PARENTAL PERCEPTIONS OF FEVER IN CHILDREN

Youssef A. Al-Eissa, MD, FAAP, FRCPC; Abdullah M. Al-Sanie, MD, MRCP;

Suleiman A. Al-Alola, MD, CABP; Mohammed A. Al-Shaalan, MD, FAAP, MRCP;
Sameeh S. Ghazal, MD, MRCP; Amal H. Al-Harbi, MD, CABP;
Anwar S. Al-Wakeel, MD, CABP

Background: Fever is a common medical problem in children which often prompts parents to seek immediate
medical care. The objective of this study was to survey parents about their knowledge and attitude concerning
fever in their children.
Patients and Methods: The study involved the random selection of Saudi parents who brought their febrile
children to the emergency rooms or walk-in clinics of four hospitals in Riyadh. Parents of 560 febrile children
were interviewed using a standard questionnaire to obtain sociodemographic information and current knowledge
of fever. Approximately 70% of the respondents were female, and the ages of the most were in the range of 20-40
years. More than 80% of the parents had two or more children.
Results: More than 70% of parents demonstrated a poor understanding of the definition of fever, high fever,
maximum temperature of untreated fever, and threshold temperature warranting antipyresis. About 25% of
parents considered temperatures less than 38.0oC to be fever, another 25% did not know the definition of fever,
64% felt that temperatures of less than 40.0oC could be dangerous to a child, and 25% could not define high
fever. Another 23% believed that if left untreated, temperatures could rise to 42.0oC or higher, but 37% could not
provide an answer, and 62% did not know the minimum temperature for administering antipyretics.
Approximately 95% of parents demonstrated undue fear of consequent body damage from fever, including
convulsion, brain damage or stroke, coma, serious vague illness, blindness, and even death.
Conclusion: Parental misconceptions about fever reflect the lack of active health education in our community.
Health professionals have apparently not done enough to educate parents on the condition of fever and its
consequences, a common problem.
Ann Saudi Med 2000;20(3-4):202-205.
Key Words: Convulsion, fever, heat stroke, hyperpyrexia.

Fever is extremely common in childhood. Parents have

been shown to have unrealistic fears of the harmful effects
of fever in their children, and they generally see it as the
main component of an illness.1,2 Parents are unable to
define fever accurately, tend to overestimate its dangers,
and make inappropriate telephone calls and unnecessary
clinic visits, leading to excessive utilization of healthcare
services.3 Anecdotal experiences suggest that physicians
contribute to parental misconceptions about fever, although
it is unclear which part of the patient-doctor interaction
promotes this fear.4 Our clinical experience suggests that
pediatric health providers may impart mixed messages to
parents about the dangers of fever. For example, although

From the Departments of Pediatrics, College of Medicine, King Saud

University (Drs. Al-Eissa and Al-Sanie), King Fahad National Guard
Hospital (Drs. Al-Alola, Al-Shaalan, Al-Harbi, and Al-Wakeel), and
Sulaimania Childrens Hospital (Dr. Ghazal), Riyadh, Saudi Arabia.
Address reprint requests and correspondence to Prof. Al-Eissa:
Department of Pediatrics (39), College of Medicine, King Saud
University, P.O. Box 2925, Riyadh 11461, Saudi Arabia.
Accepted for publication 4 March 2000. Received 6 July 1999.

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Annals of Saudi Medicine, Vol 20, Nos 3-4, 2000

many physicians agree that treatment to reduce fever is

mostly for the comfort of the child, during consultations
many tend to prescribe antipyretic medication for any child
with a fever. Furthermore, physicians frequently differ in
their definition and management of fever.
The purpose of the study was to determine the status of
knowledge and attitude of parents about fever in their
children. The study was undertaken in the pediatric
practices at four different hospitals in Riyadh.
Patients and Methods
Parents bringing their febrile children to hospital-based
emergency departments or walk-in clinics between 8:00
a.m. and 8:00 p.m. (when research assistants were
available) were recruited at random, on the basis of
generated odd registration numbers. Febrile children who
were judged to be critically ill were excluded from the
study. Eligible parents were interviewed in the waiting
rooms as they awaited appointments with their physicians.
The study was carried out in four hospitals in different
areas of Riyadh, namely, the King Khalid University

