Scandinavian Journal of Primary Health Care, 2010; 28: 115120

ORIGINAL ARTICLE

Paracetamol for feverish children: parental motives and experiences

JANNE FANGEL JENSEN, LOUISE LINDHARDT TNNESEN, MARGARETA SDERSTRM, HANNE THORSEN & VOLKERT SIERSMA
The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Denmark

Abstract Objective. The sale of paracetamol products for children is increasing, and more children are accidentally given overdoses, even though the use of paracetamol against fever is still under discussion. This study explores Danish parents use of paracetamol for feverish children and their motives for this use. Design. A cross-sectional survey using structured interviews. Setting. Four general practices located in city, suburb, and rural area. Subjects. A total of 100 Danish parents with at least one child under the age of 10 years. Main outcome measures. Number of parents administering paracetamol to feverish children, situations triggering medication of a child, parental views regarding fever and effects of paracetamol, and sources of information on fever treatment. Results. Three in four parents use paracetamol for feverish children, mainly to reduce temperature, to decrease pain, and to help the child fall asleep. Highly educated parents medicate more often than less educated. Parents often fear fever but this does not clearly affect their use of paracetamol. Many parents believe in perceived benecial effects of paracetamol, such as increased appetite and well-being, better sleep, and prevention of fever seizures. These expectations of paracetamol inuence parental use of the drug. Parents main source of information on fever and paracetamol is their general practitioner (GP). Conclusions. Danish parents regularly treat feverish children with paracetamol. Although parents contact their GP for advice on fever treatment, paracetamol is sometimes given to children on vague indications. Clearer information for parents on when to give paracetamol as fever treatment may help regulate its use. Key Words: Antipyretic, children, family practice, fever, gender, paracetamol, parents, primary healthcare

Fever is a common symptom in childhood and a frequent reason for parents to contact their general practitioner (GP) [1]. Antipyretics are widely used for treating feverish children [25]. In Denmark, the most common antipyretic substance for children is paracetamol. The sale of child-friendly paracetamol products, i.e. suppositories and mixtures, has increased 23% in the last ve years (55.968.4 dened daily doses (DDD)/1,000 inhabitants/year) [5,6]. Paracetamol is considered a safe drug when taken in prescribed doses; however, overdosing may cause liver failure and death. Recent studies also show that intoxication in children happens after repeated doses only slightly above recommendations [7]. The number of Danish children (aged 011 years) hospitalized with paracetamol or acetylsalicylic acid (ASA) poisoning has increased from 23 in 1997 to 81 in 2006 [8]. The use of paracetamol against fever is still under discussion [9,10]. Fever involves discomfort; however,

the rise in body temperature is believed to assist the immune response against infection [11,12]. A minority of children experience fever seizures; these are often frightening to parents, but today if shortlasting they are considered benign [13]. Paracetamol has shown to be an effective analgesic and antipyretic; however, it is still unclear if the drug increases the well-being, the sleep, or the appetite of a feverish child [1416]. Paracetamol has not yet proved effective in preventing fever seizures [13,17,18]. Conversely, no studies have documented a positive effect of not giving paracetamol to feverish children. NICE guidelines recommend use of paracetamol mainly in cases of fever and discomfort or pain [19]. Internationally, numerous parents regularly give paracetamol against fever [2,3,20]. The most frequent reason for giving the drug to a feverish child is simply to lower the temperature. Some parents believe that paracetamol relieves their children of

Correspondence: Janne Fangel Jensen, Department of General Practice, Institute of Public Health, University of Copenhagen, ster Farimagsgade 5, Bygning 24 Q, Postbox 2099, 1014 Kbenhavn K, Denmark. E-mail: [email protected] (Received 5 December 2008 ; accepted 14 April 2010 ) ISSN 0281-3432 print/ISSN 1502-7724 online 2010 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS) DOI: 10.3109/02813432.2010.487346

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J. F. Jensen et al. tried out on 15 parents, who commented on the interview. All pilot interviews were audiotaped and the interview guide was continuously revised until clarity and simplicity of each item was obtained. The interview guide contained an introduction and 47 items. Twelve items collected background information of the parents (e.g. age, number and age of children, education and experience with a sick child). Thirteen items covered the use of paracetamol, seven items asked about fever phobia, and another seven about the parents expectations of paracetamols effects. Eight items addressed the parents sources of information on childhood fever.

