Fever phobia 35 years later: did we fail?

In this issue of Acta Paediatrica, Sahm et al. report the results of a well-designed qualitative study on the knowledge, attitudes and beliefs about fever displayed by 21 Danish parents living in Copenhagen 1. Interestingly, the parents were recruited outside healthcare settings and included a larger proportion of fathers than is usual in such studies. The authors used semi-structured interviews, which were transcribed verbatim and carefully analysed. This methodology does not allow for generalisation of the findings beyond the group studied, but does allow for more in-depth analysis of parental beliefs than the more common questionnaire-based studies. The parents that participated in the study had important fever-related concerns, but poor basic knowledge of areas such as the definition of fever. They also used numerous sources of information, but needed reassurance regarding the trustworthiness of that information from healthcare practitioners. The authors concluded that further initiatives were needed to provide accessible information to parents, including integrated educational programmes to make the switch from fever phobia to rational evidence-based management 2. The term educate should probably be used with caution and replaced by guidance. In addition, we should not forget that parents are the experts when it comes to their child and they can often be the ones educating the healthcare practitioner. The results reported by Sahm et al. are generally in line with those reported by other observational studies in the last three to four decades, both in Western countries and in those with more limited resources 2-5. However, the most important differences between the Sahm et al. study and previous findings are that parents taking part in the latest study declared that fever was actually a good thing for the body and they were reluctant to use medicine to treat fever. This notion may indicate a favourable evolution of parents' knowledge. However, this reluctance to use medicine was in part related to inappropriate reasons, such as a concern that medication was a major cause of autism. In addition, the parent's attitudes in real life may differ from the views they expressed during the study interviews. Has the health practitioner community failed to provide effective guidance to parents on fever management? It is difficult to objectively measure the evolution of parents' knowledge and attitudes regarding symptomatic management of fever given the variability in design and settings among studies and/or ongoing recommendations 1-5. Some practices, such as the use of acetylsalicylic acid and steroids, have been abandoned, and some, such as a cool bath, are now used less often. However, large studies seem to indicate that fever phobia persists and antipyretic drugs are still overused 3-5. Considering that we do seem to have failed in part to provide effective guidance to parents, how did this happen? Do we agree on the key messages? We have achieved widespread international consensus on three key messages 6, 7, which are to rule out severe bacterial infection, focus on the child's discomfort rather than the fever and avoid the overuse of antipyretics. However, we lack consensus on the definition of discomfort. Parents' decisions based on the child's comfort level vary greatly and are influenced by many factors, including cultural and social background. Furthermore, some remaining disputes on basic key issues can be misleading for parents. For example, the American Academy of Pediatrics (AAP) strongly encourages rectal temperature measurements, whereas the UK National Institute for Health and Clinical Excellence (NICE) strongly discourages it 6, 7. Are the messages clear enough? Although healthcare professionals have become more aware of the need for very simple and clear guidance, a 2005 systematic evaluation of the readability of AAP patient education brochures showed that half were written at higher-than-acceptable readability levels for the general public 8. An important clarification would be to shift from the word antipyretics to analgesics in order to reaffirm our treatment target, which is comfort and not normothermia. Have our messages been sufficiently disseminated using all the media at our disposal? The answer varies greatly from country to country. On the one hand, the mobile apps produced for smartphones and tablets by the UK's NICE show a strong positive evolution towards adapting educational messages to parents' technology, even if this approach needs to be extended to more parent-focused information 7. On the other hand, no national papers, videos or e-campaigns have been produced on fever in France, even though there have been some campaigns on more trivial problems, such as the risk of henna tattoos, a questionable hierarchy in public health priorities. Have knowledge and attitudes of healthcare practitioners become more consistent with recommendations than those of parents? The results of the most recent surveys indicate improvements, but also the potential for further optimisation, including basic principles such as the nonsystematic use of drugs 3, 4, 9. Fever is notoriously difficult to define, even for healthcare practitioners, because children's normal temperatures and temperaments vary. Many healthcare practitioners share several of the anxieties reported by parents, including fever phobia 10, and demonstrate practices that are not in line with the guidance that they promote 9. Thus, strong efforts are still needed to de-dramatise fever management and switch from an anxiety-driven goal of achieving normothermia to the rational management of the general condition and comfort of the child, although what is meant by comfort in this context is not always clear and perhaps promoting comfort includes managing parental anxieties. These efforts will need to consider the persistent gap in knowledge and behaviour about the early detection of at-risk situations. For example, a Canadian study found that nearly one-fifth of expectant parents (17%) reported that they would not seek medical care for their febrile neonate 11 and a French population-based study reported a delay in seeking medical care in one-third of fatal cases of febrile bacterial infections 12. The key to reassuring parents and professionals alike is to provide good safety net advice for parents and professionals, covering when parents should seek help from a professional and when healthcare professionals should refer a child for investigation or specialist care 7. The UK NICE guidelines attempted to do this by developing a traffic-light table that provides signs and symptoms associated with low, intermediate and high risks of serious underlying illnesses 7, but this table needs continual updating and needs to be carefully applied to the specific child and family. The significance of the intermediate category is vital because it explicitly acknowledges the existence of a group of children where there is a lack of certainty, as this would reduce the risk of parents receiving false reassurance from their child being discharged. In conclusion, because integrating all these new messages for change takes time, healthcare professionals need to continue their efforts to provide accurate guidance to parents regarding the rational symptomatic management of fever. This will help to avoid inappropriate attitudes, including overusing drugs and overloading doctors' surgeries and emergency departments. However, clinicians need to start believing these messages themselves. These efforts could benefit from standard international recommendations, more effective communication that uses all the available methods to reach parents, including those with low educational levels, and the constant search for the best way to communicate key messages. These efforts should also include, and probably prioritise, messages about the early detection of severe bacterial infection. Clear and child specific safety net advice will probably reassure parents and optimise safety.

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