* Correspondence author; Address: Pharmacology Department, Lagos State University College of Medicine, P.M.B 21266, Ikeja, Lagos, Nijeria E-mail: med_modhospital@yahoo.com

FeverinChildren:MothersPerceptionsandtheirHome

Management

Kazeem A Oshikoya*1,2,MD;IdowuOSenbanjo2,MD,FWACP

1. PharmacologyDepartment,LagosStateUniversityCollegeofMedicine,Ikeja,Lagos,Nigeria2. PediatricsandChildHealth,LagosStateUniversityTeachingHospital,Ikeja,Lagos.Nigeria

Received:14/03/08;Revised:26/05/08;Accepted:05/06/08

AbstractObjective:Awide rangeof childhood illnessesareaccompaniedby fever,manyofwhicharetreatedathomeprior topresentation tohospital.Anassessmentofmothersknowledgeandability to recognize fever in their child, aswell asmanagement instituted at homewere thefocusofthisstudy.

Methods:Onehundredandfortyfourmotherswhosechildrenwerelessthan12yearsold,hadfever as one of the presenting complaints, and admitted to the children emergency room ofLagosStateUniversityTeachingHospitalbetweenJulyandDecember,2006,wereinterviewedwith a structured questionnaire. Information sourced were the demographics of themothers/caregivers and the children, mothers/caregivers knowledge of fever and itsmanagement.Mothersthatdidnotgivetheirconsentswereexcluded.

Findings:Mostofthemothers(83.3%)perceivedfeverasthehotnessofthewholebodyofthepatient.Infectionwasthemostlikelycauseoffeveridentifiedby43.8%mothers.Malariawaspresumptively diagnosed by the mothers in 54.2% children similar to the 53.5% cases ofmalaria diagnosed on admission. Ninetysix mothers (66.7%) managed the fever at home.Home treatment was majorly by reducing the clothing and exposing the child to air, tepidsponging,anduseofparacetamol.Antimalarials(6.0%)andantibiotics(7.8%)groupofdrugswererarelyused.

Conclusion:HomemanagementoffeverbymothershadremainedsymptomaticinNigeria.Intheeraofartemesinincombined therapyas thechoiceofmalaria treatment inNigeria, trendtowards not using antimalarial drugs as part of homemanagement of fever in childrenwasobservedamongstthemothers.

KeyWords:Fever;Children;Mother;Knowledge;Homemanagement

Introduction

Fever is said to occur in children when thebodytemperatureisabove370C(98.60F).It

occurs when various infectious and noninfectious processes interact with the hostsdefencemechanism[1]. Inmost children fever

Original Article Iran J Pediatr Sep 2008; Vol 18 ( No 3), Pp:229-236

230 FeverinChildren:MothersPerceptions, KA Oshikoya,IOSenbanjo

is either due to identifiable microbiologicagent or occurs during exposure to excessiveenvironmental heat or during heavy physicalwork[2]. Fever from the latter causes is apassiveriseinbodytemperaturethatsubsidesafter a short time. Fever is one of the mostcommon symptoms of childhood diseases.Malaria accounts for over 60% of outpatientvisitinNigeriaandotherSubSaharanAfricancountries[3,4] and in areaswith stablemalariaor high transmission season like Nigeria, arecent history of fever is enough a criterionfordiagnosisofuncomplicatedmalaria[5].Fearandanxietyattachedtofeverbymostmothersand some physicians are so much that it islabelledFeverPhobia[69].Onesuchfearisthebeliefthatdeathmayresultfromfever[6,7].Manychildhoodfebrileillnessesaretreatedathomepriortopresentation[10].Thisisaverycommon practice among caregivers inNigeria[1113] and other malaria endemiccountriesinSubSaharanAfrica[1416].InTogo,only20%ofthechildrenwithsuspectedfeverare seen at a health centre, while theremaining 80% are treated at home with anantimalarialdrug[17]. InNigeriabetween60%and80%ofchildrenwouldhavebeentreatedat home prior to reporting at healthfacilities[11]. Majority of these children aretreatedwithantimalarialdrugs.GoingbythelargepopulationofchildreninNigeria and a small proportion of healthfacilities available to cater for them, there isneedtoinvolvemothersinthemanagementofminor diseased conditions presenting withfever. Such conditions include malaria andrespiratory tract infections; the two commoncauses of fever in Nigerian children[1416].Roles of parents in the treatment of fever intheir children could better be determinedfrom their perception of fever and theunderstanding of its management. Healthseekingbehaviourhadbeenshowninthepastto be influenced by several factors such as:accessibility and availability of drugs;availability of health personnel; cost oftreatment including drugs; perception ofseriousness of the disease; knowledge of itscause and ability to diagnose and treat[18,19].Most of these studieswere communitybased

in the rural areas and were carried out toevaluate home treatment of fever usinghouseholdsurvey.This study was aimed at determining theknowledge and attitude of mothers in Lagos,anurbanarea inNigeria, about fever in theirchildrenandhow itwasmanagedathome inthis era of changes in the national policy formalaria treatment. Other purposes of thisstudywere todetermine the appropriatenessof thehome treatment, identifypractices thatwere harmful, and to suggest more usefulmethodsof fevermanagementathomebasedonthefindingsfromthisstudy.

