Sickness behavior in feverish children is independent of the severity of fever. An observational, multicenter study

Professionals' ideas and observations on preschoolers' experiences with physical symptoms: a qualitative interview study

BACKGROUND

Preschoolers experience physical symptoms, like abdominal pain or minor injuries, almost every day. These experiences may shape how they deal with health issues later in life. To gain insight into these early life experiences, information from multiple perspectives is useful. This qualitative study aimed to explore important themes in preschoolers' experience of physical symptoms, using adult professionals from various backgrounds as informants.

METHODS

20 semi-structured interviews were performed with professionals from different fields in healthcare and education, to learn about their ideas and observations on preschoolers' experiences with physical symptoms. The interviews were verbatim transcribed and coded in Atlas.ti by two independent coders, after which thematic content analysis was applied to define themes.

RESULTS

Three themes emerged from the interviews: unawareness, seeking attention, and parental influence. Unawareness refers to the professionals' idea that preschoolers have limited cognitions about causes and consequences of physical symptoms. Seeking attention was described as important for preschoolers with symptoms, both as comfort and in a social context. Professionals described diminished attention-seeking behavior in preschoolers with more severe symptoms. Parental influence was seen as highly relevant in preschoolers' experiences with physical symptoms, with both supportive and disruptive aspects. Healthcare professionals differed from educational professionals in their observations and ideas, especially about underlying mechanisms influencing symptoms.

CONCLUSIONS

Professionals report attention-seeking and parental influence as important factors in preschoolers with physical symptoms, and they report limited cognitions about causality. Professionals in healthcare and education show different perceptions, suggesting the importance of incorporating both views into research.

Definition and assessment of fever-related discomfort in pediatric literature: a systematic review

Guidelines advocate that the symptomatic management of fever should prioritize alleviating the child's discomfort. We investigated the definition and assessment of discomfort in febrile children within the scientific pediatric literature. A systematic review was conducted in accordance with PRISMA 2020 guidelines and preregistered on the Prospero database (CRD42023471590). Databases including PubMed, Embase, and Cochrane were searched. Studies addressing discomfort in febrile children were eligible. Out of 794 initially identified articles, 27 original studies and seven guidelines specifically used the term 'discomfort'. Only 14 original articles provided a definition of discomfort, revealing substantial heterogeneity and no clear-cut definition. Discomfort was often assessed subjectively, predominantly through parent or self-report, and only two studies used a scoring system for assessment. The definitions varied widely, with terms such as crying, irritability, shivering and chills, pain and distress, goosebumps commonly used and evaluation of observable modifications such as facial modifications. Overall, no consensus on a single, standardized definition was available.

CONCLUSIONS

This systematic review shows the absence of a standardized definition and assessment of discomfort in febrile children. The findings of the present analysis might be the basis for building a consensus and developing a new tool to evaluate discomfort.

WHAT IS KNOWN

• Discomfort is currently considered the main criterion to guide antipyretic administration in children with fever. • Despite this clear-cut recommendation, it has been questioned whether a commonly accepted understanding and assessment of this condition exists.

WHAT IS NEW

• This systematic review identifies a significant heterogeneity in definitions and assessment of discomfort in children with fever. • Both subjective parameters and observable modifications in physiological parameters should be included in a new and shared characterization of discomfort.

Navigating the unknown: understanding and managing parental anxiety when a child is ill

BACKGROUND

Parents are often confronted with a difficult decision when their child falls ill: should they go to the general practitioner (GP) or not? This study aims to describe this process comprehensively in order to allow clinicians to assess the extent to which parents can recognise clinical warning signs and act accordingly. The purpose of this study is to describe parents' decision-making processes when deciding whether or not to consult a GP for their sick child.

METHODS

We used a qualitative study design based on semistructured interviews to investigate the decision-making process of 25 parents. Four case scenarios describing a developing illness in a child were presented.

RESULTS

Parents' reasons for seeking medical attention could be divided into two main categories. First, non-specific fears lead parents to consult a doctor. Parents were alarmed by the persistence and progression of symptoms, the combination of symptoms or changes in their child's behaviour or they needed reassurance. Second, several specific fears were identified. Sometimes, parents fear a specific disease, while at other times, they are concerned about warning signs. Some parents, however, would not seek medical attention at any decision point even though their child could be in a potentially life-threatening situation.

