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Iranian Journal of Pediatrics

Tehran University of Medical Sciences Press
ISSN: 1018-4406 EISSN: 2008-2150
Vol. 18, Num. 3, 2008, pp. 229-236
Iranian Journal of Pediatrics, Vol. 18, No. 3, Sept, 2008, pp. 229-236

Fever in Children: Mothers' Perceptions and their Home

Management
Kazeem A Oshikoya1,2, MD; Idowu O Senbanjo2,MD, FWACP
1. Pharmacology Department, Lagos State University College of Medicine,
Ikeja, Lagos, Nigeria
2. Pediatrics and Child Health, Lagos State University Teaching Hospital,
Ikeja, Lagos. Nigeria
* Correspondence author; Address: Pharmacology Department, Lagos State
University College of Medicine, P.M.B 21266, Ikeja, Lagos, Nijeria E-mail:
med_modhospital@yahoo.com
Code Number: pe08036
Abstract
Objective:A wide range of childhood illnesses are accompanied by fever,
many of which are treated at home prior to presentation to hospital. An
assessment of mothers knowledge and ability to recognize fever in their
child, as well as management instituted at home were the focus of this study.
Methods: One hundred and forty four mothers whose children were less than

12 years old, had fever as one of the presenting complaints, and admitted to
the children emergency room of Lagos State University Teaching Hospital
between July and December, 2006, were interviewed with a structured
questionnaire. Information sourced were the demographics of the
mothers/caregivers and the children, mothers/caregivers knowledge of fever
and its management. Mothers that did not give their consents were excluded.
Findings:Most of the mothers (83.3%) perceived fever as the hotness of the
whole body of the patient. Infection was the most likely cause of fever
identified by 43.8% mothers. Malaria was presumptively diagnosed by the
mothers in 54.2% children similar to the 53.5% cases of malaria diagnosed on
admission. Ninety-six mothers (66.7%) managed the fever at home. Home
treatment was majorly by reducing the clothing and exposing the child to air,
tepid sponging, and use of paracetamol. Antimalarials (6.0%) and antibiotics
(7.8%) group of drugs were rarely used.
Conclusion: Home management of fever by mothers had remained
symptomatic in Nigeria. In the era of artemesinin combined therapy as the
choice of malaria treatment in Nigeria, trend towards not using antimalarial
drugs as part of home management of fever in children was observed amongst
the mothers.
Key Words: Fever; Children; Mother; Knowledge; Home management
Introduction
Fever is said to occur in children when the body temperature is above 370C
(98.60F). It occurs when various infectious and non-infectious processes
interact with the hosts defence mechanism[1]. In most children fever is either
due to identifiable microbiologic agent or occurs during exposure to
excessive environmental heat or during heavy physical work[2]. Fever from
the latter causes is a passive rise in body temperature that subsides after a
short time. Fever is one of the most common symptoms of childhood
diseases. Malaria accounts for over 60% of outpatient visit in Nigeria and
other Sub-Saharan African countries[3,4] and in areas with stable malaria or
high transmission season like Nigeria, a recent history of fever is enough a
criterion for diagnosis of uncomplicated malaria[5]. Fear and anxiety attached
to fever by most mothers and some physicians are so much that it is labelled
Fever Phobia[6-9]. One such fear is the belief that death may result from
fever[6,7].
Many childhood febrile illnesses are treated at home prior to presentation[10].
This is a very common practice among caregivers in Nigeria[11-13] and other
malaria endemic countries in Sub-Saharan Africa[14-16]. In Togo, only 20% of
the children with suspected fever are seen at a health centre, while the
remaining 80% are treated at home with an antimalarial drug[17]. In Nigeria
between 60% and 80% of children would have been treated at home prior to
reporting at health facilities[11]. Majority of these children are treated with

