Year : 2009 | Volume
: 8 | Issue : 3 | Page : 173--176
Ability of mothers to assess the presence of fever in their children: Implication for the treatment of fever under the IMCI guidelines
RD Wammanda, SO Onazi
Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
R D Wammanda
Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Zaria- 810 001, Kaduna state
Background : Fever is a common reason for seeking medical attention, with febrile illnesses accounting for 10% to 20% of pediatric visits to emergency departments. A history of fever or presence of fever by palpation or measured temperature is required on the Integrated Management of Childhood Illnesses (IMCI) algorithms as a reason for the assessment of fever, which will lead to specific classifications that are linked to treatment protocols. Therefore, the WHO and its partners assume that mothers are able to assess their children for the presence of fever.
Objectives : To evaluate the ability of mothers to determine the presence of fever in their children by tactile examination of their children.
Methods : We prospectively studied 126 mother-child pairs attending the pediatric outpatient clinic of Ahmadu Bello University Teaching Hospital (ABUTH) . Mothers of children 2 months to 5 years of age who mentioned fever as part of the presenting complaints were studied using a structured questionnaire regarding their children«SQ»s illness, temperature status and their educational level.
Results : A total of 126 mother-child pairs were studied, of which 44 (34.9%) of the mothers had had their education extended to secondary school level and only 15 (11.9%) had their education extended to a tertiary level. Fever was present in 82 (65.1%) of the children when their temperatures were determined by thermometer. The mothers correctly identified 79 (sensitivity of 96.3%) of the children who were truly febrile and 19 (specificity of 43.2%) of those who were truly nonfebrile. The predictive value of a positive test was 76.0%, and the predictive value of a negative test was 86.4%.
Conclusion : The results showed that mothers in our environment, as has been observed in other parts of the world, are able to correctly assess the presence or absence of fever in their children.
|How to cite this article:|
Wammanda R D, Onazi S O. Ability of mothers to assess the presence of fever in their children: Implication for the treatment of fever under the IMCI guidelines.Ann Afr Med 2009;8:173-176
|How to cite this URL:|
Wammanda R D, Onazi S O. Ability of mothers to assess the presence of fever in their children: Implication for the treatment of fever under the IMCI guidelines. Ann Afr Med [serial online] 2009 [cited 2021 Oct 26 ];8:173-176
Available from: https://www.annalsafrmed.org/text.asp?2009/8/3/173/57240
In the pediatric age group, fever is one of the commonest reasons for seeking medical attention,  with febrile illnesses accounting for 10% to 20% of pediatric visits to emergency departments. , As part of the child survival strategy, WHO and UNICEF, in 1995, initiated the Integrated Management of Childhood Illnesses (IMCI) to assist developing countries reduce childhood mortality caused by most childhood killer diseases - diarrhea, acute respiratory infections, malaria, measles and malnutrition.  Fever is part of the assessment steps on the IMCI algorithms. A history of fever or presence of fever by palpation or measured temperature is required as a reason for the assessment of fever, which will lead to specific classifications that are linked to treatment protocols.  Therefore, the WHO and its partners assume that mothers are able to assess their children for the presence of fever. The commonest way mothers assess their children for fever is by palpation. However, it has been reported that a mother's description of tactile examination of her child as part of the clinical history provides the doctor with little useful information about fever.  To the best of our knowledge, there has not been any study in our environment designed to evaluate mothers' ability to assess the presence of fever in their children. This study was therefore aimed to evaluate the ability of mothers to assess the presence of fever in their children in our environment.
This comparative study was carried out at the pediatric outpatient department of our hospital (Ahmadu Bello University Teaching Hospital, Zaria). Despite being a referral center, over 90% of the clients present to the department directly without referral. The clinic runs on a daily basis, including weekends, and sees an average of 70 children per week. Zaria is situated in an area of northern guinea savannah, with the population consisting predominantly of farmers, artisans and traders. It has a general hospital situated in the main traditional Zaria city, many government health centers and private clinics scattered all over the town.
Mothers of children aged 2 months to 5 years who mentioned fever as part of the presenting complaints were eligible to be included in the study. Sampling of mothers was done on weekdays when one of the authors (RDW) was scheduled to attend to patients in the pediatric outpatient department according to the clinic roster. All mothers of children aged 2 months to 5 years who presented to the pediatric outpatient clinic on these days and mentioned fever as part of the presenting complaints were recruited for the study. Verbal consent was obtained from the mother/ guardian of an eligible child. Nature of the study was explained to the mothers/ guardians in details in the language they best understood. A mother-child pair was excluded from the study if the mother declined to take part in the study. A structured questionnaire regarding the child's illness and temperature status, as well as the mother's educational level, was administered to the mother of an eligible child. All interviews and temperature measurements were done by one of the authors (RDW). On presentation, a mother of an eligible child was asked to determine whether the child had fever by palpation over the child's forehead. Immediately after that, the temperature of the child was recorded using a thermometer. A mercury glass thermometer was used for temperature measurement. Fever was defined as axillary temperature of 37.2°C or more.  Comparative analysis was done by a simple 2 Χ 2 contingency table.
