Physician's perceptions of fever in children. Facts and myths.

OBJECTIVE: To ascertain the knowledge and attitude of physicians, regarding fever in children. METHODS: A self-administered questionnaire was mailed to 600 randomly selected pediatricians, family practice physicians, emergency medicine physicians and general practitioners, who practice in Saudi Arabia. Appropriateness of responses to questions was determined on the basis of current medical literature. A rectal temperature of 38.0 degrees C is generally accepted as indicative of fever in children. RESULTS: Of the 600 physicians surveyed, 419 (70%) completed and returned the questionnaire; 17% of the physicians were consultants, 28% specialists and 55% general practitioners. Fifty-eight percent of the physicians had 10 years or more of experience. A rectal temperature of less than 38.0 degrees C was considered to indicate fever by 38% of physicians. Nearly 84% of physicians would initiate antipyretic therapy at a temperature of 38.5 degrees C or less and 56% cited a temperature of 40.0 degrees C or less to be dangerous. Only 5% believed that fever was not dangerous, while the remaining cited the principal danger of fever to be convulsions (69%), brain damage (35%), or death (8%). The responses to the main purpose of antipyretic treatment were to prevent convulsions (70%), to make the child comfortable (55%) and to prevent brain damage (29%). Approximately 53% of physicians reported that the most serious consequences of febrile convulsions were brain damage, learning disability, epilepsy, or death. Only 26% of physicians agreed that a sleeping child with fever should be left undisturbed. Approximately 25% advised inappropriate dosage or administration intervals of paracetamol. Almost all physicians recommended sponging or bathing to reduce fever. All respondents try to educate parents regarding fever and its management. CONCLUSION: A significant number of the surveyed physicians have demonstrated a serious lack of knowledge of the nature, dangers and management of an extremely common health problem. Physicians differ substantially in their knowledge of, and attitude toward fever in children, which is perhaps attributed to their different background in medical education and clinical training.

Home management of fever in children: rational or ritual?

Fever is extremely common in childhood. Parents have been shown to have unrealistic fears, resulting in inappropriate management of fever in their children. This study was conducted to survey parents about their knowledge concerning home management of fever in children in their care. Parents of 560 febrile children were randomly recruited and interviewed in the waiting areas of the outpatient clinics or emergency room in four hospitals in Riyadh city using a standard questionnaire. Most of the interviewees were mothers, aged within 20-39 years. Although more than one-half of fathers and one-third of mothers in the study were well educated, most were misinformed about recognition and definition of fever. Most parents had poor knowledge regarding minimum temperatures for administering correct doses of antipyretic drugs or for sponging/bathing with water of the correct temperature. Most parents demonstrated a poor understanding of the appropriate frequency for checking the child's temperature and administering antipyretics. Only one-third of parents indicated a reasonable educational imprint by health-care providers. Considerable efforts will be required to educate parents about fever and its management.

Parental perceptions of fever in children.

BACKGROUND: Fever is a common medical problem in children which often prompts parents to seek immediate medical care. The objective of this study was to survey parents about their knowledge and attitude concerning fever in their children. PATIENTS AND METHODS: The study involved the random selection of Saudi parents who brought their febrile children to the emergency rooms or walk-in clinics of four hospitals in Riyadh. Parents of 560 febrile children were interviewed using a standard questionnaire to obtain sociodemographic information and current knowledge of fever. Approximately 70% of the respondents were female, and the ages of the most were in the range of 20-40 years. More than 80% of the parents had two or more children. RESULTS: More than 70% of parents demonstrated a poor understanding of the definition of fever, high fever, maximum temperature of untreated fever, and threshold temperature warranting antipyresis. About 25% of parents considered temperatures less than 38.0 o C to be fever, another 25% did not know the definition of fever, 64% felt that temperatures of less than 40.0 o C could be dangerous to a child, and 25% could not define high fever. Another 23% believed that if left untreated, temperatures could rise to 42.0 o C or higher, but 37% could not provide an answer, and 62% did not know the minimum temperature for administering antipyretics. Approximately 95% of parents demonstrated undue fear of consequent body damage from fever, including convulsion, brain damage or stroke, coma, serious vague illness, blindness, and even death. CONCLUSION: Parental misconceptions about fever reflect the lack of active health education in our community. Health professionals have apparently not done enough to educate parents on the condition of fever and its consequences, a common problem.

Pattern of febrile illnesses in children seen at a pediatric ambulatory care setting.

