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Tepid Sponging to Reduce Temperature in Febrile Children in a

Tropical Climate

Article  in  Clinical Pediatrics · April 1994

DOI: 10.1177/000992289403300407 · Source: PubMed

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Tepid Sponging To Reduce Temperature
in Febrile Children in a Tropical Climate

A.F. Mahar, M.B., B.S.

1
S.J. Allen, M.D.
1
P. Milligan, Ph.D.
1
S. Suthumnirund, M.Ed.
2
T. Chotpitayasunondh, 2
M.D.
A. Sabchareon, M.D.
3
J.B.S. Coulter, 1
M.D.

Summary: The effectiveness of tepid sponging, in addition to antipyretic medication, in the

reduction of temperature in febrile children living in a tropical environment, was assessed in a
prospective, randomized, open trial. Seventy-five children aged between 6 and 53 months who
attended the casualty department of the Children’s Hospital, Bangkok, Thailand, with fever
(rectal temperature ≥38.5°C) of presumed viral origin were randomized to receive either
tepid sponging and oral paracetamol (sponged group) or paracetamol alone (control
group). Rectal temperature and the occurrence of crying, irritability, and shivering were
recorded over the following 2 hours. A greater and more rapid fall in mean rectal
temperature occurred in the sponged group than in the control group. Temperature
fell below 38.5°C sooner in children in the sponged group than in control children
P <0.001). At 60 minutes, 38 (95.0%) of the controls still had a temperature of 38.5&deg;C or
(
greater, compared with only 15 children (42.9%) in the sponged group -5 <1&times;10 Crying
P
(
).
was associated with sponging, but shivering and in
irritability occurred only one child who was
being sponged. It is concluded that tepid sponging, in addition to antipyretic medication, is
clearly more effective than antipyretic medication alone in reducing temperature in febrile
children living in a tropical climate.

Introduction raise the thermal set-point of the Evidence from laboratory and ani-
hypothalamus, thereby inducing mal studies suggests that fever
lever due to viral infection is both heat production and conser- enhances many host immune de-

endogenous
mediated through release of
pyrogens, which
vation.’ The desirability of treating
fever in children is controversial.
fenses and renders some microor-
ganisms more susceptible
immune attack.2 However, there is
to

no evidence that antipyresis in chil-

Liverpool School of Tropical Medicine, Liverpool, England; 2
1 Children’s Hospital, Phyathai, dren prolongs illness or worsens
Bangkok, Thailand; 3
Department of Tropical Pediatrics, Faculty of Tropical Medicine, Mahidol
University, Bangkok, Thailand outcome.3 Parents commonly be-
lieve that fever should be treated,
Address correspondence to: S.J. Allen, M.D., PO Box 445, Madang, Madang Province, Papua because it has harmful effects and
New Guinea causes discomfort.3,4 Indeed, Kra-

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227
 mer et al4 found that the majority
of the parents of febrile children
who were eligible to participate in
a prospective study of paraceta-

mol antipyresis withdrew because

they were reluctant to risk having
their child assigned to receive a
placebo. A recent survey of pri-
mary-care physicians in Canada re-
ported that many had exaggerated
concerns regarding the possible
harmful effects of fever in young
children.~ Unless clinical studies
demonstrate specific adverse ef-
fects of antipyresis, the widespread
practice of cooling febrile children
is likely to continue.’
The administration of an anti-
pyretic drug to lower the thermal
set-point and removal of excess
clothing is considered to be ade-
quate to reduce temperature in
febrile children.7 The role of tepid
sponging to promote heat loss is
controversial. Some studies have
shown a greater fall in temperature
when tepid sponging has been
combined with antipyretic medica-
tion,S-lO but others have shown no
additional effect’ 1,12 and reported Methods sponging from head to toe (except
that tepid sponging may cause dis- the scalp) using tepid water (29 to
comfort.8e°l2 However, heat loss by Children aged 6 to 60 months 30°C) was performed by one of the
radiation and evaporation may be with rectal temperatures of>38.5°C investigators (A.F.M. or S.S.).
reduced in hot, humid climates and clinical diagnoses consistent Sponging was stopped when the
and, in such environments, the with viral infection were enrolled temperature fell to <38°C.