Subjects&Methods

Lagos is the smallest state but the mostpopulous city in Nigeria with an estimatedpopulationof about15million inhabitants asof1991nationalcensus.It isdividedintofivedivisionsandtwentyLocalGovernmentAreas(LGAs). Ikeja is one of the divisions and thestate capital. It is also an urban areawith somany industries and residents. LASUTH issituatedinIkejaandoperatesfreehealthcarefor both paediatrics and geriatrics patients.Mostofthechildrenpresentingtothishospitalwere selfpresenting, the rest were referredfrom private hospitals/clinics and primaryhealthcare centres within and outside thestate.One hundred and forty four mothers ofchildren under the age of 12 years thatwereadmitted to the children emergency room ofLASUTH for variousmedical conditionswereinterviewed with a structured questionnaireby the researcher and two trained researchassistants,whowerestaffofthepharmacologydepartment, LagosStateUniversityCollegeofMedicine, Ikeja. Responses of the motherswere filled into the questionnaire by theinterviewers because some of the motherswere illiterates and may not be able to readand fill the questionnaire appropriately. Thestudy was done prospectively between JulyandDecember,2006andwasapprovedbytheethical committee of LASUTH. All mothers

231 Iran J Pediatr, Vol 18 (No 3); Sep 2008

whose children had fever as one of thepresenting symptoms were interviewed.Mothersthatdidnotgivetheirconsentswereexcluded.The questionnaire was divided into foursections. Section A and B were for thedemographics of the mother and the childrespectively. Section C was for the mothersknowledge of fever and section D for itsmanagement. The questionnaire was pretested at the children emergency room amonthbeforethestudywascommenced.Data analysis was by SPSS version 13 anddataexpressionwasinpercentages.

Findings

Demography of the mothers and theirchildren: Sixtythree mothers (43.8%) werebetween 21 30 years. Their levels ofeducationrangedfromilliteracy30(20.9%)toabovesecondary/highschool87(60.5%).Themajority of the mothers had 2 children(31.2%). Only three (2.1%) hadmore than 6children. Their occupation varied from pettytrading42(29.2%)tocivilservice6(4.2%).Few(10.4%)ofthepatientswereneonates,42(29.2%)wereaged16months,54(37.5%)were 16 years. Majority (61.8%) of themwere males. Onset of fever in the patients,beforepresentingtothehospital,rangedfrom6 hours (2.1%) to 14 days (27.1%).Temperature of the patients ranged fromnormal (16%), below 40oC (34.7%) to highgrade(49.3%).Mothers knowledge of fever: Fever wasperceivedby83.3%mothersashotnessofthewholebodyofthepatient.Only2.1%couldnotexplainfever.Thepossiblecausesoffeverwasascribed to infection by 63 (43.8%), teethingby 48 (33.3%) and common cold by 24(16.7%) mothers (table 1). Perceivedsymptoms associated with fever werehighlighted in table 2 as decreased appetite(47.9%),vomiting(43.8%),decreasedactivity(37.5%),andshortageofblood(2.1%).Majority of the mothers believedconvulsions(75%),lossofconsciousness

Table1PerceivedcausesoffeverbyNigerianmothers

Causesoffever *Frequency(n=144)Infection 63(43.7%)Teething 48(33.3%)Exposuretosunlight 39(27.1%)Eatingsomethingbad 39(27.1%)Dirtyenvironment 36(25.0%)Excessivecry 30(20.8%)Hyperactivity 24(16.7%)Commoncold 24(16.7%)Changeinweather 21(14.6%)Exposuretocold 18(12.5%)Insomnia 18(12.5%)Drugs 12(8.3%)Colddrink 9(6.2%)Spiritual/witchcraftattack 6(4.2%)

Warmdrink 3(2.1%)*Frequencyindicatesmultipleresponses.

