Edward Purssell

Parental fever phobia and its evolutionary correlates.

AIMS This study aimed to identify parental views of fever in their children aged 1-6 years and to consider these and associated behaviours from an evolutionary perspective. BACKGROUND Fever is a common symptom of illness in children; however, many parents express high levels of anxiety. This has previously been reported in several countries, most notably the USA. The purpose behind this study was to look at parental views and examine these from an evolutionary perspective to explain the persistence and ubiquity of parental fears of fever. METHOD A questionnaire was administered to 181 parents of children attending a paediatric outpatients department at a London teaching hospital. RESULTS Many parents expressed high levels of worry and its possible complications. These manifest themselves in the frequency with which parents measured their childs temperature, and the aggressive nature of their treatment. Many reported over-using antipyretic drugs, or using non-evidence based practices such as sponging. However, in many cases they were also making appropriate behavioural alterations, for example, encouraging fluids and rest. CONCLUSION While many parents expressed high levels of worry about fever and used inappropriate treatments, this must be balanced against benefits such as increased vigilance and close attention to hydration. Lay health beliefs, such as those reported in this study, may be judged unduly negatively if individual aspects are seen in isolation. RELEVANCE TO CLINICAL PRACTICE High levels of worry have been reported internationally, suggesting that they may form part of a conserved response to fever. Although many parents reported aggressive treatment of fever, they also used appropriate symptomatic interventions. Nurses and other healthcare professionals should act to reduce the fear of fever and concentrate upon accurate diagnosis and the appropriate treatment of the underlying illness.

Systematic review of studies comparing combined treatment with paracetamol and ibuprofen, with either drug alone

Objective To evaluate the evidence surrounding the use of combinations of paracetamol and ibuprofen in the treatment of fever. Design Systematic narrative review of randomised controlled trials using the UK Economic and Social Research Council guidance on the conduct of narrative synthesis. Setting Inpatient, outpatient and home care. Patients Children with fever. Main outcome measures The effect of combination treatments of paracetamol and ibuprofen on fever and comfort, and identification of side effects. Results Seven studies were identified, six of which provided useful data for the evaluation of the effect of treatment on temperature. Overall these studies showed limited benefit from the combined treatment until around 4 h, after which there was a statistically but only marginally clinically significant benefit. Two studies contained data directly relating to comfort; these suggest a marginal benefit from the combined treatment, but the clinical significance of this was limited. There was no evidence of greater side effects or toxicities associated with the combined treatment. However, it is important to note that these studies were small, short term, and not conducted in the normal setting in which these treatments are given. Conclusions There is little evidence of any benefit or harm from the combined treatment compared with the use of each drug alone. In the absence of such benefit, there is little to recommend the unnecessary use of polypharmaceutical methods to treat a symptom that does not require treatment, when effective monotherapies exist.

Physical treatment of fever

Fever is a common symptom of childhood illness, and much time and effort is spent in the pursuit of reducing high temperature. Although antipyretic drugs are the main form of treatment, this report considers the part that physical treatments might play in reducing the temperature of febrile children. Such treatments include tepid sponging, removing clothing, and cooling the environment. Of these treatments, tepid sponging has been studied most extensively, as an addition to paracetamol, but seems to offer little advantage over paracetamol alone. It is likely that other methods might be equally ineffective because they all rely on similar methods of heat loss.

Is it really theoretical? A review of sampling in grounded theory studies in nursing journals

BACKGROUND Grounded theory is a distinct method of qualitative research, where core features are theoretical sampling and constant comparative analysis. However, inconsistent application of these activities has been observed in published studies. AIM This review assessed the use of theoretical sampling in grounded theory studies in nursing journals. DESIGN An adapted systematic review was conducted. METHOD Three leading nursing journals (2010-2014) were searched for studies stating grounded theory as the method. Sampling was assessed using a concise rating tool. RESULTS A high proportion (86%) of the 134 articles described an iterative process of data collection and analysis. However, half of the studies did not demonstrate theoretical sampling, with many studies declaring or indicating a purposive sampling approach throughout. CONCLUSION Specific reporting guidelines for grounded theory studies should be developed to ensure that study reports describe an iterative process of fieldwork and theoretical development.

Does the use of antipyretics in children who have acute infections prolong febrile illness? A systematic review and meta-analysis.

