Family Practice Advance Access originally published online on October 11, 2006
Family Practice 2006 23(6):618-623; doi:10.1093/fampra/cml046
Severity of illness and the use of paracetamol in febrile preschool children; a case simulation study of parents' assessments
a Department of General Practice and Community Medicine, University of Oslo Oslo
b SINTEF Health Research Oslo
c Department of Pharmaceutical Bioscience, University of Oslo Oslo
d Department of Informatics, Bioinformatics Group, University of Oslo Oslo
Correspondence to: Per Lagerløv, Department of General Practice and Community Medicine, Faculty of Medicine, University of Oslo, Box 1130 Blindern, N-0318 Oslo, Norway. Email: per.lagerlov{at}medisin.uio.no
Received 1 November 2005; Revised 4 July 2006; Accepted 13 September 2006.
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Abstract |
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Objective. Misconceptions and exaggerated fear of fever may divert parents' attention from more predictive symptoms of childhood illness, such as appetite and level of activity. This study aims at exploring how specific predefined characteristics of febrile preschool children affected parents' assessment of the severity of the condition and the perceived need for treatment with paracetamol.
Methods. Parents judged 24 constructed cases of febrile children with different levels of fever, appetite and activity, occurring at different times of the day. For each case they decided whether the child was moderately or severely ill, and whether or not they would prefer to administer paracetamol. Parents' decision-making was examined by discriminant analyses.
Results. Of 466 invited parents, 267 supplied information about their families and 205 accepted to participate in judging constructed cases of febrile children. A total of 159 parents responded to all cases. When evaluating the severity of the illness, 119 parents (75%) responded to one or more of the four cues describing illness. Only one of four cues was used by 80 parents (67%), and 86 (72%) parents emphasized fever. When deciding to give paracetamol, one or more of four cues was used by 102 parents (64%), while 72 parents (71%) used only one cue, and 92 parents (90%) emphasized fever.
Conclusions. Parents focus on fever when they evaluate febrile illness and decide whether or not to give paracetamol. Educating parents to focus on their child's level of appetite or activity may improve management, especially when judgement is based on only one or two cues.
Keywords. Case simulation, childhood illness, clinical judgement analysis, fever, paracetamol.
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Introduction |
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Parents are often afraid that fever may harm their child.1 Although fever in some cases indicates serious illness, in most cases it does not. An unrealistic concern about fever has been termed fever phobia.2 Fever often occurs in young children and is the main complaint for as many as one-third of all paediatric consultations in general practice.3 The antipyretic medicine paracetamol is frequently used to combat fever and its use seems to be growing in several countries. In an Australian survey, 37% of primary school children had taken paracetamol in the prior 2 weeks,4 while in a Norwegian study 61% of 338 children, 1–2 years old, had at least once during a 3 month period received paracetamol and 50% had visited a GP.5
In very young children, parents have to rely on observation rather than communication when evaluating a febrile condition, which might increase focus on the easily measured level of fever. Health personnel may contribute to this focus on fever, by often recommending paracetamol to febrile children.6 In a recent study among paediatric nurses, it was concluded that knowledge of fever management was lower than expected and that the participants often believed that febrile convulsions could be prevented by paracetamol, despite evidence to the contrary.7
According to a report from the World Health Organization (WHO), there is minimal evidence of clinical benefit of antipyretics, including paracetamol, in febrile children.8 While use of paracetamol is regarded generally safe in Western countries, hepatotoxicity has occurred even with recommended dosages of the drug.8 In developing countries, where malnutrition is usual, data on safety are lacking.8 Kluger9 argues that since there is no documentation that fever is dangerous to the child, and that it may in fact be viewed as beneficial during infection, fever should not be treated per se.
It is important to explore parents' beliefs and attitudes towards paracetamol because the use of the drug is so widespread, despite the lack of evidence of its clinical benefit.
Another important issue to explore is the perceived importance of fever in relation to other clinical signs, according to parents of a febrile child. In a study of causes of fever in children attending hospitals in the north of England, Nademi and colleagues10 found that fever had less positive predictive value than reduced appetite, activity and restlessness in the child when predicting the severity of illness.
