fears of parents.¹³ Fever phobia is characterized by excessive anxiety in parents and exaggerated, unrealistic misconceptions about fever.⁶ In addition, not knowing the correct definition of fever, misunderstanding its causes, and mismanagement increase fever phobia.³ This chain of events increases the risk of aggressive and potentially harmful intervention to bring the child’s body temperature to the normothermic level.^3,14 As a result, parents unnecessarily treat fever by trying to reduce it even at low temperatures to increase their sense of security and avoid the possible negative effects of fever.^2,6,15 However, it is not always necessary to reduce fever in previously healthy children. It is recommended to use antipyretics only to increase the comfort of the child.^1,2,9,10

Therefore, it is essential to understand the current knowledge level and concerns of parents to prevent the mismanagement of fever at home, reduce the burden on health care organizations, and improve the skills of caring for their children with fever. This study aims to investigate the fever knowledge level, concerns, and practices of parents of preschool children and determine the factors associated with them.

Materials And Methods

Study Design

In this descriptive, cross-sectional study, we conducted a survey on parents of children aged 6 months to 5 years, between July 2021 and July 2022.

Target Population and Study Sample

The target population was the parents of children aged 6 months to 5 years who were followed up for any reason in Çanakkale Onsekiz Mart University Hospital, Pediatrics Clinic. Parents of children with a history of febrile seizure and/or chronic diseases, who are known to prefer to lower their child’s body temperature earlier, were excluded from the study. Additionally, parents who could not read or understand Turkish and/or were health care professionals were excluded from the study. We calculated the sample size using the formula n = Z _α ² P (1-P)/d ², assuming that the parents correctly identified a childhood fever rate of 50%. In the formula, Z _α = 1.96 for the 95% CI, the estimated acceptable margin of error was d = 0.05, and the minimum sample size was calculated as 384 parents.

Study Procedure

The protocol of the study were approved by the Clinical Research Ethics Committee of Çanakkale Onsekiz Mart University (dates February 26, 2020, no. 04-19). After the research team introduced themselves to the parents, they asked if the parents could participate in the study. Willing participants were informed about the researchers’ purpose and the importance of the study, and they were reminded that participation was completely voluntary. They were also informed that the survey was anonymous, would not contain the personal information of the participants, and that they could stop filling out the survey at any time. The participants were told that the information would only be used for scientific research purposes, and then written informed consent was obtained from those who agreed to participate in the study.

Survey Instrument

In this study, a survey form developed based on the current literature was used to determine the attitudes of parents towards fever.^10,16,17 The survey consisted of 3 parts: The first part contained the sociodemographic information of the parent, including their age, the length of parenting, and their education level (bachelor’s degree or higher/high school or lower).The second section included their knowledge about fever, including the definition of fever, how it is measured, and anticipated adverse effects. The third section included parental practices regarding the management of fever, including the body temperature at which antipyretics are started, the antipyretic used, and the time to seek medical help. The survey consisted of 17 questions that could be completed in 10 minutes (Tables 1 and 2).

Table 1.

Parents’ Level of Knowledge About Fever

Question		Answer (n = 386) n (%)
Fever Definition and Measurement
What body temperature do you consider “fever”?	36.5°C and above	46 (11.9)
	37°C and above	47 (12.2)
	37.5°C and above	104 (27)
	38°C and above	129 (33.4)
	38.5°C and above	34 (8.8)
	39°C and above	26 (6.7)
What body temperature do you consider to be “high fever”?	37.5°C and above	31 (8)
	38°C and above	142 (36.8)
	39°C and above	168 (43.5)
	40°C and above	45 (11.7)
How high can it get if you don’t treat your child’s fever?	Does not exceed 41°C	268 (69.4)
	It can rise up to 41-43°C	107 (27.7)
	Exceeds 43°C	11 (2.9)
Which place shows your child’s body temperature (fever) best?	the armpit	185 (47.9)
	on the forehead	125 (32.4)
	the ear	39 (10.1)
	the anus/rectum	26 (6.7)
	the mouth	11 (2.9)
What type of thermometer do you use to measure your child’s body temperature (fever)?	Digital	210 (54.4)
	Mercury-in-glass	66 (17.1)
	Skin infrared	64 (16.6)
	Auricular	30 (7.8)
	I don’t have a thermometer	16 (4.1)
When you think your child has a fever, how often do you continue to measure their body temperature (fever)?	every 15 minutes at the latest	165 (42.7)
	every 16-30 minutes	128 (33.2)
	every 31-60 minutes	74 (19.2)
	every 61-120 minutes	14 (3.6)
	more than 120 minutes	5 (1.3)
Expected Adverse Effects Due to Fever
What adverse effects can fever have on your child?	Seizure	368 (95.3)
	Brain damage	142 (36.8)
	Worsen the child’s illness	66 (17)
	Dehydration	61 (15.8)
	Death	57 (14.8)
	Delirium	33 (8.6)
	Coma	9 (2.3)

Table 2.