Table2Symptomsassociatedwithfever

Symptoms *Frequency(n=144)

Decreasedappetite 69(47.9%)Vomiting 63(43.7%)Decreasedactivity 54(37.5%)Generalbodyache/pain 52(36.1%)Headache 48(33.3%)Excessivecry 45(31.2%)Passageofloosestools 45(31.2%)Cough 45(31.2%)Runnynose 39(27.1%)Shivering 39(27.1%)Passage of yellowcolouredurine 30(20.8%)

Excessivesweating 30(20.8%)Yellownessoftheeye 27(18.7%)Restlessness 27(18.7%)Fretfulness 27(18.7%)Abdominalpain 24(16.7%)Flushingoftheface 21(14.6%)Skinrashes 15(10.4%)Constipation 15(10.4%)Shortageofblood 3(2.1%)

*Frequencyindicatesmultipleresponses

232 FeverinChildren:MothersPerceptions, KA Oshikoya,IOSenbanjo

(22.9%) and irrational talk (27.1%) couldresult from fever. Death (31.3%), braindamage(31.3%),mentalretardation(27.1%),paralysis (18.8%) and blindness (10.4%) areotherindefinableeffectsoffever.Only(8.3%)mothersthoughtfeverwasharmless.Fever was detected by 120 (83.3%)mothers by feeling the skin of the patientswith their backhand and thermometer 24(16.7%).Touching the forehead,chestandallthe limbs of the patient with the hands wasused todetect fever in4.2%cases.Change inthe facial look of the child was attributed tofever in three cases. Majority (75%) of themothers that used thermometer to detectfeverwereabletocorrectlyuseitbycleaningthe thermometer with savlon solution (npropyl alcohol 2.84% m/v, chlorhexidinegluconate0.3g and centrimide3.0g) ormethylatedspiritbeforeandafteruse,shakingit very well before use, inserting it either inthe armpit or anus, and allowing a contacttime of at least 5 minutes before thethermometer is read. Normal bodytemperature was considered 36oC to 37oCwiththermometeruse.Ninety three mothers (64.6%) wereinformed about fever from health educationtalksatclinics/hospitals.Televisionandradioprogrammes (8.3%), newspapers andmagazines(8.3%)andbillboardadvertswerethe other sources of information to themothersaboutfever.Mothers presumptivediagnosisof fever intheirchildrenisrepresentedbytable3.Whilemalaria 78 (54.2%) was diagnosed most, 33(22.9%) mothers were not sure of thediagnosis. The physicians diagnosis of thefebrile condition was as shown in table 4.Malariawasdiagnosedin68(47.2%)patients:acute uncomplicatedmalaria (44.1%), severemalaria with anaemia (45.6%) and cerebralmalaria (10.3%), followed by meningitis 21(14.6%), bronchopneumonia and septicaemia20(13.9%)respectively.Management of fever by the mothers:Majorityof themothers96 (66.7%)managedthe fever at home. Only a few mothers(20.1%)correctlymanagedthefeverbytakingtheirchildrentohospitalandprimaryhealth

Table3Presumeddiagnosismadebymothersinfebrilechildren

Diagnosis *Frequency(n=144)

Malaria 78(54.2%)Nodiagnosis 33(22.9%)Teething 9(6.2%)Diarrhea 6(4.2%)Fever 3(2.1%)Bonepaincrisis 3(2.1%)Convulsion 3(2.1%)Typhoid 3(2.1%)Anemia 3(2.1%)Infection 3(2.1%)

*Frequencyindicatesmultipleresponses

Table4Physicianspresumeddiagnosisinfebrilechildren.

Diagnosis Frequency(n=144)MalariaSeveremalariawithanaemiaAcuteuncomplicatedmalariaCerebralmalaria

68(47.2%)(31)

(30)

(7)Meningitis 21(14.6%)Bronchopneumonia 20(13.9%)Septicemia 20(13.9%)Diarrheadisease 6(4.2%)Sickle cell anemiawithosteomyelitis 5(3.5%)

care centre. Taking the child to a chemist(4.2%), laboratory for investigation (2.8%),self medication (2.1%) and laboratory withself medication (2.1%) were the alternativemethodsofhomemanagementoffeverbythemothers. All the 96 mothers involved in selfmanagementofthefeverwereinvolvedinselfmedication. Supportive ways of fevermanagementathomeadoptedbythemothersincludereducingclothingandexposure toair(91.7%), tepid sponging (90.1%), cold bath(67.7%),fanning(9.4%),andtakingaharmful

233 Iran J Pediatr, Vol 18 (No 3); Sep 2008

stepbywrapping the childupwithablanket(4.2%).Drugs used at home by mothers to treatfeverintheirchildren:Table5showsthelistof selfmedicated drugs in fevermanagementin the children. All the children with feverweregivenparacetamol.Antimalarials(6.0%)and antibiotics (7.8%) were the other majorgroup of drugs used by the children. Withregards to the number of children that weregivendrugs at home, 10.4%and13.5%weretreated with antimalarials and antibioticsgroup of drugs respectively. Oral herbalpreparationswereusedbysixofthechildrenand topical herbal preparationswere appliedto the whole body of three of the children.Remnant of the previously used paracetamolthatwaskeptathomewasadministeredto54(56.3%)childrenwithfever.