CONCLUSIONS

Although parents make carefully considered decisions on whether or not to consult a doctor, many appear to miss red flags, including more experienced parents. Conversely, some become overly concerned with certain specific symptoms such as fever, and few parents are familiar with self-management strategies.

Discomfort relief after paracetamol administration in febrile children admitted to a third level paediatric emergency department

Background

international guidelines recommend treating fever in children not at a predefined body temperature limit but based on the presence of discomfort. However few studies evaluated discomfort relief after administration of antipyretics in children.

Methods

Between 1st January and 30th September 2021 a single-center prospective observational study was performed in febrile children consecutively admitted to a pediatric emergency department and treated with paracetamol orally. For each child, body temperature, presence and severity of discomfort, defined using a previously published semiquantitative likert scale, were evaluated at baseline and 60 min after administration of paracetamol, and differences were analyzed.

Results

172 children (males: 91/172; 52.9%; median age: 41.7 months) were included. Significant reductions in body temperature (median body temperature at T0: 38.9 °C; IQR: 38.3-39.4, median body temperature at T60: 36.9 °C; IQR: 36.4-37.5; P < 0.0001), and in the level of discomfort (proportion of children with severe discomfort at T0: 85% and at T60:14%; P < 0.0001) were observed. Severe discomfort at T60 persisted in a minority of children (24/172; 14%) and it was not related to body temperature values.

Conclusions

paracetamol in febrile children is associated not only with significantly reduction in body temperature but also with discomfort relief.

Data Completeness and Concordance in the FeverApp Registry: Comparative Study

BACKGROUND

The FeverApp registry uses ecological momentary assessment (EMA) to collect parental data on pediatric fever for scientific research. The mobile app FeverApp educates parents on safe fever management and serves as a fever diary.

OBJECTIVE

The focus of this study was to evaluate the completeness and concordance of the EMA-based FeverApp registry with regard to its data quality from a multilevel perspective.

METHODS

Structured descriptions of fever episodes by health care professionals from an office were used as reference. The number of children, their sociodemographic data, and agreement of fever episodes, with maximum temperature, intake of antipyretics and antibiotics, and physician visits, were compared with the entries in the corresponding physician's reference records. The data quality indicators for completeness, meaning the extent to which the necessary data for the registry has actually been submitted, and concordance, which is the correspondence of the value of a data element with a reference source, were chosen to analyze whether EMA may be a suitable method for this kind of registry.

RESULTS

In both data sources, 1012 children were available for comparison over 16 months. The completeness of gender (1012/1012, 100%) and date of birth (1004/1012, 99.2%) information was high, and the mismatches were 0.69% (7/1012) and 1.19% (12/1012), respectively, between the sources. Of these 1012 children, 668 (66%) registered fever episodes in FeverApp. They relate to 534 families with 953 fever episodes in the reference records and 1452 episodes in the FeverApp registry. Of the 534 families, 183 (34.3%) refrained from visiting the office during fever episodes but nevertheless documented them in FeverApp. Largest part (766/1452, 52.75%) episodes were recorded exclusively in the FeverApp registry by 371 (371/534, 69.5%) families. The remaining 686 (47.2%) episodes of 391 (58.5%) children from 351 (65.7%) families were comparable with the reference data source in terms of physician visits, medication, and temperature. The completeness ranged, depending on the kind of variable, from 11.5% to 65% in the registry and from 7.6% to 42.6% in the office. The 953 fever episodes reported by the reference office consisted of 681 (71.5%) acute and 272 (28.5%) past episodes. In FeverApp, most past (262/272, 96.3%) but less acute (424/681, 62.3%) episodes have been entered. The concordance rates were varied: 90.2% for antibiotic use, 66.6% for antipyretic use, 61.7% for physician visits, and 16% for the highest temperature during the fever episode.