Parents recognize illness among their children either intuitively, for instance by pattern recognition, or analytically by taking notice of specific symptoms or signs.11 In the present study we have chosen to follow the analytical path since education on how to handle children often is based on how elements of information combine into conclusions. The intuitive approach is much more difficult to examine and has at the moment less practical impact in educating parents. Clinical judgement analysis has been used to examine decisions of doctors evaluating diagnoses and treatments.12 Such examination is based on evaluating series of constructed cases (paper-patients) with varying intensities of cues, reflecting the condition of the patient, and analysing the significance of the different cues by means of discriminant analyses.13
This study aims to explore to what degree parents respond to the child's reduced appetite and restlessness compared with levels of fever when they judge the severity of the illness and whether or not to give the febrile child paracetamol. We have used predefined levels of symptoms in order to explore parental strategies, using a clinical judgement analysis.
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Methods |
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Two strategies were used for recruiting parents to the current trial.
First, we attempted to recruit those parents who brought their 2- or 5-year old child to a routine examination at a public health centre. Preschool children in Norway are offered regular physical examinations and vaccinations at public health centres during their first 5 years of life. The public health centre selected for this trial, served two-thirds of the preschool children in a medium-sized town of 50 000 inhabitants. In the written invitation, parents were given information about the current study and invited to participate in examining constructed cases. They were asked to respond to a questionnaire about their family and care-giver setting, irrespective of whether they decided to participate or not. These questionnaires were collected at the public health centre. A poster describing the study was displayed in the public health centre. Parents who decided to enrol in the study received a set of constructed cases together with a pre-paid return envelope to our research department. The set of constructed cases and the questionnaire were supplied with an ID-number, which was linked to the parent's name and address, the latter only accessible to the personnel at the public health centre. Recruitment of parents terminated after 6 months. At that time, we had enrolled 100 parents.
Our second strategy was to recruit parents whose child was enrolled in one kindergarten with about 100 children (1–5 years), located in one of the more affluent counties of Norway (Baerum). The head of this kindergarten informed parents about the current study. A poster describing the study was displayed at the entrances of the kindergarten. After these presentations, two members of the research staff attended the kindergarten in the morning and evening when parents delivered or collected their child. The parents were asked to respond to a similar questionnaire described above about their care-giver setting and to examine the set of constructed cases. An ID-number attached to the questionnaire with the set of constructed cases was linked to the name and address of the parent. Research staff visited the kindergarten eight times during a fortnight's period and terminated the recruitment when no new responses were forthcoming.
This study aimed at recruiting parents with own experience in parenting toddlers, including parents with at least one child one year or older. The few parents with only one child <1 year old were therefore excluded. The Regional Committee on Medical Research Ethics approved the study.
The descriptions of the constructed cases were developed in collaboration with visitors, nurses and other personnel at a public health centre not participating in the study. Eleven parents participated in a pilot study.
The age of the constructed cases was selected to be one-and-a-half years old. At this age, language is not fully developed and parents have to rely more on their own observations and intuitions than on direct communication with the child. Also at this age, fever is observed to occur frequently.
The perceived importance of fever may relate to the time of the day the child is ill, as the possibility of observing the child is reduced during the night. Likewise, the aim of using paracetamol may be different in the middle of the day (fever reduction) compared with the evening, when parents try to calm the child in preparation for sleep. To allow for this contextual influence, we chose to examine whether peak time of illness (noon or evening) affected the parents' decision-making.
Twenty-four different constructed cases were developed combining three different cues describing the condition of the child and one cue describing whether the child was ill in the middle of the day or in the evening (1 hour before regular bedtime). The child may have a temperature of 38.5 or 39.5°C, it may have normal or reduced appetite, and its activity may be restless and irritated, normal, or it may be silent, slack and sleepy. All combinations of cues should be clinically relevant and the constructed cases were presented in a random order to each parent.
Totally six constructed cases were drawn by chance from the 24 cases. These six cases were presented again at random to the parents to check for re-test consistency. Thus they responded to a total of 30 constructed cases, including the six duplicates.
The sequence of the cues for each constructed case was randomized, so that no single cue should have preference based on being presented first or last in describing the case. A sample of a constructed case questionnaire is presented in the appendix.