The sale of child-friendly paracetamol products is increasing in Denmark, even though use of paracetamol as treatment of fever is still being debated. Parents give paracetamol to improve wellbeing, appetite, and sleep of feverish children research only vaguely supports this use. Highly educated parents medicate more often than less educated. Danish parents main source of information concerning fever and its treatment is their general practitioner.

discomfort, and gives them more appetite and energy. [3,20,21]. Additionally, paracetamol may be a way of coping with a sick child in a busy daily life [20]. Some parents fear that fever might harm their child by causing seizures, brain damage, and even death, if the temperature is high or rapidly rising. This unrealistic fear, termed fever phobia, may be linked to the wide use of antipyretics among parents [2224]. For some parents fever is considered the disease in itself, and paracetamol is believed to cure the child [20]. This study aimed at exploring: 1. to what extent and in which situations parents give their children antipyretics; 2. if parental views of the effects of paracetamol are consistent with existing evidence, and if their views inuence the use of the drug; 3. if fever phobia is present among parents and if it motivates them to give paracetamol; 4. where parents seek information on handling a feverish child. Material and methods This study was carried out as a cross-sectional interview survey. Population Danish parents with at least one child under the age of 10 years, recruited in four general practices during April and May 2008. Parents who did not understand Danish were excluded. Interview guide A structured interview guide was developed from international surveys [3,24,25]. A test version was

The interviews The interviews were conducted by JFJ and LLT in four general practices: one located in the centre of Copenhagen, one in a Copenhagen suburb, and two in a rural area. These practices were selected because of diversity in location, and because the authors had personal connections with the general practitioners. The interviewers stayed in the waiting rooms and asked all eligible parents who appeared with or without children to participate. Interviews were carried out in the waiting room or an examination room, and took approximately 15 minutes. The interviewers read aloud the interview guide in a neutral tone, and the participants replied to one item before moving on to the next. In items with several response options the parents were shown cards including all possible answers. Furthermore, they were presented with pictures of all available antipyretics for recognition.

Statistics Differences in characteristics of the parents between practice locations were assessed by chi-squared tests and KruskalWallis tests. Fever phobia was dened as partly or fully agreeing with one or more of the items concerning harmful effects of fever (see Table IIIA, items labelled with ). Associations between views regarding fever phobia and expectations of paracetamol and whether the parents had ever given paracetamol to a child, and associations between education and information sources were assessed with chi-squared tests. In the former, the original ve-category Likert scale was transformed into a three-point scale prior to the analyses. Associations between having given paracetamol to a feverish child and six social variables were assessed in logistic regression analyses, both unadjusted and adjusted for the other ve variables.

Paracetamol for feverish children Ethical considerations According to Danish rules interview surveys do not need approval by the Ethics Committee and all participants remained anonymous. No personal data were collected except for gender, age, and number of children. Results In total 104 parents were asked to participate and 100 accepted. Reasons for not participating were lack of time, a sick child, and unwillingness. Parents in the city and suburb had a higher education and fewer children compared with parents in the rural area (Table I). Of the 100 parents 75 had ever given antipyretics to their feverish child. During the last three months 61 parents had administered antipyretics to one or more of their children; 58 parents gave paracetamol only, two gave paracetamol and ibuprofen, and one gave paracetamol and ASA. In 66% of cases the drug was given to reduce fever, while 54% of the children received the drug against pain. The decision to give the child paracetamol was made by the mother in 49 cases and by both parents in 47 cases. Only four parents replied that the father decided whether to medicate or not. The situations where most parents would give paracetamol were if the fever was high, or if the child experienced pain or needed to sleep (Table II). However, 18 parents reported never administering paracetamol to a child before consulting a doctor, irrespective of symptoms. The parents views on the role of fever in children are presented in Table IIIA. In total, 85 parents met

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the denition of fever phobia. Three in four parents believed that a very high fever can be harmful to a child, and a larger proportion of these parents had given paracetamol to their feverish child compared with parents not perceiving fever as harmful, 79% and 46% respectively, p 0.036. For the remaining items regarding fever phobia there was no signicant association between fear of fever and use of paracetamol (Table IIIA). Parental views of paracetamol were that their feverish child felt better, became more alert, and slept easier after taking paracetamol. However, the majority of the parents disagreed that paracetamol results in a faster recovery. Signicantly more parents convinced of perceived benecial effects of paracetamol had ever given the antipyretic to a feverish child, compared with parents of the opposite opinion (Table IIIB). Highly educated parents and parents who used paracetamol themselves against fever gave paracetamol more often than parents with less education and non-users of paracetamol (Table IV). The GP was the most common source of information on how to treat fever. In total 92% contacted their GP for advice when their child had a fever. Highly educated parents found information in books (74% vs. 42%, p 0.001) and on the internet (74% vs. 47%, p 0.005) more often than less educated parents who instead asked their own parents for advice (62% vs. 43%, p 0.049).