promotion of heat loss by physical
means may be an important addi-
tion to antipyretic medication.
Tepid sponging is an appropriate
method for use in developing
in the study. Children who re-
quired hospital admission and
those who had received antipyret-
ics within the preceding 4 hours
were excluded. Informed consent
Observations of temperature
and presence of discomfort were
made at 0, 15, 30, 45, 60, 90, and
120 minutes. Rectal temperature
was measured using an electronic

countries in that it can be taught
easily to parents and, therefore,
does not divert nursing staff from
other duties. Although it is prac-
ticed widely, we are not aware of
any study in which the role of tepid
sponging in the management of
febrile children in a tropical envi-
was obtained from the parents.
Participants were assigned ran-
domly by drawing a numbered en-
velope to receive oral paracetamol
and tepid sponging (sponged
group) or paracetamol only (con-
trol group). All children were na-
ked and placed in a room
thermometer (Terumo Corpora-
tion, Japan). The same nurse (S.S.)
recorded whether the child was
crying, irritable, or shivering be-
fore each measurement of tem-
perature. She was encouraged to
make objective assessments and
was not aware of the specific pur-

ronment has been evaluated. This ventilated by fixed wall fans which poses of the study. Observations
report assesses the effect of tepid provided moderate air movement. were continued after sponging was

sponging on the reduction of fever Paracetamol (Wellcome, UK) 10 to stopped, but sponging was not
and the level of discomfort in feb- 15 mg/kg body weight was admin- repeated if a temperature of
rile children in Thailand. istered by mouth. Continuous ¿38.5C recurred. The ambient

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228
temperature was recorded, and the
daily level of humidity was
tained from the Bangkok Meteoro-
logical Office. Mean rateof fall of
rectal temperature in each group
was calculated for each observa-
tion period (expressed as °C/hr)
and compared between the two
groups by Student’s t test. The pro-
portion of children in each group
whose temperature first fell
<38.5°C each observation point
at
was compared by the log rank test.
The effect of other variables on
the time taken for temperature to
first fall below 38.5°C was assessed
by the improvement of fit when
each was included in a propor-
tional hazards model. 13
Results
children aged be-
Seventy-five
tween 6 to 53 months were enrolled
in the study. The sponged (n 35) =
and control groups (n 40) were
=
similar in respect to age, sex, rela-
tive body surface area, duration of
fever, and initial temperature (Ta-
ble 1 ) . A diagnosis of viral infection
was made in all children by exclu-
sion of other common causes of
fever by clinical assessment. A
more specific diagnosis of viral up-
per respiratory tract infection was
made in 30 children (85.7%) in the
sponged group and 36 children
(90.0%) in the control group,
based on typical signs (e.g., coryza,
pharyngitis). The dosage of
paracetamol did not differ in the
two groups (mean [SD] mg per kg
body weight; sponged group: 14.2
[0.86]; control group: 14.1 [0.92];
P =
0.5). Humidity ranged from
65% to 90% and ambient tempera-
ture from 28.0 to 30.5°C, and these
variable were similar on the days
that children in the sponged and
control groups were studied (hu-
midity: mean [SD] = 78.9% [7.23] vs
i6.8% [7.14]; P = 0.2 and ambient
ob-
to
Figure 1. Median quartile SD rate of temperature fall (°C/hr) during each time period. · sponged
=
group (n 35); A, = control group (n 40). Temperature fall during 15-minute periods was multiplied
= =
by 4 and during 30-minute periods by 2. Data includes measurements made in the sponged group after
sponging was discontinued.
temperature: 29.4°C [0.97] vs minutes, 38 (95.0%) of the con-
29.6°C [8.4]; P= 0.5). trols still had a temperature of
No child withdrew from the >38.5°C, compared with only 15
study, and observations on all chil- children (42.9%) in the sponged
dren were carried out. Average rec- group (x2 22.0; P <1 X 10-5) . A
=
tal temperature fell in both groups temperature of >38.5°C recurred
between each successive observa- in three of 30 children (10%) in
tion point (Figure 1), but the mean whom sponging was stopped be-
rate of fall was significantly greater fore the end of the study (38.9°C
in the sponged group than in the in one child at 90 minutes and
control group during the periods 38.7°C in two children at 120 min-
16 to 30 minutes (mean [SD] °C, utes). No recurrence of tempera-
0.44 [0.43] vs 0.12 [0.24] P= 0.0004) ture of >38.5°C was observed
and 31 to 45 minutes (0.44 [0.35] among the controls. Apart from
vs 0.21 [0.30] P= 0.003). The maxi- sponging, only initial temperature
mum rate of fall in temperature also affected outcome (propor-
occurred during the 16- to 30- min- tional hazards model;12 X2 = 8.50, P
ute period in children in the =
0.004). The time taken for tem-
sponged group but did not occur perature to first fall below 38.5°C
until the 46- to 60-minute period in was not dependent on age, relative
the controls (Figure 1). Children body surface area, humidity, or am-
in the sponged group reached bient temperature (P > 0.1 ) .
38.5°C or less sooner than control- Crying was observed much
group children (Figure 2; log rank more frequently in the sponged
test;’o ~=27.1, P <0.0001). At 60 children than the controls ( 135 of
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229