Reducing Fever and Seeking Medical Help

Question		Answer (n = 386) n (%)
Reduce Fever
When do you start giving antipyretics when your child has a fever?	Between 36.5-37.9°C	125 (32.4)
	Between 38-38.9°C	202 (52.3)
	Between 39-40°C	48 (12.4)
	When it rises above 40°C	11 (2.9)
Which antipyretic drugs do you administer?	Only paracetamol (calpol, paranox etc.)	167 (43.3)
	Paracetamol and ibuprofen alternative	133 (34.5)
	Only ibuprofen (dolven, pedifen, etc.)	75 (19.4)
	metamizole (novalgin)	6 (1.5)
	Aspirin (babyprin)	5 (1.3)
How do you administer antipyretic?	Orally	384 (99.5)
	Rectally (Suppository)	127 (32.9)
If you are using it as rectal suppository, why do you prefer this way? (n = 127)	the doctor suggested so	61 (48)
	I cannot give it orally (vomiting etc.)	26 (20.5)
	It is more useful	25 (19.7)
	For refusing oral medications	11 (8.7)
	It is more practical	4 (3.1)
What do you think about giving high-dose antipyretic drugs to reduce fever?	More dangerous	214 (55.4)
	More effective	95 (24.6)
	More effective but dangerous	77 (20)
How do you determine the right antipyretic dose to be given to your child?	According to the doctor’s recommended dose	355 (92)
	According to the prescription of the drug	22 (5.7)
	I consult my friends	5 (1.3)
	According to information on the internet	4 (1)
How do you think the dose of antipyretic drugs in children is determined?	Weight	269 (69.7)
	Age	111 (28.7)
	Height	6 (1.6)
Which tool do you use to give the antipyretic drug at the right dose?	Own dosimeter of the antipyretic drug	334 (86.6)
	Tablespoon or teaspoon, etc.	48 (12.4)
	Dosimeters of other drugs	4 (1)
What do you do in addition to antipyretic drugs to reduce your child’s fever?	Tepid (29-32°C), bath (or wiping)	172 (44.6)
	Cold (≤28°C, tap water, etc.), bath (or wiping)	163 (42.2)
	Placing an ice pack on their armpits, groin, or forehead	6 (1.6)
Seeking medical help
When do you take your child to the hospital if they have fever?	Within 6 hours	180 (46.6)
	Within 7-12 hours	79 (20.5)
	Within 13-24 hours	67 (17.3)
	Within 25-48 hours (the second day)	39 (10.1)
	Within 49-72 hours (the third day)	18 (4.7)
	73rd hour and later (after the third day)	3 (0.8)

Study Outcomes

The primary outcome of the study was finding the proportion of parents who correctly identified a fever. Secondary outcome was the identification of parents’ concerns about fever. The tertiary outcome was to understand parents’ attitudes towards reducing fever and to determine when they would seek medical help.

Statistical Analysis

The Statistical Package for the Social Sciences program, version 23.0 (IBM corp., Armonk, NY, USA) was used for statistical analysis of the data. Categorical variables were defined as numbers (n) and percentages (%), and continuous variables were defined as the mean and standard deviation. Univariate binary logistic regression was used to determine the OR between the sociodemographic characteristics of the participants (parent’s age, length of parenting, education level, and number of children) and the dependent variables (not defining fever correctly, the frequency of fever measurement, anticipated adverse effects of fever, the body temperature at which antipyretics are started, the alternate use of antipyretics, and the time to seek medical help) and their 95% CIs.

Results

Participant Characteristics

Of the 406 parents eligible to participate in the study, 11 were excluded from the study because they were not mothers or fathers (e.g., grandmother, aunt, babysitter), and 9 were excluded from the study because they did not answer all the survey questions, and as a result, 386 parents (95%) were analyzed (Figure 1). The mean age of the parents was 33.6 ± 6.38 years, the mean length of parenting was 6.87 ± 5.28 years, and the mean number of children was 1.85 ± 0.9. The majority of participants were mothers (77.7%, n = 300), had 2 or more children (59.8%, n = 231), and received secondary education or lower (57.2%, n = 221).

Figure 1.

Flow chart of participant selection.

Fever Definition

The proportion of parents who could correctly define fever as the body temperature of ≥38°C was 33.4% (n = 129). The proportion of parents describing even body temperatures below 39°C as “high” fever was 44.8% (n = 173). Less than one-third (30.6%, n = 118) of the parents thought that the body temperature could rise >41°C (Table 1). Fathers were more likely than mothers to not define fever correctly [OR 1.74 (1.01-3), P = .046] (Table 3).

Table 3.

