Physical interventions to reduce fever

After so much debate about the use of tepid sponging to reduce fever, I am compelled to write another article to address this issue. Tepid sponging is not the only commonly used method to bring down the body temperature in the event of fever. In fact, there are a number of physical interventions that can be used to reduce body temperature, including undressing, fanning and sponging with cool or cold water. These take advantage of heat loss through convection and evaporation but do not treat the underlying causes of the fever; either the disease or the alteration in hypothalamic set-point.

National Institute for Health and Care Excellence (NICE) of UK had recently summarized the evidence and published a guideline on “Feverish illness in children: Assessment and initial management in children younger than 5 years” dated May 2013. After searching through the literature, they found these observations. There is a lack of evidence regarding opening windows or fanning as methods of reducing temperature. Tepid sponging offers no significant benefit over antipyretic agents alone. In studies looking at combinations of sponging techniques and drugs, sponging seemed to have no or only short-lived additive effects on the reduction in temperature. Adverse effects in some children included crying and shivering in those treated with sponging. Undressing alone had little effect on temperature. A small study in adult volunteers with artificially induced fever showed that, during active external cooling, shivering was common, and both heat production and blood pressure were raised. Discomfort was also significant, a finding that is supported by some studies of tepid sponging in children.

From these set of evidence, these are the conclusions made by NICE found in this guideline. Physical methods of temperature reduction do not treat the cause of fever, which is the action of circulating pyrogens (fever producing substance) occurring as the result of the underlying condition. Tepid sponging is time consuming, may cause distress, and has minimal medium-to long-term effects on temperature. Undressing appears to have little, if any, effect on temperature. There was no evidence regarding other physical methods of temperature control, for example fanning, although this shares the above limitation. Physical methods may also cause shivering if the cooling is too much or too quick. This may cause constriction of blood vessels, therefore interfering with heat loss mechanisms. It then results in rebound increase in temperature and metabolism.

Because there is limited evidence regarding clothing of the feverish child, NICE agreed by consensus that children with fever should be clothed appropriately for their surroundings, with the aim of preventing overheating or shivering. The major consideration should be the comfort of the child, and the prevention of over-rapid cooling that may cause shivering which may be distressing for child and parents. Care also needs to be taken not to overdress febrile children.

In view of the available evidence, the recommendations by NICE guideline on physical intervention for the treatment of fever in children are as below:

1. Tepid sponging is not recommended for the treatment of fever.
2. Children with fever should not be underdressed or over-wrapped.

However, because of the lack of evidence from clinical studies for or against the use of physical cooling methods, the NICE also concluded that research in this area may be beneficial. My opinion is, until further evidence are produced, it is best to abstain from performing the above mentioned physical interventions for the reduction of body temperature of our feverish children because of the lack of benefits and reported adverse effects that accompany such methods.

(Adapted from NICE Guideline CG160: Feverish illness in children: Assessment and initial management in children younger than 5 years, published in May 2013. https://www.nice.org.uk/guidance/cg160)