antimalarial drugs.
Going by the large population of children in Nigeria and a small proportion of
health facilities available to cater for them, there is need to involve mothers in
the management of minor diseased conditions presenting with fever. Such
conditions include malaria and respiratory tract infections; the two common
causes of fever in Nigerian children[14-16]. Roles of parents in the treatment of
fever in their children could better be determined from their perception of
fever and the understanding of its management. Health seeking behaviour
had been shown in the past to be influenced by several factors such as:
accessibility and availability of drugs; availability of health personnel; cost of
treatment including drugs; perception of seriousness of the disease;
knowledge of its cause and ability to diagnose and treat[18,19]. Most of these
studies were community based in the rural areas and were carried out to
evaluate home treatment of fever using household survey.
This study was aimed at determining the knowledge and attitude of mothers
in Lagos, an urban area in Nigeria, about fever in their children and how it
was managed at home in this era of changes in the national policy for malaria
treatment. Other purposes of this study were to determine the appropriateness
of the home treatment, identify practices that were harmful, and to suggest
more useful methods of fever management at home based on the findings
from this study.
Subjects & Methods
Lagos is the smallest state but the most populous city in Nigeria with an
estimated population of about 15 million inhabitants as of 1991 national
census. It is divided into five divisions and twenty Local Government Areas
(LGAs). Ikeja is one of the divisions and the state capital. It is also an urban
area with so many industries and residents. LASUTH is situated in Ikeja and
operates free health care for both paediatrics and geriatrics patients. Most of
the children presenting to this hospital were self-presenting, the rest were
referred from private hospitals/clinics and primary healthcare centres within
and outside the state.
One hundred and forty four mothers of children under the age of 12 years that
were admitted to the children emergency room of LASUTH for various
medical conditions were interviewed with a structured questionnaire by the
researcher and two trained research assistants, who were staff of the
pharmacology department, Lagos State University College of Medicine,
Ikeja. Responses of the mothers were filled into the questionnaire by the
interviewers because some of the mothers were illiterates and may not be able
to read and fill the questionnaire appropriately. The study was done
prospectively between July and December, 2006 and was approved by the
ethical committee of LASUTH. All mothers whose children had fever as one
of the presenting symptoms were interviewed. Mothers that did not give their

consents were excluded.

The questionnaire was divided into four sections. Section A and B were for
the demographics of the mother and the child respectively. Section C was for
the mothers knowledge of fever and section D for its management. The
questionnaire was pre-tested at the children emergency room a month before
the study was commenced.
Data analysis was by SPSS version 13 and data expression was in
percentages.
Findings
Demography of the mothers and their children: Sixty-three mothers (43.8%)
were between 21- 30 years. Their levels of education ranged from illiteracy
30 (20.9%) to above secondary/high school 87 (60.5%). The majority of the
mothers had 2 children (31.2%). Only three (2.1%) had more than 6 children.
Their occupation varied from petty trading 42 (29.2%) to civil service 6
(4.2%).
Few (10.4%) of the patients were neonates, 42 (29.2%) were aged 1-6
months, 54 (37.5%) were 1-6 years. Majority (61.8%) of them were males.
Onset of fever in the patients, before presenting to the hospital, ranged from 6
hours (2.1%) to 14 days (27.1%). Temperature of the patients ranged from
normal (16%), below 40oC (34.7%) to high grade (49.3%).
Mothers knowledge of fever: Fever was perceived by 83.3% mothers as
hotness of the whole body of the patient. Only 2.1% could not explain fever.
The possible causes of fever was ascribed to infection by 63 (43.8%), teething
by 48 (33.3%) and common cold by 24 (16.7%) mothers (Table 1). Perceived
symptoms associated with fever were highlighted in Table 2 as decreased
appetite (47.9%), vomiting (43.8%), decreased activity (37.5%), and shortage
of blood (2.1%).
Majority of the mothers believed convulsions (75%), loss of
consciousness (22.9%) and irrational talk (27.1%) could result from fever.
Death (31.3%), brain damage (31.3%), mental retardation (27.1%), paralysis
(18.8%) and blindness (10.4%) are other indefinable effects of fever. Only
(8.3%) mothers thought fever was harmless.
Fever was detected by 120 (83.3%) mothers by feeling the skin of the patients
with their back-hand and thermometer 24 (16.7%). Touching the forehead,
chest and all the limbs of the patient with the hands was used to detect fever
in 4.2% cases. Change in the facial look of the child was attributed to fever in
three cases. Majority (75%) of the mothers that used thermometer to detect
fever were able to correctly use it by cleaning the thermometer with savlon
solution (n-propyl alcohol- 2.84% m/v, chlorhexidine gluconate-0.3g and

