Are Helicopter Parents to Blame for Excessive ED Visits?

It is after midnight and the preschooler running around your ED is showing considerably more energy than you feel as you step in the room to talk to his parents. Your general rule: Children who are difficult to catch and examine are unlikely to be seriously ill. You’re fairly certain this belief is going to be confirmed.

But then again, do you really know for sure? The child is an otherwise healthy, fully-immunized two-year-old boy, and the reason the parents came to the ED in the middle of the night was that this evening, when they checked on him, he felt warm and his rectal temperature was 39°C, for which he was given ibuprofen. When you ask why they came to the ED, they look at you with complete surprise. “Obviously,” they say, “his pediatrician’s office isn’t open at night.” “But why,” you reply, “do you feel your generally healthy little boy needed to be seen right away?” Their answer: “Because he has a fever!”

The Cost: Billions of Dollars Annually 
Just about everyone who practices emergency medicine has seen this scenario. In 1980, Schmitt coined the term fever phobia to describe the widely held belief that fever was a serious threat in and of itself, and could cause serious harm to otherwise healthy children. Fever phobia remains highly prevalent. Fever is the most common reason for Urgent Care and ED visits by children in the United States, costing billions of dollars annually.

ADVERTISEMENT

Fever is defined by most practitioners as a rectal temperature > 38 degrees. It is a part of the body’s inflammatory response and may play a role in the fight against infection, although the potential benefits of fever are still under investigation. In a normal, healthy child the only adverse outcome of fever is discomfort. There is no evidence that the failure of the temperature to return to normal after antipyretic therapy is a marker for more severe disease.

Parental Involvement
What parents think about fever is a different story. In 2006, Betz and Grunfeld published a survey of 264 parents and guardians in an affluent, urban ED setting in the United Arab Emirates. In this study one-third of the respondents felt that a temperature < 37.9 should be treated with antipyretics. 82 % were “very worried” about fever, 24% thought it could cause brain damage, 19.4% thought it could cause seizures and 5.3% that it could cause death.

A survey published in 2010 by Rupe, Ahlers-Schmidt and Wittler looked at fever beliefs in a US hospital-based clinic for the underserved. 348 caregivers were analyzed. Two-thirds believed that a fever would continue to rise unless treated with antipyretics. 40% believed that a fever itself could cause death. 57% were “very worried” about fever. Interestingly, in a logistic regression model Hispanic ethnicity was found to be the strongest predictor of a higher level of concern about fever. About 30% of this study’s respondents were Hispanic.

ADVERTISEMENT

Yet another ED-based survey was published in 2010 by Poirier, Collins and McGuire. In this US based ED setting, 230 caregivers were administered a questionnaire by a research assistant. The median temperature the respondents defined as a fever was 37.8 degrees (so, half of them defined fever below that number). 73% were very concerned about the harmful effects of fever, 88% were very concerned when a fever was not reduced by antipyretics although 40% did not give antipyretics correctly.

Waking Children from Deep Sleeps
Of these caregivers, more than three-quarters of them (77%) reported that they would wake a child from sleep to give antipyretics. A third (32%) took a child’s temperature every hour or more frequently. The median temperature they reported to contact their pediatrician was 38.3 degrees and to go to the ED 39.4 degrees. Most (81%) reported they would take a child to the ED with fever. The study reported lesser levels of concern among caregivers with higher levels of education.

In 2014, Teagle and Powell published a study of fever beliefs in Welsh parents at a hospital-based assessment clinic. In this study again, a majority of parents were concerned about dehydration or seizures from a fever, and almost a third feared brain damage, coma or death. A study published by Wallenstein and colleagues in 2012 looked at fever beliefs in approximately 100 caregivers in two clinics in California. 81% defined the threshold for fever as below 38 degrees. 93% believed a high fever could cause brain damage. 59% would treat with antipyretics a well-appearing child with a temperature between 37.4 and 37.8 and 38% would schedule a clinic appointment for that child.

ADVERTISEMENT

In 2016, Gunduz, Usak, Koksal, and Canbal surveyed caregivers in hospital-based clinics in Turkey. Their study also showed a majority of caregivers were highly anxious about fever and seizures with a number concerned about brain damage and death.

The above are only a smattering of the articles describing fever phobia around the world. An interesting take on the problem was a review and meta-analysis published by Purssell and Collin in 2016. These authors looked at 40 studies of fever phobia from across the globe. They were looking for geographic patterns in the prevalence of fever phobia. They also wanted to see if the level of fear corresponded to child mortality < 5 years of age. What they found is that fever phobia is very common throughout the world and cannot be explained by geography or child mortality.