Discussion This study shows that in Denmark parents often use paracetamol to treat feverish children. The drug is

Table I. Characteristics of the 100 interviewed parents stratied on practice location. Parents Age, years; average (minmax) Mothers, n (%) Fathers, n (%) Single parent, n (%) With partner, n (%) Number of children, average(minmax) Highly educated,2 n (%) Less educated,2 n (%) Has experienced fever seizure, n (% ) Has experienced an acutely ill child,3 n (%) Has a chronically ill child,4 n (%) Uses antipyretics themselves, n (%) Total (n 100) 33.5 82 18 14 86 2.2 (1855) (82.0) (18.0) (14.0) (86.0) (18) City (n 45) 34.2 34 11 4 41 1.7 (2255) (75.6) (24.4) (8.9) (91.1) (14) Suburb (n 19) 33.2 17 2 2 17 2.1 (2749) (89.5) (10.5) (10.5) (89.5) (13) Rural area (n 36) 31 5 8 28 2.8 32.8 (86.1) (13.9) (22.2) (77.8) (18) p-value1 0.979 0.302 0.203 0.008 0.000 0.130 0.064 0.084 0.370

47 (47.0) 53 (53.0) 14 (14.0) 18 (18.0) 19 (19.0) 59 (59.0)

32 (71.1) 13 (28.9) 3 (6.7) 9 (20.0) 6 (13.3) 30 (66.7)

9 (47.4) 10 (52.6) 3 (15.8) 0 (0.0) 2 (10.5) 10 (52.6)

6 (16.7) 30 (83.3) 8 (22.2) 9 (25.0) 11 (30.6) 19 (52.8)

Notes: 1Differences between the locations are assessed by chi-squared tests or KruskalWallis tests. were divided into two groups of education: highly educated parents had a university degree (bachelor or higher) or were studying for such the remainder of the parents were dened as less educated. 3An acutely ill child was dened as a child who at any time had experienced a potentially life-threatening acute illness. 4A chronically ill child was dened as a child who received medications for his/her condition at least three months within a year.
2Parents

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Table II. Parents responses (out of 100 respondents) to the question: Would you give your child paracetamol in the following situations, before contacting a doctor? Medication when fever reaches 38C The The The The The The The child child child child child child child has has has has has has has a a a a a a a fever fever, is drowsy, and you are unable to uphold contact fever and doesnt eat and drink fever and needs to sleep fever, feels pain fever, and needs to attend kindergarten fever and needs to attend a family arrangement 6 19 20 26 72 3 12 39C 30 32 31 41 69 1 7 40C 37 32 32 40 57 0 2 No medication 50 60 59 48 23 95 87

more frequently used by highly educated parents compared with less educated, and it is most common to medicate to reduce a high temperature, to decrease

pain, to increase appetite, and to help the child fall asleep. More than 90% of parents contact their doctor for advice about feverish children; however, their

Table III. Distribution of views (agrees, neutral, and disagrees) on 14 statements regarding fever phobia and effects of paracetamol in feverish children, and percentage of parents within each view group who have given paracetamol to a child at any time. Agrees (partly/fully) % of these who have given paracetamol 73.6 79.2 Neutral2 % of these who have given paracetamol 80.0 80.0 Disagrees (partly/fully) % of these who have given paracetamol 100.0 46.2

n A: Fever is the bodys reaction to an illness A very high fever may harm3 children, and should be reduced A very high fever may cause boiling of the child, and should be reduced A very high fever may cause brain damage in children, and should be reduced A very high fever may worsen the illness of the child A child can more easily ght a disease without the fever Fever helps in ghting the disease, and should NOT be reduced B: When a child has a fever and receives paracetamol the child has a faster recovery the child feels better the child has more appetite the child is more eager to drink the child is more alert the child sleeps easier the medication prevents fever seizures
1These