OBJECTIVE To review the literature and test the hypothesis that the use of antipyretic drugs in children with acute infections slows recovery. STUDY DESIGN A systematic review and meta-analysis of the literature was undertaken to investigate the effect of antipyretic drugs upon recovery from infectious diseases in children. A search of Medline (1946 until November 2012) and EMBASE (1980 until November 1, 2012) was undertaken to identify studies in which the authors compared the use of antipyretic medications with nonpharmacologic treatments for fever. RESULTS Six papers were identified, 5 of which were included in the meta-analysis. Three studies focused on children with malaria and the other 3 considered general viral and respiratory infections and varicella. The pooled mean difference in time to fever clearance was 4.16 hours and was faster in those receiving antipyretics compared with those not (95% CI -6.35 to -1.96 hours; P = .0002). There was little evidence of statistical heterogeneity (χ(2) 4.84; 4 df; P = .3; I(2) 17%). CONCLUSION There is no evidence from these studies that the use of antipyretics slows the resolution of fever in children.

Fever phobia 35 years later: did we fail?

In this issue of Acta Paediatrica, Sahm et al. report the results of a well-designed qualitative study on the knowledge, attitudes and beliefs about fever displayed by 21 Danish parents living in Copenhagen (1). Interestingly, the parents were recruited outside healthcare settings and included a larger proportion of fathers than is usual in such studies. The authors used semi-structured interviews, which were transcribed verbatim and carefully analysed. This methodology does not allow for generalisation of the findings beyond the group studied, but does allow for more in-depth analysis of parental beliefs than the more common questionnaire-based studies. The parents that participated in the study had important fever-related concerns, but poor basic knowledge of areas such as the definition of fever. They also used numerous sources of information, but needed reassurance regarding the trustworthiness of that information from healthcare practitioners. The authors concluded that further initiatives were needed to provide accessible information to parents, including integrated educational programmes to make the switch from fever phobia to rational evidence-based management (2). The term educate should probably be used with caution and replaced by guidance. In addition, we should not forget that parents are the experts when it comes to their child and they can often be the ones educating the healthcare practitioner. The results reported by Sahm et al. are generally in line with those reported by other observational studies in the last three to four decades, both in Western countries and in those with more limited resources (2–5). However, the most important differences between the Sahm et al. study and previous findings are that parents taking part in the latest study declared that fever was actually a good thing for the body and they were reluctant to use medicine to treat fever. This notion may indicate a favourable evolution of parents’ knowledge. However, this reluctance to use medicine was in part related to inappropriate reasons, such as a concern that medication was a major cause of autism. In addition, the parent’s attitudes in real life may differ from the views they expressed during the study interviews. Has the health practitioner community failed to provide effective guidance to parents on fever management? It is difficult to objectively measure the evolution of parents’ knowledge and attitudes regarding symptomatic management of fever given the variability in design and settings among studies and/or ongoing recommendations (1–5). Some practices, such as the use of acetylsalicylic acid and steroids, have been abandoned, and some, such as a cool bath, are now used less often. However, large studies seem to indicate that fever phobia persists and antipyretic drugs are still overused (3–5). Considering that we do seem to have failed in part to provide effective guidance to parents, how did this happen? Do we agree on the key messages? We have achieved widespread international consensus on three key messages (6, 7), which are to rule out severe bacterial infection, focus on the child’s discomfort rather than the fever and avoid the overuse of antipyretics. However, we lack consensus on the definition of discomfort. Parents’ decisions based on the child’s comfort level vary greatly and are influenced by many factors, including cultural and social background. Furthermore, some remaining disputes on basic key issues can be misleading for parents. For example, the American Academy of Pediatrics (AAP) strongly encourages rectal temperature measurements, whereas the UK National Institute for Health and Clinical Excellence (NICE) strongly discourages it (6, 7). Are the messages clear enough? Although healthcare professionals have become more aware of the need for very simple and clear guidance, a 2005 systematic evaluation of the readability of AAP patient education brochures showed that half were written at higher-than-acceptable readability levels for the general public (8). An important clarification would be to shift from the word antipyretics to analgesics in order to reaffirm our treatment target, which is comfort and not normothermia. Have our messages been sufficiently disseminated using all the media at our disposal? The answer varies greatly from country to country. On the one hand, the mobile apps produced for smartphones and tablets by the UK’s NICE show a strong positive evolution towards adapting educational messages to parents’ technology, even if this approach needs to be extended to more parent-focused information (7). On the other hand, no national papers, videos or e-campaigns have been produced on fever in France, even though there have been some campaigns on more trivial problems, such as the risk of henna tattoos, a questionable hierarchy in public health priorities. Have knowledge and attitudes of healthcare practitioners become more consistent with recommendations than those of parents? The results of the most recent surveys indicate improvements, but also the potential for further optimisation, including basic principles such as the nonsystematic use of drugs (3,4,9). Fever is notoriously difficult to define, even for healthcare practitioners, because children’s normal temperatures and temperaments vary. Many healthcare practitioners share several of the anxieties reported by parents, including fever phobia (10), and demonstrate