centrimide-3.0g) or methylated spirit before and after use, shaking it very

well before use, inserting it either in the armpit or anus, and allowing a
contact time of at least 5 minutes before the thermometer is read. Normal
body temperature was considered 36oC to 37oC with thermometer use.
Ninety three mothers (64.6%) were informed about fever from health
education talks at clinics/hospitals. Television and radio programmes (8.3%),
newspapers and magazines (8.3%) and billboard adverts were the other
sources of information to the mothers about fever.
Mothers presumptive diagnosis of fever in their children is represented by
Table 3. While malaria 78 (54.2%) was diagnosed most, 33 (22.9%) mothers
were not sure of the diagnosis. The physicians diagnosis of the febrile
condition was as shown in Table 4. Malaria was diagnosed in 68 (47.2%)
patients: acute uncomplicated malaria (44.1%), severe malaria with anaemia
(45.6%) and cerebral malaria (10.3%), followed by meningitis 21 (14.6%),
bronchopneumonia and septicaemia 20 (13.9%) respectively.
Management of fever by the mothers: Majority of the mothers 96 (66.7%)
managed the fever at home. Only a few mothers (20.1%) correctly managed
the fever by taking their children to hospital and primary health care centre.
Taking the child to a chemist (4.2%), laboratory for investigation (2.8%), self
medication (2.1%) and laboratory with self medication (2.1%) were the
alternative methods of home management of fever by the mothers. All the 96
mothers involved in self management of the fever were involved in self
medication. Supportive ways of fever management at home adopted by the
mothers include reducing clothing and exposure to air (91.7%), tepid
sponging (90.1%), cold bath (67.7%), fanning (9.4%), and taking a harmful
step by wrapping the child up with a blanket (4.2%).
Drugs used at home by mothers to treat fever in their children: Table 5
shows the list of self medicated drugs in fever management in the children.
All the children with fever were given paracetamol. Antimalarials (6.0%) and
antibiotics (7.8%) were the other major group of drugs used by the children.
With regards to the number of children that were given drugs at home, 10.4%
and 13.5% were treated with antimalarials and antibiotics group of drugs
respectively. Oral herbal preparations were used by six of the children and
topical herbal preparations were applied to the whole body of three of the
children. Remnant of the previously used paracetamol that was kept at home
was administered to 54 (56.3%) children with fever.
Among those parents that administered paracetamol to their children, only 9
(9.4%) were able to identify liver problems as their potential adverse effects.
Three of the five mothers were able to identify gastritis as a potential adverse
effect of ibuprofen. Of the 13 mothers that administered antibiotics to their
children, deaths and skin rashes respectively (46.2%), convulsion (38.5%),
diarrhoea (30.8%), and skin peeling (23.1%) were the identified potential

adverse effects of the drug.

Discussion
Previous studies in both Nigeria and other African countries on home
management of fever in children concentrated on fever as a result of
malaria[10,11,12,17,20-23], moreso those studies were done in the era when
chloroquine and sulphadoxine/pyrimethamine were the first line of treatment.
This study has however evaluated home management of fever in children;
irrespective of the cause, in the era when artemesinin based combination
therapy (ACT) remains the first choice of malaria treatment in Sub-Saharan
African countries; endemic areas for resistant malaria.
The results of this study have further reiterated that most childhood fever are
first treated at home by their mothers or care givers. Help was sought
thereafter if the fever was unremitting despite the initial treatment or
complication sets in. Similar reports to this have been widely published in
other studies from Nigeria[10,11,12].
Contrary to the reports of previous studies in urban areas of Uganda and
Nigeria, mothers in this study were quite knowledgeable of the definition of
fever, causes and associated symptoms[10-12,18]. This might be as a result of a
larger percentage of the mothers (60.4%) being educated up to secondary
level and beyond. Our findings however agree with the results of studies from
Kenya, Togo, Ethiopia, and Sri Lanka[20-24]. Further analysis of the mothers
knowledge of fever showed that they were able to correctly perceive fever in
their children using their hands or thermometer which was corroborated by
the 80.0% of the children presenting to the CHER with temperature above
normal values. Also their knowledge of convulsion being a major
consequence of fever is highly commendable. These findings are similar to
the reports from Ethiopia[24] and Iraq[25] which may be a reflection of their
level of education and their reliable sources of information about fever.
The 54.2% mothers that made a presumptive diagnosis of malaria were less
than the 47.2% children with fever that were diagnosed of malaria on
admission to CHER (Table 3 and 4). Malaria being diagnosed most by both
the mothers and the physicians further support the results of other studies that
had reported malaria as a major ailment affecting most children in Nigeria[4,1012,26-28]
. It further corroborates the good knowledge of the mothers about
malaria fever earlier observed in this study. However, the mothers were
unable to identify the severe forms of malaria (malaria with anaemia and
cerebral malaria) that carry a high morbidity and mortality in children.
Similarly, mothers overdiagnosis of malaria can cause other life threatening
conditions that require urgent medical attention, such as septicaemia,
bronchopneumonia and meningitis that afflicted 42.4% of the children to be
missed out by the mothers and further delay their treatments. This therefore
calls for further education to the mothers on how to recognise malaria with