Table5Homemedicationsusedintreatingfebrilechildrenbytheirmothers

Typeofdrugused *FrequencyAntipyreticsParacetamolIbuprofen

101(60.8%)(96)(5)

HematinicsandvitaminsVitaminBcomplexIronbloodtonicAscorbicacid

16(9.6%)(7)(6)(3)

Bonababe 13(7.8%)AntibioticsAmoxicillinAmpicillin/cloxacillinCotrimoxazoleAmoxiclavulanicacid

13(7.8)(5)(3)(3)(2)

AntimalarialsChloroquineArtesunate

10(6.0%)(7)(3)

Herbalmedicines 9(5.5%)Kidcare 4(2.5%)Totaldrugsused 166(100%)

Bonababe:containsparacetamolanddiphenhydramine.Kidcare:containschloroquine*Frequencyindicatesmultipleresponses

Among those parents that administeredparacetamol to their children, only 9 (9.4%)were able to identify liver problems as theirpotential adverse effects. Three of the fivemothers were able to identify gastritis as apotentialadverseeffectofibuprofen.Ofthe13mothersthatadministeredantibioticstotheirchildren, deaths and skin rashes respectively(46.2%), convulsion (38.5%), diarrhoea(30.8%), and skin peeling (23.1%) were theidentifiedpotentialadverseeffectsofthedrug.

Discussion

Previous studies in both Nigeria and otherAfrican countries on home management offever in children concentrated on fever as aresult of malaria[10,11,12,17,2023], moreso thosestudies were done in the era whenchloroquine and sulphadoxine/pyrimethamine were the first line of treatment.This study has however evaluated homemanagementof fever inchildren; irrespectiveof the cause, in the era when artemesininbasedcombinationtherapy(ACT)remainsthefirst choice of malaria treatment in SubSaharan African countries; endemic areas forresistantmalaria.The results of this study have furtherreiterated thatmost childhood fever are firsttreated at home by their mothers or caregivers.Helpwassoughtthereafterifthefeverwas unremitting despite the initial treatmentorcomplicationsetsin.Similarreportstothishave been widely published in other studiesfromNigeria[10,11,12].Contrary to thereportsofpreviousstudiesinurbanareasofUgandaandNigeria,mothersinthisstudywerequiteknowledgeableofthedefinition of fever, causes and associatedsymptoms[1012,18].Thismightbeasaresultofa larger percentage of the mothers (60.4%)being educated up to secondary level andbeyond.Our findingshoweveragreewith theresultsof studies fromKenya,Togo,Ethiopia,and Sri Lanka[2024]. Further analysis of themothersknowledgeoffevershowedthattheywere able to correctly perceive fever in their

234 FeverinChildren:MothersPerceptions, KA Oshikoya,IOSenbanjo

children using their hands or thermometerwhichwas corroborated by the 80.0%of thechildren presenting to the CHER withtemperature above normal values. Also theirknowledge of convulsion being a majorconsequence of fever is highly commendable.ThesefindingsaresimilartothereportsfromEthiopia[24] and Iraq[25] which may be areflectionoftheir levelofeducationandtheirreliablesourcesofinformationaboutfever.The 54.2% mothers that made apresumptive diagnosis of malaria were lessthan the47.2%childrenwith fever thatwerediagnosed of malaria on admission to CHER(tables3and4).Malariabeingdiagnosedmostby both the mothers and the physiciansfurther support the results of other studiesthathad reportedmalaria as amajor ailmentaffectingmostchildreninNigeria[4,1012,2628].Itfurther corroborates the good knowledge ofthe mothers about malaria fever earlierobserved in thisstudy.However, themotherswere unable to identify the severe forms ofmalaria (malaria with anaemia and cerebralmalaria) that carry a high morbidity andmortality in children. Similarly, mothersoverdiagnosis of malaria can cause other lifethreatening conditions that require urgentmedical attention, such as septicaemia,bronchopneumonia and meningitis thatafflicted 42.4% of the children to be missedout by the mothers and further delay theirtreatments. This therefore calls for furthereducationtothemothersonhowtorecognisemalaria with complications and other lifethreatening conditions that may mimicmalariasoastopresenttheirchildearlytothehospital.In Mali[23] and Nigeria[1012] mothersmanagedtheirchildsfeverathomesimilartoourfindingof66.7%childrentreatedforfeverat home. Antimalarials (chloroquine andsulphadoxime/pyrimethamine) were thedrugs used in home treatment of fever fromprevious studies[1012,2628], but contrarilyparacetamol was the most commonlyadministered drug to the children in thisstudy, despite the presumptive diagnosis ofmalariabymostofthemothers.Antimalarials(6.0%) and antibiotics (7.8%) were seldom