Data on care-giver settings included: the parents' age, relationship to the child, the number of children they cared for, the age of the child attending the public health centre or the kindergarten, their number of years of education after junior high school, and their current occupation. Whether they were a single parent, had other adults to consult with when their child was ill, and their experience in caring for a child with chronic disease were also recorded.
Discriminant analyses were used to evaluate how changes in the characteristics describing the constructed cases were associated with a change in judgements. The dependent variables were the judgement on severity of illness (moderate versus severe) and the decision to give paracetamol (definitely/probably versus no). The independent variables were the different characteristics or cues; fever, appetite, activity, and time of the day. For each parent, 30 dichotomous decisions on severity of illness and whether to use paracetamol were entered into the model. In this study we have focused on whether or not certain characteristics affected a judgement—not to what degree it might have affected the decision. Logistic regression methods, the odds ratio (OR) with 95% confidence intervals (CI) were used to indicate a significant association (95% CI that exclude the value 1.0 are considered statistically significant).
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Results |
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Of the 390 parents who visited the public health centre, 209 (54%) gave information about their care-giver situation, 147 of these parents accepted to participate in judging constructed cases, and 105 completed the questionnaires. Of the 76 parents in the kindergarten, 58 (76%) gave information about their care-giver situation and accepted to participate in judging constructed cases, and 54 (69%) completed the questionnaires.
A comparison on the characteristics of parents who participated in evaluating constructed cases and those who did not is presented in Table 1. Parents who partook in the evaluation were generally better educated than those only supplying demographic data. The kindergarten is mainly for children where both parents are working, and this group of respondents had a lower mean age of the attending child, compared with the children of parents recruited from the public health centre. Although the parents examining constructed cases from these two recruited populations show some minor differences, they are examined jointly.
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The predefined characteristics (cues) of febrile one-and-half-year old children that parents assessed in deciding the severity of illness are shown in Table 2. Among the 40 parents not showing any cue preference, five parents gave the same judgements to all children. Among the 119 parents who assessed the characteristics in a systematic way, 72% emphasized fever and 67% made use of only one cue.
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The cues of febrile one-and-half-year old children that parents emphasized in deciding whether or not to give/probably give paracetamol are presented in Table 3. Among the 57 parents not showing any cue preference, 21 parents had the same decisions for all children; not giving paracetamol. Among the 102 parents who assessed the cues in a systematic way, 90% emphasized fever, 18 (18%) emphasized the time of the day the child was ill, preferring to give paracetamol in the afternoon, and 72 parents (71%) made use of only one cue when deciding to treat the child with paracetamol.
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The six duplicated constructed cases that were included to check internal consistency were compared for equal judgements given by the parents regarding the severity of the condition. In the case with lowest consistency, 116 out of 159 parents (73%) judged the case equally. In the case with the highest consistency, 153 parents (96%) gave the same judgements. Regarding treatment with paracetamol, the lowest and highest consistencies were 118 and 151 parents (74 and 95%) giving equal judgements out of 159 parents, respectively.
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Discussion |
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In this study, many parents used fever as the sole guide to judge severity of illness in their child. Almost two-thirds of parents paying attention to a single cue, focused on fever. With increasing number of cues used in the decision-making, levels of appetite and activity were emphasized with equal frequency.
Although a patient's condition could be described by a variety of characteristics, it is anticipated that usually no more than three different characteristics are compiled to make a judgement, and even fewer cues are used under situations of constrained time and anxiety.14 A large proportion of parents who systematically assessed the cues presented in this study emphasized only one cue. This observation may be especially important in real life. If parents turn anxious, they may be less able to make rational judgements. It is shown that parents with high levels of anxiety more frequently overestimate the seriousness of their child's illness compared with parents with lower levels of anxiety.15 One reason could be that they use fewer cues and focus on the less useful cue; fever. Low levels of education may also influence the ability to make rational judgements. Socially disadvantaged parents more frequently attend health care services for their children, compared with their socially advantaged counterparts.16 Moreover, health centres guidance and instructions on how to manage children with illness is mainly presented in textual formats, making it less accessible to parents with low education. Inability to handle information may create anxiety, which in turn may disable judgements.11 The accuracy of judgement of these parents might improve if they were guided to focus more on their child's levels of activity and appetite during illness.