n 5 10

n 4 13

p-value1 0.474 0.036

91 77

58

74.1

16

81.3

26

73.1

0.816

34

76.5

35

77.1

31

71.0

0.821

24

70.8

25

84.0

51

72.5

0.481

21

71.4

27

74.1

52

76.9

0.879

47

76.6

16

75.0

37

73.0

0.930

16 89 45 41 78 86 41

87.5 73.0 86.7 78.0 79.5 77.9 87.8

10 4 27 34 9 8 46

80.0 100.0 70.4 76.5 44.4 75.5 67.4

74 7 28 25 13 6 13

71.6 85.7 60.7 68.0 62.2 33.3 61.5

0.383 0.378 0.036 0.639 0.062 0.051 0.044

Notes: Parents agreeing with one or more of the items labelled with were dened as fever phobic (n 85). relationships are assessed with a chi-squared test of which the p-value is listed. 2The neutral group includes all parents responding Do not know and Neither agrees, nor disagrees. 3Harm is dened as danger associated specically with the rise in temperature.

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Table IV. Logistic regression on whether the parents have given paracetamol to a child at any time. Reported are unadjusted and adjusted odds ratios (OR), with 95% condence intervals (CI), of six selected social variables. The reference group for the OR estimate is the underlined category. Unadjusted OR Education, (High/Low) Experience with an acutely ill child2, (Yes/No) Experience with a chronically ill child, (Yes/No) More than one child (Yes/No) Location (Rural area/City or suburb) Parent takes antipyretics him/herself (Yes/No)
1The 2An

Adjusted1 95% CI 0.96.0 0.43.1 0.44.4 0.64.1 0.64.4 1.49.2 OR 4.42 0.59 1.23 0.88 4.46 4.77 95% CI 1.414.3 0.21.9 0.34.8 0.32.7 1.216.9 1.614.4

2.30 1.14 1.31 1.61 1.62 3.56

OR is adjusted for all other social variables in this table. acutely ill child includes a child with fever seizures, or who has been admitted to a hospital with an acute illness.

ideas about fever and paracetamol resemble those found in international studies [3,20,23,24]. Some parents fear that fever may harm their child, by causing boiling or brain damage. The majority believe that paracetamol improves the well-being of a feverish child. It is interesting that while paracetamol is widely used for feverish children in Denmark, and the general opinion among parents is that the drug greatly benets their child, research does not yet fully support this use. This discrepancy may be due to insufcient research, as to our knowledge only two placebo-controlled studies exist investigating the well-being of feverish children [14,16]. Our material may not entirely represent the population of Denmark, because our data were collected in general practices, and some parents see their GP more often than others for advice. However, because of the Danish child examination programme, all children (and their parents) see a GP regularly in their rst years. Our ndings regarding parental use of paracetamol for feverish children are consistent with international studies [2]. Giving ibuprofen and alternating between drugs when treating fever is not yet common in Denmark [3,4]. Fever phobia seems to be present among parents in Denmark. However, in creating our interview guide we found it difcult to distinguish between fever phobia and the reasonable concern that a child is seriously ill. This problem in dening and delimiting fever phobia has not yet been addressed, and may have inuenced our results. Surprisingly, we did not nd a clear association between fever phobia and use of paracetamol. Parents who fear fever might react by contacting their doctor for reassurance instead of giving paracetamol [26]. Thus, the information given by the GP seems important. In our study, parents own use of paracetamol was correlated with giving the drug to their child. This nding is consistent with a previous study regarding prescription drugs for young children and their mothers [27]. It may also be related to gender aspects