PARENTAL PERCEPTIONS OF FEVER

Hospital, King Fahad National Guard Hospital, Sulaimania

Childrens Hospital, and Childrens Hospital of Riyadh
Medical Complex. These hospitals were selected to ensure
enrolment of a truly representative Saudi population sample
of all socioeconomic strata. Each eligible male or female
parent was interviewed in Arabic by a male or female
research assistant, using a standard questionnaire designed
to obtain background sociodemographic information and
current knowledge of fever.
Parents were given no assistance with answering the
questions and none refused to be interviewed. In an attempt
to obtain unbiased data that truly reflected parents
perceptions about fever, the questionnaire relied principally
upon open-ended questions (i.e., no suggestions of the
right answer).
Demographic data obtained included age of both
parents, accompanying parent, level of education attained,
current occupation of parents, and number of children cared
for by the parent. The questionnaire items were designed to
ascertain parents knowledge, attitudes and fears
concerning fever in their child. The questions asked were as
follows: how do you know if your child has a fever?; what
is the temperature reading that constitutes a fever in a
child?; what do you consider a high fever?; how high could
the fever go if it is not treated?; what is the greatest harm
that high fever can cause to a child? The questions were
framed in a way as to enable the average lay person to
understand and respond, yet an attempt was also made to
obtain definitive data. Fever was defined as a documented
temperature of 38.0C or higher per rectum (or rectal
equivalent). A rectal equivalent temperature was
calculated by adding 0.5C to the oral temperature and
0.8C to the axillary temperature. The appropriateness of
responses to questions was determined on the basis of
current medical literature.
Results
A total of 560 parents of febrile children were
interviewed. A description of the sociodemographic
characteristics of the study parents is presented in Table 1.
The majority of the parents surveyed were living in Riyadh
city. A wide range in parental age, educational level,
occupation and family size was noted. Most parents
participating in the study were housewives in their late
twenties or early thirties, with at least a primary school
education. Only one-third of fathers brought their febrile
children to the hospital. Roughly one-half of respondents
cared for four children or more.
The majority of parents believed that they could tell
whether their child had a fever by the appearance or
palpation of the child. Only 24% of parents had their
childs temperature measured at home.
Data concerning parental knowledge and attitudes about
fever are shown in Table 2. In this study, the quoted body

TABLE 1. Sociodemographic characteristics of 560 study parents.

Characteristic
Number
%
Accompanying parent
Mother
397
70.9
Father
84
15
Both parents
79
14.1
Residence
Riyadh city
424
75.7
Outside Riyadh city
136
24.3
Age of father (range 19-70, mean 37 years)
<30
122
21.8
30-39
247
44.1
191
34.1
40
Age of mother (range 15-55, mean 29.6 years)
<30
305
54.5
30-39
193
34.4
62
11.1
40
Fathers education
Illiterate
71
12.7
Primary/secondary school
176
31.4
High school/some university
172
30.7
University graduate and above
141
25.2
Mothers education
Illiterate
142
25.4
Primary/secondary school
217
38.7
High school/some university
151
27
University graduate and above
50
8.9
Fathers occupation
Skilled
187
33.4
Semiskilled
217
38.7
Unskilled
126
22.5
Retired
14
2.5
Student
16
2.9
Mothers occupation
Skilled
29
5.2
Semiskilled
54
9.6
Unskilled
2
0.4
Housewife
436
77.9
Student
39
6.9
Number of children(range 1-15, mean 4)
1
99
17.7
2-3
195
34.8
4-5
126
22.5
140
25
6

temperatures refer either to the true rectal measurement or

its rectal equivalent. Twenty-six percent of the parents
considered body temperatures of less than 38.0C to be
fever, 30% considered 38.0C to be fever, and 26% did not
know the definition of fever. A dangerous fever was said to
be a temperature of 40.0C or less by 67% of parents, and
39.0C or less by 33%. Approximately 23% of all parents
thought an untreated fever could keep rising to 42.0C or
higher, 2% responded that the body temperature could
climb to 50.0C and 0.4% believed that untreated fever
could soar to 100.0C.

