FormalPara Learning Objectives

  • How to take a focused history from parents with a child with fever?

  • How to effectively use the 5 As model to counsel parents on managing their child’s fever?

  • How to implement good communication skills when advising parents on managing their child’s fever?

Focus areas include Differential diagnoses of fever include upper or lower respiratory tract infection, gastroenteritis, otitis media, viral illness, and urinary tract infection.

  1. 1.

    Introduce yourself and establish a good rapport.

  2. 2.

    Ask:

    1. (a)

      Onset, duration, readings if any, associated symptoms (runny nose, cough, rash, nausea or vomiting, diarrhea, earache, or headache), and relieving factors (paracetamol or ibuprofen). If any medications are given, ask about the dose, frequency, and last given dose.

    2. (b)

      History of recent travel or contact with sick individuals.

    3. (c)

      Vaccination status and recent ones.

    4. (d)

      Parent’s ideas, concerns and expectations (ICE) (medication, vaccination, care related to underlying condition). Correct any myths (teething does not cause fever).

    5. (e)

      Past medical, family, and social history.

    6. (f)

      Growth, development, and vaccine history.

  3. 3.

    Advise:

    1. (a)

      “I understand your worries, fever is a very common source of mothers’ anxiety.”

    2. (b)

      “Fever is a very good sign of your child’s body being strong enough to fight germs and does not cause brain damage, but we must be very careful it doesn’t persist or increase. This is because it can lead to dehydration so give your child lots of fluids. It can also lead to febrile convulsions.”

    3. (c)

      “Fever does not mean the child has a serious illness. It is normal for them to have at least 5–6 episodes of fever in a year.”

    4. (d)

      “There is no evidence that reducing fever reduces the morbidity or mortality from a febrile illness and response to treatment does not differentiate a viral cause from bacterial cause.”

    5. (e)

      “Potential benefits of treating fever with antipyretics include improvement of discomfort and decrease in insensible water loss, which may decrease the risk of dehydration. Antipyretic agents also have analgesic effects, which may enhance their overall effect. Potential downsides of treating fever include delayed identification of an underlying illness and drug toxicity; it is uncertain whether treating fever increases the risk for or complications of certain types of infections.”

  4. 4.

    Assess:

    1. (a)

      “A clinically significant fever in children younger than 3 years is a rectal temperature of at least 38 °C (100.4 °F). Axillary, tympanic, and temporal artery measurements have been shown to be unreliable.”

    2. (b)

      Exclude red flags (febrile convulsions, urinary symptoms, recent travel, neck stiffness, altered mental status, nonconsolable crying, rash).

    3. (c)

      Perform a thorough physical examination.

    4. (d)

      Reassurance when a serious illness is excluded (child interested in playing, eating, and drinking well, no skin changes, good and fast response to antipyretics).

    5. (e)

      Identify if fever without apparent source (“acute febrile illness with no obvious source of fever after a thorough history and physical exam”) or fever of unknown origin (“core body temperature ≥38.1 °C measured at least once daily for ≥14 consecutive days and diagnosis inapparent after careful history, physical exam, and relatively simple, noninvasive tests”).

    6. (f)

      Reassurance and clear addressing of the mother’s concern: “For now I think you can take good care of your child with a few tips, and we will follow him or her closely.”

    7. (g)

      Fever in young children (less than 2 years of age): Evaluation of febrile infants younger than 29 days should include complete blood count with differentials, lumbar puncture, blood culture, chest radiography, urinalysis, and urine culture. Stool testing should be performed if diarrhea is present. Moreover, evaluation of febrile young infants (more than 28 days but less than 3 months) should include urinalysis and urine culture and complete blood count with differentials. Nevertheless, urinalysis and urine culture are recommended as part of the evaluation for all febrile infants 24 months of age or younger with unexplained fever.

  5. 5.

    Assist: “Let’s share a plan together to help you.”

    1. (a)

      “Encourage fluid intake, dress lightly, cotton, single layer and avoid covering your child with multiple or thick blankets.”

    2. (b)

      “Measure body temperature and if higher than 38° for 3 consecutive days go back to your doctor.”

    3. (c)

      “Give your child a warm bath. Cold towels are irritating, so try to avoid them.”

    4. (d)

      “Do not use alcohol or vinegar for bathing a child with fever, it is dangerous!”

    5. (e)

      “Do not use aspirin.”

    6. (f)

      “Use Adol (paracetamol) or Ibuprofen for lowering body temperature, use weight to determine the proper dose or call your doctor for help, give doses regularly every 6–8 h at least in the first 24 h of onset.”

    7. (g)

      “To prevent overdosing of antipyretics, store them out of reach of children.”

  6. 6.

    Arrange:

    1. (a)

      Admission and investigation for all neonates (younger than 28 days).

    2. (b)

      Follow up in 2 days or earlier if no improvement.

    3. (c)

      Brief assessment of underlying conditions, age-appropriate screening, and vaccination.

    4. (d)

      Give away reading materials if available.

    5. (e)

      Safety netting: “If he or she developed a rash, neck stiffness, altered mental status or nonconsolable cry, please come back to the clinic.”

  7. 7.

    Communication skills: ensure organized approach, mixed questioning style (open and closed-ended questions), active listening, clear language, and reflection on the parent’s ICE.