BACKGROUND: Fever is the most common sign of childhood illnesses and febrile children constitute a substantial proportion of the practice of pediatrics and family medicine. OBJECTIVES: To highlight the pattern of febrile illnesses in children attending pediatric ambulatory health-care settings. METHODS: A one-year prospective study was conducted on febrile children who were consecutively seen and managed at two walk-in primary-care clinics in Sulaimania Children's Hospital, Riyadh. Data collection and analysis were structured around the principal study objectives. RESULTS: Among the 16,173 children seen, 4086 (25.3%) were identified as having a fever and evaluated to determine the aetiology of their febrile illness. Boys outnumbered girls and a significant increase in the frequency of febrile illnesses was noted in children 4 to 24 months of age. Upper respiratory tract infections were the commonest cause of fever (75%) and most of these infections were viral rhinopharyngitis. Viral gastroenteritis and pneumonia were prominent diagnoses, each accounting for 5% of febrile illnesses. Notably of low frequency were serious bacterial infections, such as meningitis (0.5%), cellulitis and bone or joint infection (1.8%) and urinary tract infection (0.7%). Only 9% of the febrile children required hospitalization. The ambulatory management of the other febrile children included the prescription of oral antibiotics to 64% of them. CONCLUSION: The proper clinical assessment of these febrile children and the prudent use of laboratory tests and antimicrobials remain the most important management strategies in primary health-care practice.

Non-group A streptococci: are they pathogens in the throat?

A total of 3,184 paediatric patients with sporadic pharyngitis was studied at King Khalid University Hospital in Riyadh, Saudi Arabia. In addition, 478 children without pharyngitis who were matched for age and sex were included as controls. Group A beta-haemolytic streptococci (beta HS) were detected significantly more often among the children with pharyngitis than among the controls (8.4% vs 2.3%; p < 0.0001). In contrast, total non-group A and group C beta HS were isolated at lower frequency from the sick than control children (0.9% vs 2.5% and 0.2% vs 1.2% respectively; p < 0.01) while other non-group A beta HS such as groups B, G and F were each isolated in similar frequency from both the sick and control children. We conclude that non-group A beta HS appear not to be as important as aetiological agents of sporadic pharyngitis in these children.

Severe hypertension: an unusual presentation of Guillain-Barré syndrome in a child with brucellosis.

UNLABELLED: A 9-year-old girl suffered from protracted paroxysms of severe hypertension before she developed classical signs of Guillain-Barré syndrome. Significant brucella antibody titres were found in the serum and CSF. Complete recovery was observed after appropriate therapy. CONCLUSION: Brucella organisms should be sought as a possible aetiological agent of Guillain-Barré syndrome in patients living in or coming from endemic countries.

Lumbar puncture in the clinical evaluation of children with seizures associated with fever.

This study was prospectively conducted to determine the frequency and yield of lumbar punctures performed in children with fever and seizures and to identify the criteria that were used by emergency physicians in selecting patients for this diagnostic procedure. During the five-year period from 1988 to 1992, 200 previously healthy children aged three months to five years were brought consecutively to the pediatric emergency department, after their seizure associated with fever. Lumbar puncture was performed in 51% of the cases and resulted in the detection of seven (3.5%) cases of meningitis, three (1.5%) of which were bacterial. An age less than 18 months, a febrile illness lasting over 48 hours, suspicious symptoms and signs of meningitis, and complex seizure features had significant influence on the decision of performing a lumbar puncture. Most children with meningitis had lethargy, irritability, and vomiting, and all had complex seizure features.

The impact of the Gulf armed conflict on the health and behaviour of Kuwaiti children.

This study deals with the psychological reactions of Kuwaiti children to war-related stresses in the early period of the Gulf crisis following the summer 1990 Iraqi invasion of Kuwait. A sample of 106 children was drawn from Kuwaiti displaced families and a comparable control sample was obtained from Saudi families in Riyadh, Saudi Arabia. An interview checklist of symptoms of physical and psychological distress was administered to the index child and a female key informant in each household of cases and controls. Most Kuwaiti children were exposed to unpleasant war experiences. It was found that Kuwaiti children exhibited a substantially greater degree of dysfunctional social and emotional behaviour. The types of adverse behaviours were a function of the child's age, sex and experience of aggression. The findings support the notion that a negative relationship exists between armed conflict and the health and behaviour of the children. The complex needs of children exposed to violence require professionals to seek ways of combining psychodynamic interventions and relief programmes.

Febrile seizures: rate and risk factors of recurrence.