Annals of Saudi Medicine, Vol 20, Nos 3-4, 2000

203

AL-EISSA ET AL

TABLE 2.
Variable

Parental knowledge and attitudes about fever.

Number

Minimum temperature considered as fever (range, 30.0-41.0C)

14
<37.0C
132
37.0-37.9C
166
38.0C
92
38.1-39.0C
13
>39.0C
Unknown
143
Temperature considered as high fever (range, 35.0-50C)
47
<38.0C
144
38.0-39.0C
168
39.1-40.0C

%
2.5
23.6
29.6
16.4
2.3
25.5
8.4
25.7
30

39
7
40.1-41.0C
20
3.6
>41.0C
Unknown
142
25.3
How high could temperature go without treatment (range, 37.0-100.0C)
22
3.9
<40.0C
134
23.9
40.0-40.9C
69
12.3
41.0-41.9C
96
17.1
42.0-43.9C
33
5.9
>44.0C
Unknown
Threshold temperature for giving an antipyretic
<38.0C
38.0-39.0C
39.0C
Unknown
Threshold temperature for bathing/sponging
<38.0C
38.0-38.9C
39.0-39.9C
40.0C
Unknown

206

36.8

26
141
47
346

4.6
25.2
8.4
61.8

17
72
71
56
344

3
12.9
12.7
10
61.4

TABLE 3. Parental conceptions of principal complications of fever.

Complication
Number
%
Death
103
18.4
Brain damage/stroke
201
35.9
Convulsions
388
69.3
Loss of consciousness
194
34.6
Dehydration
105
18.8
Weight loss
86
15.4
Blindness
18
3.2
Serious illness
157
28.1
No response
26
4.6

Table 2 shows that less than 5% of all parents would

give antipyretic medications for body temperatures less
than 38.0C (i.e., possibly normal body temperature). About
25% advocated treatment for body temperatures of 38.0 to
39.0C, and less than 10% felt that body temperatures of
39.0C and more should be treated. Surprisingly, 67% of
the surveyed parents could not determine the minimum
body temperature for initiation of antipyretic medications.
Approximately 13% of parents stated they would bathe or

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Annals of Saudi Medicine, Vol 20, Nos 3-4, 2000

sponge their child if the temperature reached 38.0 or

38.9C, and an additional 13% would do the same if it
reached 39.0 to 39.9C. Only 10% of respondents indicated
their readiness to bathe or sponge their child if the body
temperature reached 40.0C or more. About 61% of parents
did not know the threshold body temperature for bathing or
sponging their febrile child.
Table 2 shows that 95% of parents believed fever can
cause harm, and 18% believed it could cause death.
Specific types of damage feared included convulsions
(69%), brain damage and stroke (36%), coma (35%),
serious illness (28%) and blindness (3%).
No significant differences in patterns of response to
questions were found among parents with regard to their
sociodemographic features such as educational level,
occupation or family size.
Discussion
The randomly selected survey parents represented a
broad demographic, cultural and socioeconomic spectrum.
They were surveyed at the time when their children were
febrile, and not when they were well. It might be argued
that parents anxiety and misunderstanding would be
exaggerated by the development of fever in their children,
and that their real fears and misconceptions would be
overestimated. However, our concern was with the
potential consequences of parents attitude when their
children actually developed a fever. Hence, it is more
relevant, in our view, to survey parents of febrile children
rather than a general poll of parents of well children,
because the opinion of the latter is of little practical
importance, as shown in a previous study.3 The results of
this study can be applied to all parents in our Saudi
community and are in agreement with the findings of other
studies in the developed countries.1,5 These findings
confirm the fact that parental misconceptions about fever
are common worldwide.6 Such misconceptions can lead to
inappropriate treatment and potential overutilization of
healthcare services.
In this study, parents showed little understanding of the
normal range of body temperature and individual diurnal
variation, and as well demonstrated inadequate knowledge
of what actually constitutes a fever or high fever. We were
also surprised that parents of high socioeconomic status and
those with many children and, therefore, with previous
experience with fever, were not different in terms of
knowledge of fever from parents of lower socioeconomic
background and limited previous experience. It seems that
healthcare providers have not done enough in educating
parents in this basic information.
The definition of normal body temperature is complex.
DuBois found the normal ranges of body temperature for
children to be from a low of 36.2C to a high of 38.0C
when measured rectally, and from 36.0C to 37.4C when
taken orally.7 The maximum body temperatures for children