CONCLUSIONS

Both sources delivered only partial data, and the rates of completeness and concordance depended on the kind of variable. However, the FeverApp registry showed higher documentation and precision rates than professional records for all considered variables. Therefore, EMA may play a unique supplement for research in ambulatory care. FeverApp could support pediatric offices, especially during the pandemic.

Cross-sectional study of parental knowledge, behaviour and anxiety in management of paediatric fever among German parents

OBJECTIVES

Fever is a common symptom among children. Parental lack of knowledge about fever could cause anxiety and lead to unnecessary measures to subside fever. There is little evidence about German parents' knowledge and their fever management.

DESIGN

A cross-sectional study using a paper-based questionnaire.

SETTING

16 kindergartens in Saarbrücken and Saarlouis regional association accepted to participate in the study. Parents from these kindergartens were requested during the pickup time to answer the questionnaire.

PARTICIPANTS

481 German parents participated in the study, 394 of them were women. Inclusion criteria were good understanding of German and being a parent of at least one child below the age of 7 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Knowledge and behaviour of parents on paediatric fever management and the factors influencing fever anxiety.

RESULTS

The older the parents were, the more anxiety they reported. Their definition of fever had a wide range of 30°C-41°C (mean 38.46, SD=0.67) and almost 90% (mean 3.05, SD=2.03) of participants reported fever as useful, whereby they felt more confident the more they found fever useful. 69% of parents felt calm when their child has fever (mean 4.47, SD=2.27). In case of fever, 55% of parents administer paracetamol, 72% ibuprofen and 32% of them would alternate between the two. Paracetamol and ibuprofen are used more by more anxious parents. In explorative factor analysis, reasons to reduce temperature were summarised in three main factors: damage prevention, illness control and well-being protection, whereby the first two were positively related to parental anxiety.

CONCLUSIONS

Both knowledge as well as level of confidence/anxiety vary largely. Taking antipyretics is related to higher level of anxiety, indicating the need for further education. Fever anxiety depends on multiple factors, which have to be further investigated.

How Does the Social Grouping of Animals in Nature Protect Against Sickness? A Perspective

Sickness behavior is broadly represented in vertebrates, usually in association with the fever response in response to acute infections. The reactions to sickness behavior in a group member or potential group member in humans is quite variable, depending upon circumstances. In animals, the reactions to sickness behavior in a group member or potential group member evoke a specific response that reflects the species-specific lifestyle. Groups of animals can employ varied strategies to reduce or address exposure to sickness. Most of these have scarcely been studied in nature from a disease perspective: (1) adjusting exposure to sick conspecifics or contaminated areas; (2) caring for a sick group member; (3) peripheralization and agonistic behaviors to strange non-group conspecifics; and (4) using special strategies at parturition when newborn are healthy but vulnerable. Unexplored in this regard is infanticide, where newborn that are born with very little immunity until they receive antibody-rich colostrum, could be a target of maternal infanticide if they manifest signs of sickness and could be infectious to littermates. The strategies used by different species are highly specific and dependent upon the particular circumstances. What is needed is a more general awareness and consideration of the possibilities that avoiding or adapting to sickness behavior may be driving some social behaviors of animals in nature.

Sociodemographic Characteristics and Interests of FeverApp Users

The FeverApp Registry is a model registry focusing on pediatric fever using a mobile app to collect data and present recommendations. The recorded interactions can clarify the relationship between user documentation and user information. This initial evaluation regarding features of participants and usage intensity of educational video, information library, and documentation of fever events covers the runtime of FeverApp for the first 14 months. Of the 1592 users, the educational opening video was viewed by 41.5%, the Info Library was viewed by 37.5%, and fever events were documented by 55.5%. In the current sample, the role of a mother (p < 0.0090), having a higher level of education (p = 0.0013), or being registered at an earlier date appear to be cues to take note of the training video, Info Library, and to document. The FeverApp was used slightly less by people with a lower level of education or who had a migration background, but at the current stage of recruitment no conclusion can be made. The user analyses presented here are plausible and should be verified with further dissemination of the registry. Ecological momentary assessment is used more than the information option, in line with the task of a registry. Data collection via app seems feasible.