When deciding whether or not to give a child paracetamol, almost all parents emphasized the level of fever. This is not unexpected, as paracetamol is an antipyretic. More surprising is the parents' low attention to the child's levels of activity and appetite. When febrile, some children may be flaccid and refuse to drink, which is an extra indication for using antipyretics.17 Irritability may be a sign of pain, and some studies indicate that parents may underestimate the presence of pain in their child and refrain from using paracetamol as an analgesic.18,19 In this study, many parents used the level of fever as the sole indication for giving paracetamol without evaluating a possible indirect gain in appetite or activity by its action on fever and pain. One explanation might be an anxiousness that fever may harm the child.1 This anxiety could be more pronounced when the child is preparing to go to bed and the parents have less ability to check the temperature level. Some parents in this study were influenced by the timing of symptoms when making their judgement and were more prone to give paracetamol in the evening.
Results in this study are based on parents' responses to constructed cases. The degree to which constructed cases mirror real patients remains controversial. Good descriptions of such cases are essential to optimize congruence.20 Children in this study were described by using abstract terms describing levels of activity and appetite, which are important aspects when judging illness. The temperatures were given as exact values. Descriptions might have been more pictorial or descriptive, for example; ‘the child with high fever was boiling hot and had shiny eyes’. On the other hand, such descriptions could include connotations and possibly direct the parent's focus to qualitative, rather than quantitative, aspects of illness; such as associating ‘high fever’ with serious disease. The case descriptions are therefore short, with the expectation that parents will make associations to their own experience. These associations may differ among parents but should not affect the regression modelling of cue preference, as long as they are not changed significantly during judgements of the constructed cases. To prevent artificial focus on a single cue, all cues except from activity level had two levels with equal intensities. The cue combinations were in orthogonal design and the cue succession was presented in random. In the design we have made efforts to allow parents multiple actions and not only focus on the use of antipyretics.
Five parents who judged the severity of illness and 21 parents who judged treatment with paracetamol made their judgement on the grounds of principle—not changing decisions according to the described conditions of the constructed cases. These parents did not show any cue preference. No cue preference was identified for a further one-fifth of the parents. Since the parents as a group seemed to reply fairly consistently to the different cases, it might be that some of these parents without cue preference included unknown cues, or used more complex rules in their decision-making than were detectable using our methods.
The capability to judge situations analytically may be a prerequisite or a motivating factor to participate in this study. The included parents had a mean of more than 6 years of education after junior high school, compared with 5 years among the non-participants. Thus, they were exposed to some training in analytical thinking and might have been more able to access and use guidelines, which often are presented as algorithms for actions, than less educated parents. Although the results of this study might not be applicable to all parents, it tells us that even those with higher education and more experience have the potential for improvement when judging their preschool child.
To conclude, the socially advantaged parents participating in this study focused to a large degree on fever as the single variable to describe the severity of their child's illness and the subsequent need for medication with paracetamol. There is a potential to educate parents in a more rational evaluation of illness in children.
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Appendix |
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One of 24 constructed cases
Your child is one-and-a-half year old. During the last couple of hours a changed condition has occurred.
Now it is one hour before bedtime
The body temperature is 39.5 centigrade
The child is more calm, slack and sleeps more than usual
The child has normal appetite
Put only one tick at each question or action:
How sick is your child?
The child has only a minor illness
The child is definitely sick
Actions:
I will undress the child
No Probably Yes
I will supply extra fluid to the child
No Probably Yes
I will give paracetamol to the child
No Probably Yes
I will
Just observe the situation
Observe the situation and awake the child during the night for inspection
Contact the healthcare service immediately
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Notes |
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Lagerløv P, Loeb M, Slettevoll J, Lingjærde O and Fetveit A. Severity of illness and the use of paracetamol in febrile preschool children; a case simulation study of parents' assessments. Family Practice 2006; 23: 618–623.
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References |
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1 Blumenthal I. (1998) What parents think of fever. Fam Pract 15:513–518.
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