PARENTAL PERCEPTIONS OF FEVER

occur between 5 and 7 p.m., and the minimum temperatures

occur between the hours of 2 and 6 a.m. Hence, it is not
unusual for an active normal childs temperature to be as
high as 38.0C rectally in the late afternoon. A rise in
temperature above 38.0C may also be caused by physical
exercise, warm clothing, hot or humid weather, or warm
food/drinks.2 Such external factors should be eliminated
before measuring the temperature.
Fever is defined as a temperature above the normal
range. A rectal temperature of 38.0C or more, an oral
temperature of 37.5C or more, and an axillary temperature
of 37.2C or more, are all considered fever.2,8 About 25% of
the study parents identified fever as a temperature of 37.9C
or less, and another 25% did not know the temperature
level that constituted a fever.
Although the definition of high fever is arbitrary (i.e.,
>40.0C), 67% of the parents defined high fever as 40.0C
or less. Also of great concern is the misconception on the
part of 25% of study parents who indicated that untreated
fever could reach 42.0C and above, and those parents who
did not know the effects of untreated fever. With these
misconceptions of fever, it is not surprising that parents
would treat fever aggressively. An analysis of temperature
charts during febrile illnesses before the advent of
antimicrobial therapy showed that peak temperatures
almost never exceeded 41.1C.7
Hyperpyrexia is defined as a temperature of 41.0C or
greater. Fevers of this magnitude are rare. Tomlinson
reported temperatures of higher than 41.1C in only two
children in his study on high fevers in ambulatory patients
during 13 years of private pediatric practice.9 McCarthy
and Dolan found only 100 children with temperatures of
41.1C or higher among 210,000 consecutive patients over
an eight-year span,10 an incidence of only 0.05%.
The body temperature is controlled by a thermoregulatory center in the hypothalmus via a complex
feedback system.11 This hypothalmic thermostat, if
uninfluenced by complicating circumstance (e.g., heat
stroke or drugs), seems to exert a shutoff valve
phenomenon so that high temperatures are generally kept
below a level that would seriously damage body tissues.
Most temperatures above 41.1C in children are due to
human errors from excessive heat load or from interference
with heat loss. Examples are wrapping a febrile child in too
much clothing or blankets, placing a baby near a heat
radiator, or placing a child in a car in direct sunlight.1 Too
much clothing is more dangerous during a heat wave in
tropical countries.12 Children uncommonly develop
hyperpyrexia (temperatures of 41.1C or greater) because of
central nervous system infections, namely meningitis,9,13
and cerebral malaria,14 underlying structural brain defects
such as Down syndrome or hydrocephalus, and brain
tumor.13
Our study showed that parents were overly concerned
about the harmful effects of fever. The type of harm that

parents thought their children would suffer from fever were

varied, and included convulsions, brain damage or stroke,
coma, dehydration, blindness and death. The same fears
were found among parents in other previous studies.1,3 The
adverse effects of fever include discomfort, mild
dehydration, febrile delirium and uncomplicated seizures.
Heat stroke, a catastrophic circulatory failure characterized
by hyperpyrexia, delirium, coma and anhidrosis, rarely
occurs in children, and is mostly caused by environmental
factors such as overheating or too much clothing.2,15
Although febrile convulsions are terrifying to parents, they
carry no risk to subsequent neurologic or developmental
disabilities.16
This study indicates that child health care providers
have apparently not done enough in educating parents
about fever and its consequences, and considerable efforts
will be required to correct such parental misconceptions.
Health education is all too often given short shrift in the
busy ambulatory care setting. The harried clinician is
frequently so pressed that the delivery of health information
is abbreviated and perfunctory. When these cursory
instructions fall on the ears of an anxious mother distracted
by a screaming child, the efforts become almost futile. Use
of well-designed health education aids that present
information in a clear, consistent and entertaining manner
would be more effective. Hence, an audio-visual health
education message on fever would be superior to the
written material containing the same information.
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