used.Thismusthavebeenasaresultgradualphasingoffofchloroquineandsulphadoxime/pyrimethamine in the market, lack ofawareness of artemesinin based combinationdrug as the recommended first line drug formalariatreatmentortheexorbitantcostoftheartemesinin based drug combination in theopenmarket. Thenonuse of antimalarials inthe febrile children might explain theprogressionof some theuncomplicatedacutemalaria to severe malaria with anemia andcerebralmalariaobservedinthisstudy.Thesefindings therefore suggest that more studiesneed tobedone toassess theacceptabilityofACTbyNigerianmothersand theeffectof itscost on home management of fever inchildren. Surprisingly, freemalaria treatmentpolicyisbeingpracticedinallthegovernmenthospitals in Lagos where this study wasconducted,andACTwasthechoiceofdrug.Inspite of this only 2.1% of the childrenpresentedearlytothehospital(within6hoursoffeveronset).The attitudes of the mothers thereforenegate the effort of the government atreducing child mortality and morbidity;through free health care for children, thusincreasingtheburdenofillnessinthehospitaland overstretching the inadequate healthfacilities. Therefore one of the limitations ofthis study is our inability to evaluate thefactors that prevented the mothers frompresenting early to the hospital.Homeuseofantibioticsasobservedinthisstudyisofgreatconcern.The13.5%antibioticsutilizationratein this study is lower than 31.3% previouslyreported in Nigeria[10] and much lower than62.0%reported in Iraq[25].The implicationofthis is that the children are at risk ofdevelopingadversereactionssinceantibioticsconstitute the leading cause of moderate tosevere adverse drug reactions in children[29].Alsothepotentialforantibioticresistanceandtreatmentfailureishighinthesechildren;thismaypossiblyexplaintheprolongedtreatmentand morbidity that were observed in thechildren from this study treated forbronchopneumoniaandmeningitis.Inadditiontoadministeringparacetamoltoall the children with fever by their mothers,

235 Iran J Pediatr, Vol 18 (No 3); Sep 2008

other methods of reducing fever, such asreducingtheclothingandexposingthechildtoair, tepid sponging, and cold bath, were wellpractised by the mothers, thus reducing theriskofconvulsionanditsattendingrisksinthechildren. Similar reports had been made invarious studies on fever management inchildreninNigeria[10,11,28].Remnant of the previously usedparacetamol thatwaskeptathomewasusedin 56.3% children with fever. Drugs kept inhomeinatemperateweatherareknowntobeineffective as a result of loss of potency,besides their metabolites are known to betoxic[30]. This in addition to not treating theunderlying cause of fever might explain theunremitting fever observed in these childrenwhentheypresentedtotheCHER.Mostofthemothersdidnotusetheparacetamolcorrectlywithrespecttothedoseandfrequencyofuse.Theusewasassociatedwithoverdosageerror.This might be as a result of lack of themothers knowledge of the potential adverseeffects of paracetamol. We have earlierreported overdosage error from paracetamoluse in children[31], thus the children are therisk of liver problem from irrational use ofparacetamol[32].Thisstudywasdoneinanurbansetting;thesituation may be very different in a ruralsetting where people are at disadvantages ofgood health care facilities, quality education,andpoverty.Similarstudyintheruralsettingis suggested so as to achieve generalizedapplication of the observed interventions offeverhomemanagements.

Conclusion

Thisstudyhashighlightedhomemanagementoffeveramongstchildrenfromanurbanareaof Nigeria by their mothers/caregivers.Malaria, being a major cause of fever in thechildren, requires mothers/caregivers to beeducatedandprovidedguidelinesonitsearlyrecognition; through symptoms and signs,appropriate diagnosis and treatment withartemesinin combination therapy. There is

need to createmore awarenesson theuseofartemesinincombinationtherapyamongstthemothersasthechoiceofmalariatreatmentinchildren.Mothersneedtoalsobeeducatedonwhen toconsulthealth facilitiesshouldhometreatment of malaria fails or the presentingsymptoms and signs go beyond those ofmalaria.

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