Figure 2. Proportion of children whose rectal temperature had not fallen <38°C at each observation
point. x sponged group (n 35); . control group (n 40); * sponged and control groups. Data
= = = =
include measurements made in one child after sponging was stopped at 30 minutes.
245 [55.1 % observations vs 25 of
280 [8.9%] observations; x9 = 129.3,
P< 0.001). Irritability and shivering
were observed in only one child, a
3-year-old boy who had had fever
for 1 day. Significant discomfort
occurred after sponging for 30
minutes, when his rectal tempera-
ture had fallen to 39.5°C from an
initial level of 40.2°C. Sponging
was stopped, and the child’s tem-
perature continued to fall and was
below 38.5°C at the 60-minute ob-
servation.
Discussion
Tepid sponging, in addition to
oral paracetamol, was more effec-
tive in reducing temperature than
paracetamol alone. Although it
caused children to cry, it did not
result in undue distress and irrita-
bility, and shivering occurred in
only one child. Comparison with
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230
=
previous studies regarding the effi-
cacy of tepid sponging in reducing
temperature in febrile children is
confounded by differences in
study designs. Previous studies in
Hawaiian,’ American,9 and Brit-
ishl° children have reported that
reduction of fever was greater
when sponging was combined with
oral paracetamol than when
paracetamol was used alone. In
contrast, no additional benefit of
tepid sponging was detected in
Australian 1 and Canadian’2 chil-
dren. However, the former study&dquo;1
included only a small number of
children, and the etiology of fever
was not stated. In the latter sturdy, 12
sponging was performed for only
20 minutes, and the temperature
was not recorded until 30 minutes
after sponging was stopped. The
duration of sponging may have
been insufficient since, in our
study, no difference between the
two groups was observed until after
30 minutes of sponging.
Reduction of fever following
comparable doses of oral paraceta-
mol may be less in tropical than
temperate climates. In the Austral-
ian study, where ambient tempera-
ture was 21 to 22°C and humidity
was 50% to 55%, mean rectal tem-
perature fell by 1.1 °C at 60 minutes
and 1.6°C at 120 minutes. 11 Among
Hawaiian children (mean ambient
temperature 25.5°C; humidity
69% to 74%), mean rectal tem-
perature had fallen by only ap-
proximately0.8°C at 60 minutes
and 1.3°C 120 minutes.s Despite
at
greater mean ambient tempera-
ture and humidity during our
study (29.4°C and 78.8%, respec-
tively) than the Hawaiian study, the
fall in temperature in our control
children and Hawaiian children
who were treated with paracetamol
only was comparable. However,
heat loss may have been enhanced
in our study, because children were
exposed to fanning. Tepid spong-
ing may have less benefit in tem-
perate climates because heat is lost
readily to the environment follow-
ing antipyretic medication. In con-
trast, our findings in febrile
children in a tropical climate show
that reduction in temperature was
much greater when, in addition to
antipyretic medication, heat loss
from the body was promoted by
tepid sponging.
It is often stated that tepid
sponging causes discomfort,8,9,12
but the effect on the level of com-
fort of tepid sponging combined
with antipyretic medication has rarely
been assessed objectively. Steele et
al’ reported greater discomfort in
children who were managed with
the combined intervention, com-
pared with paracetamol alone. How
ever, children with fever caused bv
bacterial infections (e.g., otitis me-
dia, pneumonia) as well as vral
infections were included. Specific
causes of fever may have resulted
in greater discomfort and been Conclusion 4. Kramer MS, Naimark LE, Roberts-
al. Risks and benefits of
Br&auml;uer R, et
overrepresented in the combined
intervention group. In a study of The of reducing
desirability paracetamol antipyresis in young chil-
dren with fever of presumed viral ori-
the management of febrile chil- temperature in febrile children re-
. 1991;337:591-594.
gin. Lancet
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was found to be acceptable to required in a febrile child in a fever in children 3 months
to 2 years of

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. 1993;32:66-70.
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