The rate of recurrence of febrile seizures and the factors predictive of a recurrence were prospectively examined in a cohort of 98 Saudi children who presented consecutively with their first febrile seizure at the pediatric emergency department of the King Khalid University Hospital, Riyadh, Saudi Arabia. Children with prior afebrile seizures or evidence of a neurodevelopmental deficit were excluded. The median age was 15 months (range, 4 to 60 months). Of the 98 children, 72 had simple and 26 had complex initial febrile seizures. In a follow-up of 3 to 6 years (mean, 49 months), 26% of the 98 untreated children had at least one recurrence and only 8% had more than three recurrent febrile seizures; 30% of first recurrences took place within 3 months, 60% within 6 months, 72% within 12 months, and 96% within 24 months of the onset. Four major risk factors for recurrent febrile seizures were identified: early age at onset (< 12 months), first-degree consanguinity of parents, epilepsy in a first-degree relative, and complex initial febrile seizure. Gender, family history of febrile seizures, and degree of fever were not related to recurrence.

Determinants of term intrauterine growth retardation: the Saudi experience.

In a clinical study from an unselected Saudi obstetric population, the incidence of and risk factors for intrauterine growth retardation among live births were investigated. From a total study group of 4578 consecutive live births, 76 (1.7%) infants were found to be growth retarded. These infants were then compared with a randomly selected control group of 76 term newborns with appropriate birthweight for their gestational ages. Delivery at term of a growth-retarded infant was significantly associated with maternal age under 20 years, maternal body mass index less than 23, first degree consanguinity, poor housing, primiparity, and inadequate prenatal care in univariate analysis. When considered jointly in multivariate logistic regression analysis, the significant determinants were reduced to primiparity, first degree consanguinity, and poor housing. These risk factors correctly predicted 63% and 71% of the intrauterine growth-retarded infants or normal birthweight infants, respectively.

PIP: In Saudi Arabia, physicians compared data on 76 term intrauterine growth retardation (IUGR) infants with data on 76 randomly selected term newborns of appropriate birth weight to study the determinants of term IUGR. The term IUGR rate was 1.7% (76/4578 consecutive live births). The univariate analysis found significant risk factors to be a maternal age of less than 20 years (odds ratio [OR] = 4.89), a maternal body mass index of less than 23 (OR = 2.86), first degree consanguinity (OR = 3.1), living in a mud house (OR = 5.10), primiparity (OR = 3), and inadequate prenatal care (OR = 2.86). A stepwise multiple logistic regression model revealed that the significant risk factors of term IUGR included primiparity (OR = 3.3), first degree consanguinity (OR = 3.4), and living in a mud house (OR = 7.5). These three risk factors correctly predicted 63% and 71% of the IUGR and normal-birth-weight infants, respectively. These findings suggest that health care providers may be able to identify pregnancies at risk of IUGR and can thus prevent and manage IUGR births.

Down's syndrome in Saudi Arabia: incidence and cytogenetics.

A study has been carried out in Riyadh to determine the incidence and distribution of Down's syndrome births during a 9-year period from July 1982 to June 1991. Down's syndrome was ascertained in 42 (23 females and 19 males) of 23,261 consecutive babies born alive to Saudi women, giving an incidence of 1 in 554 live births (1.8 per 1,000). A trend towards an increased incidence of Down's syndrome with advanced maternal age or increased maternal parity was found. Cytogenetic studies were performed on 37 cases of which all but 1 were non-disjunction trisomy 21, while the remaining infant had a translocation. This study provides the first step for further epidemiological surveys of Down's syndrome in the Kingdom of Saudi Arabia in order to prepare the ground for an effective antenatal screening programme for chromosomal disorders.

Prevalence of intestinal parasites in Saudi children: a community-based study.

A community-based study was undertaken to determine the prevalence and types of intestinal parasites in the pediatric population of Al-Baha region, Saudi Arabia. Stool samples were randomly collected from 19,939 children of whom 4208 (21.1%) were found to harbour intestinal parasites. The most affected age group was 5-9 years and the sex distribution was almost equal in all age groups. Specific prevalence rates were Giardia lamblia 9 per cent, entamoeba histolytica 5 per cent, Hymenolepis nana 2 per cent, and Enterobius vermicularis 2 per cent. The findings of this survey confirm the extremely complex nature of parasitic profile in developing communities, and indicate that relationships exist between cultural and ecological factors, sanitation, and observed pattern of intestinal parasites.

Clinical and therapeutic features of childhood neurobrucellosis.