The American Academy of Pediatrics reviewed the problem in a clinical report published in 2011. They reiterated that the purpose of treating a fever in an otherwise normal child is to improve their overall comfort. Reducing fever does not impact morbidity or mortality from febrile illness in such children and there is no evidence that antipyretics reduce the recurrence of febrile seizures. They pointed out that up to half of parent’s dose antipyretics incorrectly. And while alternating acetaminophen and ibuprofen was noted to be more effective in reducing temperature they counseled against the practice on the grounds that it is more error-prone, promotes fever phobia and is generally unnecessary.

Febrile seizures are the most common seizure disorder in childhood. There appears to be some genetic predilection. They have a very good prognosis and do not affect later cognitive function. They can recurr but resolve by 5-6 years of age. Because they typically come on at the onset of fever, antipyretics do not prevent the majority of febrile seizures.

ADVERTISEMENT

So let’s go back to our active and playful two year-old patient. Your examination confirms no source for infection on physical exam. As a healthy and vaccinated preschooler, his chances of serious occult bacterial infection are low and no labs or studies are indicated. You can give general advice about viral infections and return precautions. But have you addressed adequately the fever phobia that brought him into the ED in the first place?

Practical Recommendations for Emergency Physicians

1. Make sure to explain to the parents the physiologic function of a fever, using understandable terms like “it helps the body fight infection.”
2. Explain that fevers are not dangerous by themselves. Every healthy, normal child will get a fever from time to time. They are generally benign. Fevers do not cause brain damage or death. While some children do get febrile seizures, giving antipyretics won’t stop this and febrile seizures are also generally benign.
3. Make sure the family knows what constitutes a fever (temperature > 100.4F).
4. Make sure the family know the proper dose of acetaminophen or ibuprofen for the child.
5. It is not necessary to treat every fever. It is only for the child’s comfort. Don’t wake them up to treat them or follow them around constantly checking their temperature. It is the appearance of the child, the accompanying signs or symptoms and the duration of the illness, not the fever itself that are important.
6. It may be reasonable for a child that has had fever for more than 72 hours to see their physician. Hyperpyrexia, or temperature over 105.8F is associated with an increased risk of severe infection and should be seen.
7. You might also make sure you are not inadvertently promoting the fever phobia. Does your ED treat every elevated temperature, no matter how mild or how the child looks? Do you insist that the child is unstable for discharge if there is a fever present? Do you concoct elaborate regimens for alternating antipyretics when they are not needed and may just increase the risk of medication error? If you do any of those things, you are treating the fever as a serious problem to be avoided at all costs. If the doctors and nurses seem worried about fever, the parents will pick that up. So stamping out fever phobia has to include changing our own practices.

REFERENCES

1. Schmitt BD. Fever phobia: misconceptions of parents about fevers. Am J Dis Child. 1980;134:176-181.
2. Williams RN. The costs of visits to emergency departments. N Eng J Med. 1996;334:642-646.
3. Kliegman RM, Stanton BF, Geme JW, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th edition. Philadelphia, PA:Elsevier/Saunders;2001.
4. Ward MA, Edwards MS, Torchia MM. Fever in infants and children: pathophysiology and management. Uptodate, downloaded 10/30/2016.
5. Betz MG, Grunfeld AF. ‘Fever phobia’ in the emergency department: a survey of children’s caregivers. Eur J of Emerg Med. 2006;13:129-133.
6. Rupe A, Ahlers-Schmidt CR, Wittler R. A comparison of perceptions of fever and fever phobia by ethnicity. Clin Peds. 2010;49(2):172-176.
7. Poirier MP, Collins EP, McGuire E. Fever phobia: a survey of caregivers of children seen in a pediatric emergency department. Clin Peds. 2010;49(6):530-534.
8. Teagle AR, Powell CVE. Is fever phobia driving inappropriate use of antipyretics? Arch Dis Child. 2014;99(7):701-702.
9. Wallenstein MB, Schroeder AR, Hole MK, et al. Fever literacy and fever phobia. Clin Peds. 2012;52(3):254-259.
10. Gunduz S, Usak E, Koksal T, Canbal M. Why fever phobia is still common? Iran Red Cresc Med J. 2016;18(8):e23827.
11. Purssell E, Collin J. Fever phobia:The impact of time and mortality – A systematic review and meta-analysis. Int J Nurs Studies. 2016;56:81-89.
12. Sullivan JE, Farrar HC, et al. Clinical report – fever and antipyretic use in children. Pediatrics. 2011;127:580-587.