We studied 126 mother-child pairs, out of which 120 were brought by their biological mothers. There were 66 (52.4%) boys and 60 (47.6%) girls. The ages of the children ranged from 2 months to 59 months. All the children had a history of fever on presentation to the clinic. Of the 126 mothers, 44 (34.9%) had had their education extended to secondary school level, 15 (11.9%) had their education extended to a tertiary level while another 15 (11.9%) had no formal education. In 104 (82.5%) of the 126 children, fever was present when the mothers were asked to determine the presence of fever by palpation of the child's forehead, while fever was present in 82 (65.1%) of the 126 children when the temperature was determined by thermometer. Compared to the gold standard, mothers' determination of fever by palpation was correct in 79 (96.3%) of these children. This is shown in [Table 1]. Among the 44 children without fever by temperature measurement, the mothers correctly identified 19 (43.2%) of them as nonfebrile, giving the sensitivity and specificity of mothers' tactile determination of fever as 96.3% and 43.2%, respectively. The predictive value of a positive test was 76.0%, and the predictive value of a negative test was 86.4%. The performance characteristics of the mothers' determination of fever by palpation were similar across the various educational levels, as displayed in [Table 2].
This study has demonstrated a high sensitivity (96.3%) of mothers' tactile determination of fever in their children by palpation of the child's forehead. This finding is similar to those reported by Nwanyanwu et al. (sensitivity of 97.3%);  Ernst and Philips, 90.0%;  Graneto and Soglin, 84%;  while Alves and Correia,  as well as Banco and Veltri,  reported a slightly lower sensitivity of 75.9% and 73.9%, respectively. However, the specificity of 43.2% obtained in the present study was lower than the specificities reported by these other workers, ranging from 73.3% to 90.6%, but was higher than the 19.2% reported by Nwanyanwu et al. from Malawi. All these reports seem to suggest that a mother's palpation of her child may be an adequate alternative for the assessment of childhood fever. This is in contrast to an earlier report by Bergenson and Steinfeld  that a mother's description of her tactile examination of the child, as part of the clinical history, provides the doctor little useful information. A possible explanation for the difference in the findings of Bergenson and Steinfeld  when compared with those in most other reports is that paramedical personnel were used to assess the child's fever by palpation in the study by Bergenson and Steinfeld.  A similar situation was found in the report by Nwanyanwu et al., where clinical officers incorrectly classified as nonfebrile 17.8% of children found to be truly febrile, whereas the mothers incorrectly classified as nonfebrile only 2.6% of the febrile children, making the clinical officers 7-fold more likely than mothers to misjudge fever as being absent when actually it was present. It is possible that the paramedical officers could have been influenced by their background training and therefore were concerned about possible overdiagnosis.
The negative predictive value of 86.4% in this study is similar to that in the report by Nwanyanwu et al., who obtained a negative predictive value of 92.5%, but much higher than in the report by Alves and Correiea (46.8%).  This high negative predictive value is an essential requirement of maternal tactile determination of fever as a screening tool for the presence of fever in children. This is because a negative predictive value is the likelihood that a subject with a negative test does not have the condition tested for.  This is particularly important in poor developing countries where simple clinical tools like a thermometer sometimes are unavailable in health centers. This study has also shown that the ability of mothers to determine the presence of fever in their children by palpation is similar across the various educational levels.
The fever box on the IMCI algorithm leads to the classification of malaria by mothers or other caregivers simply answering "yes" when asked, "Has your child been having fever?" Therefore, a mother's ability to assess the presence of fever in her child is an essential ingredient for achieving the goal of the IMCI strategy. Underdiagnosis of fever by mothers may delay appropriate care, resulting in many children developing severe disease or even dying at home. On the other hand, overdiagnosis of fever, which consequently results in overclassification of malaria on the IMCI algorithm, will lead to increased exposure of children to potentially toxic drugs and may accelerate the development of antimalarial resistance by the malarial parasite.
This study has shown that mothers in our environment, as has been observed in other parts of the world, are able to correctly assess the presence or absence of fever in their children. Although determination of temperature by the use of a thermometer is the gold standard, mothers' tactile description of fever in their children can be adequate as an alternative method of determining the presence or absence of fever in children, which appears not to be influenced by their educational level.
|1||Schmitt BD. Fever in childhood. Pediatrics 1984;74:929-36.|
|2||Krauss BS, Harakal T, Fleisher GR. The spectrum and frequency of illness presenting to a pediatric emergency department. Pediatr Emerg Care 1991;7:67-71.|
|3||Nelson DS, Walsh K, Fleisher GR. Spectrum and frequency of pediatric illness presenting to a general community hospital emergency department. Pediatrics 1992;90:5-10.|
|4||Integrated management of childhood illnesses: a WHO/UNICEF initiative. Bull World Health Organ 1997;75: 25-32.|
|5||Bergeson PS, Steinfeld HJ. How dependable is palpation as a screening method for fever? Clin Pediatr 1974;13:350-1.|
|6||Nwanyanwu OC, Ziba C, Redd C, Luby SP. Palpation as a method of fever determination in Malawian children who are less than 5 years old: how reliable is it? Ann Trop Med Parasitol 1997;91:359-63.|
|7||Ernst TN, Philip M. Temperature assessment by parental palpation. Am J Dis Child 1985;139:546-7.|
|8||Graneto JW, Soglin DF. Maternal screening of childhood fever by palpation. Pediatr Emerg Care 1996;12:183-4.|
|9||Alves JG, Correia JB. Ability of mothers to asses the presence of fever in their children without using a thermometer. Trop Doc 2002;32:145-6.|
|10||Banco L, Veltri D. Ability of mothers to subjectively asses the presence of fever in their children. Am J Dis Child 1984;138:976-8.|
|11||Griner PF, Mayewski RJ, Mushlin AI, Greenland P. Selection and interpretation of diagnostic tests and procedures: Principles and applications. Ann Intern Med 1981;94:553-60.|