Brucellosis is a multisystem disease with diverse clinical presentations, and involvement of the nervous system is considered to be rare in childhood. Five children with meningitis (n=2), meningoencephalitis (n=1), meningomyelitis (n=1), or cerebellar ataxia (n=1) are described, all of whom had a history of exposure to a possible source of brucellosis. Examination of cerebrospinal fluid (CSF) revealed lymphocytic pleocytosis in 4 patients, high protein concentration in 5 and low glucose concentration in 3. Reciprocal brucella agglutination titers were significantly elevated in serum (> or = 160) and in CSF (> or = 80) of all patients. Brucella melitensis was isolated from blood and CSF in one patient, from blood only in 2, and from bone marrow only in another one. All patients were treated successfully by a three-drug combination of streptomycin (4 patients) or doxycycline (one patient) with trimethoprim-sulfamethoxazole and rifampin, and in one patient dexamethasone was also added. In endemic areas, neurobrucellosis should be suspected in the evaluation of patients with unexplained neurologic symptoms.

Risk factors for spontaneous preterm birth in a Saudi population.

Preterm birth (< 37 weeks completed gestation), the primary predictor of infant morbidity and mortality, can result from diverse biologic and sociodemographic variables. A case-control study was undertaken to determine risk factors that were significantly associated with preterm birth in our population. Pertinent data were collected by structured interviews with eligible subjects and by medical record abstraction. The study population consisted of 118 mothers of singleton, preterm, appropriate for gestational age infants (cases) and 118 mothers of singleton, term, appropriate for gestational age infants (controls). A multiple logistic regression analysis indicated that significant risk factors for preterm birth were first or second trimester vaginal bleeding during current pregnancy, a previous preterm birth, inadequate prenatal care, consanguinity, maternal body mass index of < 23, and short inter-pregnancy interval. Awareness of such risk factors is essential in planning public education programs and in considering appropriate perinatal care options for women at potentially higher risk for preterm delivery.

Factors influencing linear growth in Saudi Arabian children aged 6-24 months.

This study was carried out to identify possible factors influencing the growth pattern of Saudi children in the first 2 years of life. The body length and weight of 400 healthy babies attending the well-baby care clinic of King Khalid University Hospital, Riyadh, Saudi Arabia, were measured at various determined ages in a cross-sectional study design. Nutritional indicators were calculated and the proportions with low height-for-age, low weight-for-height and low weight-for-age were compared with the reference population. The results showed a prevalence of 2 per cent of wasted children and 18 per cent of children with stunted growth. A univariate and multivariate analysis of personal and nutritional variables with the standard nutritional indicators identified age, sex, bottle feeding, and type of solid foods as significant risk factors for stunted growth. Stunting increases with age and males have poorer growth pattern than females. Genetic factors and poor feeding practices of the children are suggested reasons for the observed faltering growth between 6 and 24 months of age. A public health education programme for good nutrition is highly recommended.

Management of acute childhood diarrhoea in Saudi Arabia: practices versus the WHO recommendations.

The fluid management of 247 infants and children who were admitted to King Fahad Hospital at Al Baha, Saudi Arabia with acute diarrhoea was reviewed. Half of them were infants and 25% were exclusively breast fed. Although dehydration was mild in 149 (60.3%) patients and 227 (92.7%) were at the most moderately dehydrated, as many as 95.8% were given intravenous (IV) hydration at least initially. This indicates that the WHO recommendation to prescribe oral rehydrating solution (ORS) for the control of diarrhoeal diseases, is still not implemented at some of the regional hospitals in Saudi Arabia, and emphasizes the need for urgent and effective efforts to rectify this situation.

PIP: Acute diarrhea remains a major cause of morbidity and mortality among infants and children in developing countries accounting for up to 20% of admissions to pediatric wards in Saudi Arabia. Oral rehydration therapy is recognized by the WHO as being a safe and effective way to treat this manifestation of infectious disease, but many physicians are reluctant to adopt its practice. 247 of the infants and children admitted to King Fahad Hospital at Al Baha, Saudi Arabia between July 1, 1990 and June 30, 1991, suffered from acute diarrhea. This paper reviews the fluid management of these patients to determine whether and to what extent WHO guidelines are being followed. Half of the patients were infants and 25% were exclusively breastfed. The mean duration of diarrhea at the time of presentation was 3.8 days in a range of 1-8 days. Although only mild dehydration was observed in 149 of the patients and moderate dehydration in 227, 95.8% were nonetheless given intravenous hydration initially for the first 24 hours. These findings suggest that the WHO recommendation to prescribe oral rehydration solution to control diarrheal diseases is not being implemented at some regional hospitals in Saudi Arabia.