complications and other life threatening conditions that may mimic malaria so
as to present their child early to the hospital.
In Mali[23] and Nigeria[10-12] mothers managed their childs fever at home
similar to our finding of 66.7% children treated for fever at home.
Antimalarials (chloroquine and sulphadoxime/pyrimethamine) were the drugs
used in home treatment of fever from previous studies[10-12,26-28], but contrarily
paracetamol was the most commonly administered drug to the children in this
study, despite the presumptive diagnosis of malaria by most of the mothers.
Antimalarials (6.0%) and antibiotics (7.8%) were seldom used. This must
have been as a result gradual phasing off of chloroquine and sulphadoxime/
pyrimethamine in the market, lack of awareness of artemesinin based
combination drug as the recommended first line drug for malaria treatment or
the exorbitant cost of the artemesinin based drug combination in the open
market. The non use of antimalarials in the febrile children might explain the
progression of some the uncomplicated acute malaria to severe malaria with
anemia and cerebral malaria observed in this study. These findings therefore
suggest that more studies need to be done to assess the acceptability of ACT
by Nigerian mothers and the effect of its cost on home management of fever
in children. Surprisingly, free malaria treatment policy is being practiced in
all the government hospitals in Lagos where this study was conducted, and
ACT was the choice of drug. In spite of this only 2.1% of the children
presented early to the hospital (within 6 hours of fever onset).
The attitudes of the mothers therefore negate the effort of the government at
reducing child mortality and morbidity; through free health care for children,
thus increasing the burden of illness in the hospital and overstretching the
inadequate health facilities. Therefore one of the limitations of this study is
our inability to evaluate the factors that prevented the mothers from
presenting early to the hospital. Home use of antibiotics as observed in this
study is of great concern. The 13.5% antibiotics utilization rate in this study is
lower than 31.3% previously reported in Nigeria[10] and much lower than
62.0% reported in Iraq[25]. The implication of this is that the children are at
risk of developing adverse reactions since antibiotics constitute the leading
cause of moderate to severe adverse drug reactions in children[29]. Also the
potential for antibiotic resistance and treatment failure is high in these
children; this may possibly explain the prolonged treatment and morbidity
that were observed in the children from this study treated for
bronchopneumonia and meningitis.
In addition to administering paracetamol to all the children with fever by their
mothers, other methods of reducing fever, such as reducing the clothing and
exposing the child to air, tepid sponging, and cold bath, were well practised
by the mothers, thus reducing the risk of convulsion and its attending risks in
the children. Similar reports had been made in various studies on fever
management in children in Nigeria[10,11,28].

Remnant of the previously used paracetamol that was kept at home was used
in 56.3% children with fever. Drugs kept in home in a temperate weather are
known to be ineffective as a result of loss of potency, besides their
metabolites are known to be toxic[30]. This in addition to not treating the
underlying cause of fever might explain the unremitting fever observed in
these children when they presented to the CHER. Most of the mothers did not
use the paracetamol correctly with respect to the dose and frequency of use.
The use was associated with overdosage error. This might be as a result of
lack of the mothers knowledge of the potential adverse effects of
paracetamol. We have earlier reported overdosage error from paracetamol use
in children[31], thus the children are the risk of liver problem from irrational
use of paracetamol[32].
This study was done in an urban setting; the situation may be very different in
a rural setting where people are at disadvantages of good health care facilities,
quality education, and poverty. Similar study in the rural setting is suggested
so as to achieve generalized application of the observed interventions of fever
home managements.
Conclusion
This study has highlighted home management of fever amongst children from
an urban area of Nigeria by their mothers/caregivers. Malaria, being a major
cause of fever in the children, requires mothers/caregivers to be educated and
provided guidelines on its early recognition; through symptoms and signs,
appropriate diagnosis and treatment with artemesinin combination therapy.
There is need to create more awareness on the use of artemesinin combination
therapy amongst the mothers as the choice of malaria treatment in children.
Mothers need to also be educated on when to consult health facilities should
home treatment of malaria fails or the presenting symptoms and signs go
beyond those of malaria.
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