Factors Associated with Parents’ Knowledge, Concerns, and Practices of Fever

Factors	Odds Ratio (95% Cl)*	P**
Can not define fever correctly
Parent
Mother	Reference
Father	1.74 (1.03-3)	.046
Monitoring of fever at ≤30 minute intervals
Education
Bachelor’s degree or higher	Reference
High school or lower	3.11 (1.58-4.12)	<.001
Possibility of fever worsening the disease
Length of parenting	0.92 (0.87-0.98)	.013
Number of children	0.64 (0.44-0.92)	.017
Starting antipyretic before the body temperature reaches 38ºC
Length of parenting	1.04 (1.01-1.08)	.048
Number of children	1.61 (1.26-2.06)	<.001
Correctly defined fever
Yes	Reference
No	2.83 (1.70-4.71)	<.001
Alternate administration of antipyretics
Parent age	1.04 (1.01-1.07)	.014
Length of parenting	1.07 (1.03-1.11)	.001
Number of children	1.28 (1.02-1.62)	.031
Seeking medical help within the first 12 hours
Parent
Mother	Reference
Father	1.98 (1.13-3.47)	.017
Education
Bachelor’s degree or higher	Reference
Secondary education or lower	1.97 (1.92-4.64)	<.001
Correctly defined fever
Yes	Reference
No	1.81 (1.16-2.82)	.008

Fever Measurement

Regarding the measurement of body temperature, almost half (47.9%, n = 185) of the parents thought that the axillary region calculated the best body temperature most correctly. The majority (95.9%, n = 370) of them had a thermometer at home; mostly digital thermometers were used (54.4%, n = 210). Regarding the monitoring of fever, 75.9% (n = 293) of the parents continued to measure their body temperature at ≤ 30-minute intervals and 42.7% (n = 165) at ≤ 15-minute intervals (Table 1). Parents with secondary education or lower were more likely to measure body temperature at ≤ 30-minute intervals (OR 3.11 [1.58-4.12], P = <.001) (Table 3).

Expected Adverse Effects Due to Fever

The most anticipated adverse effects associated with fever were febrile seizure (95.3%, n = 368), brain damage (36.8%, n = 142), and worsening of the illness (17%, n = 66) (Table 1). As the number of children and the length of parenting increased, likelihood of thinking that fever would worsen the illness decreased [OR 0.64 (0.44-0.92), P = .017; OR 0.92 (0.87-0.98), P = .013] (Table 3). No sociodemographic characteristics associated with other anticipated adverse effects such as brain damage and death were identified.

Reduce Fever

While less than one-third (32.4%, n = 125) of the parents reported that they started giving antipyretics without waiting for their child’s body temperature to reach 38°C, only 15.3% of them (n = 59) allowed it to rise above 39°C (Table 2). When the number of children or length of parenting increases, or when they are unable to accurately define a fever, they were more likely to start giving antipyretics before their body temperature reached 38°C (OR 1.04 [1.01-1.08], P = .048; OR 1.61 [1.26-2.06], P < .001; OR 2.83 [1.70-4.71], P < .001) (Table 3). Parents reported that they used only paracetamol (43.3%, n = 167), paracetamol and ibuprofen, alternately (34.5%, n = 133) or only ibuprofen (19.4%, n = 75) to reduce fever (Table 2). The likelihood of alternating antipyretics increased as the parent’s age, number of children, and length of parenting increased (OR 1.04 [1.01-1.07], P = .014; OR 1.28 [1.02-1.62], P = .031; OR 1.07 [1.03-1.11], P = .001) (Table 3). Less than one-third of the parents (32.9%, n = 127) also gave rectal antipyretics, and some of them (19.7%, n = 25) think it is more effective. In addition, 44.6% (n = 172) of the parents thought that high doses of antipyretics were more effective. Majority of parents (92%, n = 355) applied the antipyretic dose as recommended by their doctor, 28.7% (n = 111) thought that the dose was determined by age, and 12.4% (n = 48) gave the medicine using a tablespoon or teaspoon. Parents reported that in addition to antipyretics to reduce fever, 44.6% (n = 172) took a tepid, and 42.2% (n = 163) took a cold bath/wiping with a damp towel (Table 2). Fathers were more likely to apply a cold bath/wiping (OR 2.39 [1.46-3.9], P = <.001).

Seeking Medical Help

When their child has a fever, only 0.8% (n = 3) of parents said they could wait until the end of 72 hours to seek medical help. In addition, 67.1% (n = 259) of them stated that they would seek medical help within the first 12 hours, and 46.6% (n = 180) within the first 6 hours (Table 2). Fathers, those with secondary education or lower, and those who could not define fever correctly were more likely to seek medical help within the first 12 hours (OR 1.98 [1.13-3.47], P = .017; OR 1.97 [1.92-4.64], P = < .001; OR 1.81 [1.16-2.82], P = .008) (Table 3).