on medicating, as the majority of our respondents were women. Women have been shown to medicate more often than men [28], and this could inuence the inclination to give their child medicine as well [29]. However, for half of the women the decision to give their child paracetamol was made in agreement with their partner. Our results may indicate that parents medicating habits to some extent pass on to their children. This is, however, speculative. The increasing use of paracetamol for children may have numerous explanations. An obvious cause is easier access to over-the-counter drugs and public advertising. The current view among parents that paracetamol improves the well-being of feverish children may also motivate them to give the drug. Moreover, the attitude towards illness in general seems to be changing in Western societies. Illness is often considered an inconvenience in our daily lives [30], and there is not always room for feverish children. Reducing the fever with paracetamol may lessen the burden of a sick child. Perhaps highly educated parents with long working hours have more difculty prioritizing a sick child. This study does not give exact gures of paracetamol use in children and it cannot tell if children in Denmark receive too much paracetamol. However, our results show that paracetamol is sometimes given on vague indications, i.e. to reduce fever when a child is otherwise well, or to improve the childs appetite and sleep or prevent fever seizures, even though evidence of these effects is still unclear. Thus, the NICE recommendations [19], to give paracetamol only in case of pain or discomfort, are disregarded, or unknown to many parents in Denmark. In some cases paracetamol may work mainly by relieving parents of their worries. Furthermore, this study suggests that information given by GPs inuences parents paracetamol use. Some Danish GPs may also need an update on recommendations regarding use of paracetamol, to give parents appropriate advice. The current knowledge

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[13] Uhari M, Rantala H, Vainionp L, Kurttila R. Effect of acetaminophen and of low intermittent doses of diazepam on prevention of recurrences of febrile seizures. J Pediatrics 1995;126:9915. [14] Gupta H, Shah D, Gupta P, Sharma KK. Role of paracetamol in treatment of childhood fever: A double-blind randomized placebo controlled trial. Indian Pediatrics 2007;44:90311. [15] Meremikwu M, Oyo-Ita A. Paracetamol for treating fever in children. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No. CD003676. DOI:10.1002/14651858. CD003676. [16] Kramer MS, Naimark LE, Roberts-Bruer R, McDougall A, Leduc DG. Risks and benets of paracetamol antipyresis in young children with fever of presumed viral origin. Lancet 1991;337:5914. [17] Watts R. Robertson J, Thomas G. Nursing management of fever in children: A systematic review. Int J Nurs Pract 2003;9:18. [18] Schnaiderman D, Lahat E, Sheefer T, Aladjem M. Antipyretic effectiveness of acetaminophen in febrile seizures: Ongoing prophylaxis versus sporadic usage. Eur J Pediatrics 1993;152:7479. [19] Richardson M, Lakhanpaul M. Assessment and initial management of feverish illness in children younger than 5 years: Summary of NICE guidance. BMJ 2007;334:11634. [20] Lagerlv P, Helseth S, Holager T. Childhood illnesses and the use of paracetamol (acetaminophen): A qualitative study of parents management of common childhood illnesses. Fam Pract 2003;20:71723. [21] Lagerlv P, Loeb M, Slettevol J, Lingjerde O, Fetveit A. Severity of illness and the use of paracetamol in febrile preschool children: A case simulation study of parents assessments. Fam Pract 2006;23:61823. [22] Crocetti M, Moghbeli N, Serwint J. Fever phobia revisited: Have parental misconceptions about fever changed in 20 years? Pediatrics 2001;107:124146. [23] Walsh A, Edwards H. Management of childhood fever by parents: Literature review. J Adv Nurs 2006;54:21727. [24] Karwowska A, Nijssen-Jordan C, Johnson D, Davies HD. Parental and health care provider understanding of childhood fever: A Canadian perspective. Pediatr Emerg Med 2002;4:394400. [25] Kelly L, Morin K,Young D. Improving caretakers knowledge of fever management in preschool children: Is it possible? J Pediatr Health Care 1996;10:16773. [26] Ertmann RK, Sderstrm M, Reventlow S. Parents motivation for seeing a physician. Scand J Prim Health Care 2005;23:1548. [27] Rasmussen F, Smedby B. Physician visits and prescribed drugs among young children and their mothers. Scand J Prim Health Care 1987;5:22531. [28] Obermeyer CM, Schulein M, Hardon A, Sievert LL, Price K, Santiago AC, et al. Gender and medication use: An exploratory, multi-site study. Women Health 2004;39:5773. [29] Rasmussen F, Smedby B. Physician visits and prescribed drugs among young children and their mothers. Scand J Primary Health Care 1987;5:22531. [30] Fugelli P. The zero-vision: Potential side effects of communicating health perfection and zero risk. Patient Educ Couns 2006;60:26771.

among GPs regarding childhood fevers and their treatment is worth exploring in future studies.

Acknowledgements The survey was funded by a grant from Praktiserende Lgers Udviklingsfond (PLU). Thanks are offered to the four GPs who provided the interview locations. Declaration of interest: The authors report no conicts of interest. The authors alone are responsible for the content and writing of the paper.

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