Let fever do its job: The meaning of fever in the pandemic era

Although fever is one of the main presenting symptoms of COVID-19 infection, little public attention has been given to fever as an evolved defense. Fever, the regulated increase in the body temperature, is part of the evolved systemic reaction to infection known as the acute phase response. The heat of fever augments the performance of immune cells, induces stress on pathogens and infected cells directly, and combines with other stressors to provide a nonspecific immune defense. Observational trials in humans suggest a survival benefit from fever, and randomized trials published before COVID-19 do not support fever reduction in patients with infection. Like public health measures that seem burdensome and excessive, fevers involve costly trade-offs but they can prevent infection from getting out of control. For infections with novel SARS-CoV-2, the precautionary principle applies: unless evidence suggests otherwise, we advise that fever should be allowed to run its course. Lay summary: For COVID-19, many public health organizations have advised treating fever with medicines such as acetaminophen or ibuprofen. Even though this is a common practice, lowering body temperature has not improved survival in laboratory animals or in patients with infections. Blocking fever can be harmful because fever, along with other sickness symptoms, evolved as a defense against infection. Fever works by causing more damage to pathogens and infected cells than it does to healthy cells in the body. During pandemic COVID-19, the benefits of allowing fever to occur probably outweigh its harms, for individuals and for the public at large.

The Legacy of Sickness Behaviors

Systemic infections of all types lead to a syndrome known as sickness behaviors. Changes in the behavior of febrile humans and animals formed the original basis for this concept. Body temperature is behaviorally regulated in both endotherms and ectotherms. However, infections cause other changes in body functions, including sleep disruption, anorexia, cognitive and memory deficits and disorientation. The brain mediates this entire cluster of symptoms, even though most major infections occur outside the brain. The true importance of sickness behaviors is not the numerous discoveries of symptoms that affect all of us when we get sick. Instead, the legacy of 30 years of research in sickness behaviors is that it established the physiologic importance of reciprocal communication systems between the immune system and the brain. This conceptual advance remains in its infancy.

Understanding Discomfort in Order to Appropriately Treat Fever

Although national and international guidelines on the management of childhood and adolescent fever are available, some inadequate practices persist, both from parents and healthcare professionals. The main goal of bringing children’s temperature back to normal can lead to the choice of inappropriate drugs or non-necessary combination/alternation of antipyretic treatments. This behavior has been described in the last 35 years with the concept of fever-phobia, caused also by the dissemination of unscientific information and social media. It is therefore increasingly important that pediatricians continue to provide adequate information to parents in order to assess the onset of signs of a possible condition of the child’s discomfort rather than focusing only on temperature. In fact, there is no clear and unambiguous definition of discomfort in literature. Clarifying the extent of the feverish child’s discomfort and the tools that could be used to evaluate it would therefore help recommend that antipyretic treatment is appropriate only if fever is associated with discomfort.

Parental management of children's fever: Assessment of knowledge and use of health record information

INTRODUCTION

To assess parents' knowledge regarding how to deal with children's fever in comparison to the updated recommendations published in 2016 by the HAS and to collect their views on the fever advice card of the 2006 health record to offer suggestions for possible improvements in order to disseminate the message.

METHODS

Observational, descriptive, quantitative national study conducted with an online questionnaire among adult parents with children born between 2006 and 2017 who had a French health record.

RESULTS

A total of 3295 parents were included from 03/12/2017 to 04/02/2018. The concordance of knowledge compared to current recommendations has improved in 10 years, especially regarding physical treatment (31% of parents had all the right answers) and drugs (95% paracetamol monotherapy). Shortcomings mainly concern the definition of fever, the idea that the temperature is correlated with severity, and the lack of knowledge of the sign of severity "age less than 3 months." The use of the fever advice card in the health record is limited (33% of parents only). They approve by a large majority its promotion and the standardization of the message of healthcare professionals.

CONCLUSIONS

The improvement of how parents manage their child's fever first requires an update of the knowledge of healthcare professionals to homogenize their messages and practices. One of their essential roles is to inform parents of the existence of the fever advice card updated in the 2018 health record, which most particularly contains information that remains poorly known by parents. The health record should be the medium of dialogue with families to promote children's health.