Discussion

This study, in which we examined the knowledge and attitudes of preschool children’s parents about fever, has 2 main findings. First, approximately two-thirds of the parents cannot define fever correctly, and these parents were in the group who started giving antipyretics before the body temperature reached 38°C and sought medical help early. Second, experienced parents with multiple children and/or longer length of parenting tend to start giving antipyretics before the body temperature reached 38°C. They used antipyretics alternately. But these parents were less likely to think that fever would make the illness worse.

The lack of parental knowledge regarding pediatric fever is a significant public health issue.² Studies have shown that despite its common occurrence, nearly half of the parents are unaware of the correct definition of fever, and approximately one-third consider body temperatures below 38°C as fever.^{1,3,4,6,11,12,18} Unfortunately, this knowledge gap among parents has been a subject of discussion for decades, with limited progress.¹⁹ Although the rate of parents owning thermometers has increased significantly in Türkiye over the past 20 years (43%-50.8% vs. 81.8%-86.5%), there has not been a substantial change in the perception of body temperatures below 38°C as fever (23.2%-46.5% vs. 19.3%-35%).^20-26 On the other hand, the probability of parents seeking medical help on the first day of fever has increased significantly in these 20 years (1.9%-18.1% vs. 53.5%-64.3%).^20,21,24,27 Considering that although the accessibility of medical help has increased over the years, there has been no significant change in parents’ concerns that fever would cause febrile seizure (86.6% vs. 89.4%),^20,24 it can be thought that Turk parents feel more inadequate in home care of pediatric fever over the years. In this respect, our study shows that although communication skills have increased today, similar to previous studies, there is still a lack of information on accurately defining fever and therefore seeking medical help.^20-26 It is worth noting that parents actively seek information about pediatric fever and value reliable and accessible sources.²⁸ Therefore, considering that one of the primary responsibilities of health care professionals in contact with children is safeguarding child health,²⁹ it is crucial for them to regularly educate parents about pediatric fever during well-child visits and also during the antenatal period.

Pediatric fever is much more significant than just an increase in body temperature.^8,15 As parents who prioritize the well-being of their children, they make every effort to reduce fever.^15,19 However, these endeavors often instill fear and anxiety, particularly among parents with lower education levels and young mothers.³⁰ This leads them to take potentially harmful interventions to reduce fever^3,14 because most parents are not even aware that antipyretics have harmful effects on the illness process and high doses can lead to toxicity.³¹ Not only parents but also health care providers have exaggerated fears about pediatric fever and a tendency to overtreat fever.^30,32,33 This is probably due to the lack of awareness of health care providers on the immunological role of fever or that it is easier to recommend giving antipyretics than to try to reassure the parents.^34,35 However, this approach sends the wrong message to parents, fueling their fear and fostering a desire to achieve normothermia in their children. This leads to the use of aggressive treatments such as antipyretic and alternate therapy even at acceptable body temperatures.^33,36 However, the guidelines aim to alleviate fever phobia by encouraging the use of antipyretics to increase the child’s overall comfort rather than controlling body temperature.^30,37,38 In our study, although experienced parents with multiple children and/or longer lengths of parenting did not think that fever would worsen the existing illness, their tendency to initiate antipyretic medication before their child’s body temperature reached 38°C and their increased use of alternate antipyretics suggest a misunderstanding of fever management over the years. It is known that parent education reduces fever phobia, and pediatric health care providers have a unique position to make an impact in this education.^39-41 However, in addition to parental education, there is a need for education among health care providers, especially in pediatric emergency services, who serve as role models for parents in fever management.^5,34 Therefore, we believe that sharing brochures on fever management at home and in emergency settings, prepared by experts in the field, with parents during routine well-child visits and emergency visits, or incorporating them into the child health reports as “fever information cards”²⁹ will increase awareness among health care providers and reduce the unnecessary use of antipyretics.

This study has some limitations that we are aware of. First, as with most surveys, parents may have given socially desirable responses rather than actual behaviors, so interpreting the real situation can be difficult. Second, there is a potential risk of selection bias as the study may have included parents with higher literacy and therefore better knowledge. Finally, since the research was conducted in a specific region of Turkey, it may not reflect the situation nationwide. However, the design of the study provides enough information to clarify the study purpose.

In conclusion, this study offers a current snapshot for institutions responsible for shaping public policies in pediatric health care, emphasizing the need for education among parents and pediatric health care providers. It reveals that a substantial proportion of parents cannot define fever correctly and that inappropriate antipyretic use is more common among experienced parents with multiple children and/or longer length of parenting. In this context, continuous training should be given to parents and pediatric health care providers, especially on the first application to be made to a child with fever.

Funding Statement

This study received no funding.