Shingles vaccination: background and advice for community nurses

Shingles (or zoster) is a reactivation of an existing varicella-zoster virus (VZV) infection. During the initial infection, VZV causes a systemic disease known as varicella or chickenpox, and this initial infection normally occurs early in childhood in the absence of routine vaccination. Although varicella is normally a mild disease, shingles is associated with significant morbidity and some mortality, particularly in older people. The most significant severe consequence is post-herpetic neuralgia. There is an effective vaccine available for this, known as Zostavax, which is a live-attenuated VZV vaccine. Guidelines in the UK recommend that this is offered to everyone when they become 70 years of age, plus those aged 79 years as part of a catch-up campaign, with those between these ages not being eligible. It is important for all health-care professionals, including district and community nurses, to proactively promote this vaccine, so that those eligible can make an informed decision about whether to receive it.

Uncertainties and Anxieties about Vaccination, Answering Parent's Concerns

Vaccination is one of the most significant public health interventions responsible for saving millions of lives and preventing significant morbidity. Despite this, there remain concerns about a number of vaccines. Although vaccines are extensively tested, there are genuine questions that many parents have about a number of vaccine-related issues. It is important that practitioners can discuss these concerns because denying or dismissing them may lead parents and patients to seek advice from uninformed sources. This article discusses some of the major concerns about vaccines, including their safety, immunogenicity, and the development of national immunization programs. It concludes that although vaccines are overwhelmingly safe, constant vigilance is required.

Parental self-efficacy and its measurement - an evaluation of a parental self-efficacy measurement scale

AIMS AND OBJECTIVES To field test a parental self-efficacy scale regarding its acceptability and feasibility and to describe parental self-efficacy in a convenience sample of parents with children aged 6 years old or less. BACKGROUND Self-care within families is increasingly emphasised in health policy as a means of maximising healthcare resources. This study reports the field testing of a scale designed to measure parental self-efficacy. DESIGN Cross-sectional survey of parents of children aged 6 years old or less. METHODS Subjects were recruited through a parenting internet website (n = 84) and local parenting and community organisations (n = 68) and asked to complete a questionnaire containing the scale. Data collection took place between January and August 2011. RESULTS The scale, previously validated with an expert panel of professionals, gathered information about parental self-efficacy when administered either directly or through an on-line data collection portal, although there were more missing data when administered via the Internet. Although convenience and self-selecting samples precluded parameter estimation, areas of concern highlighted were difficulties differentiating children with serious illnesses and the use of the Personal Child Health Record. Use of the Internet was widespread, as was use of community pharmacists and nursery staff. CONCLUSION Although the primary purpose was not to collect specific data, the data indicated the continuing concern of parents regarding serious illness and where additional investment may be required to meet parental needs and expectations. RELEVANCE TO CLINICAL PRACTICE The previously validated scale can be used to collect information about parental self-efficacy either through a paper questionnaire or the Internet. Although there was slightly more missing data from the Internet version, the ease of its administration makes this an attractive option. Parents generally reported high levels of self-efficacy and satisfaction with services; however, the scale was able to identify areas where further investment might be useful.

High rates of elevated diabetes distress in research populations: A systematic review and meta-analysis

Diabetes distress has implications for diabetes end-points, hence targeted interventions are indicated; yet, preliminary work quantifying and characterising the problem is required. We sought to identify the potential magnitude and determinants of elevated diabetes distress across study populations. Databases such as Medline, PsycINFO and Embase were searched for studies (n ≥50) administering the problem areas in Diabetes scale or Diabetes Distress scale, in adults with Type 1 or 2 diabetes. Random effects meta-analysis and meta-regression estimated the average rate of elevated diabetes distress and prognostic contribution of age, gender, HbA1c, and health-care context. Of the 16,627 citations identified, adequate data were available for 58 studies. On average, 22% of participants reported elevated diabetes distress. Only female gender and secondary care predicted a higher rate of elevated diabetes distress. A quarter of people with diabetes have a level of distress likely to impact outcomes. Secondary-care practitioners should be vigilant of women with diabetes.