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Three Part Question

[In febrile children under the age of 12] is [tepid sponging effective at reducing the temperature] [compared with no tepid sponging at all]

Clinical Scenario

A 6 month old child arrives in the emergency department distressed (crying) with a fever of 38.5°c, she received oral Paracetamol treatment to reduce the temperature but the mother asks if there is anything else that could possibly be done to cool her child down as she is worried the high temperature may cause a febrile convulsion.

Search Strategy

OVID Medline <1966-June week 3 2006>
EMBASE < 1980 to 2006 week 26>
CINAHL <1982 to June week 5 2006>
The Cochrane Library 2006
Paediatric filter applied
([febrile seizure.mp. OR exp Febrile Convulsion/ OR febrile fit.mp. OR exp SEIZURE/ or seizure.mp. OR fit.mp.] AND (tepid adj sponging).mp. OR sponging.mp. OR colling.mp. or exp COOLING/ OR bath$.mp. or exp BATH/ OR tepid spong$.mp. OR (cool adj down).mp. OR spong$.mp.) AND (temperature.mp. OR exp TEMPERATURE/ OR exp BODY TEMPERATURE/ OR exp FEVER/)

Search Outcome

Medline: 33 papers found
EMBASE: 36 papers found
CINAHL: 29 papers found
Cochrane Library: 1 relevant paper found
4 relevant papers found; 1 from Cochrane Library, 1 from CINAHL and 2 from references form other articles.
When randomised controlled trial filter applied:
Medline: 12 papers found
EMBASE: 18 papers found
CINAHL: 6

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Donahue, A.M. 1983		Educational paper.	Selective use of tepid sponging in the emergency dept in febrile children with temp <40°c. If the high set point is the cause of the fever antipyretic drug therapy should be instituted first.		Low grade evidence only one authors opinion.
Clarita, R. & Pacis 1986	Data gathered over 11 week period in 1986. 45 patients 15 in each treatment group. 16 infants, 13 toddlers, 9 preschoolers, 7 schoolers.	Prospective cohort.	Temp reduction due to sponging	There was a significant reduction in temperature in the medicated and non-medictaed groups from the pre-treatment to post-treatment period.	Doesn't mention childrens exact ages in demographics just says toddlers, infants etc. Researcher not blinded to investigation. Doesn't say how long carried out the treatment of sponging for. No inclusion or exclusion criteria. Says looking at 3 different methods of tepid sponging these are not described anywhere in the article. The details of how much medication the patients in the medicated group had are not documented. Also some of the patients took aspirin which is not recommended for antiptyretic use in children anymore.
			Non-Medicated	P<0.001
			Medicated	P<0.01
Meremikwu, M. and Oyo-Ita, A. 2002	7 randomised and quasi randomised controlled trials comparing physical methods with with a drug placebo or no treatment in children with a fever.	Cochrane Review	Physical method vs drug placebo	1 study (small) no significant difference in number children without fever after 1 hr.	On occasions just says physical method of cooling but doesn't explain what the method is. Small number of studies included
			Antipyretic drug vs antipyretic and physical method.	2 studies, higher proportion of children without fever at 1 hr with combination (n=125, RR 11.76; 95%Ci 3.39 to 40.79)
			Proportion with adverse events	3 trials, more adverse events in sponging group than in paracetamol alone group. (RR 5.09;95% CI 1.56 to 16.60)
Watts, R. Robertson, J. 2003 Australia	10 studies randomised or quasi-randomised trials.	Systematic Review	Paracetamol vs sponging	7 studies reported statistical significance in 3 studies paracetamol better.	Different methods of rating discomfort used therefore difficult to compare results. Published and unpublished research was used.
			Antipyretic and sponging vs sponging alone	5 studies found 3 reported with statistical significance combination better
			Antipyretic and sponging vs antipyretic alone	8 studies found 4 reported with statistical significance combination better.
			Discomfort due to sponging	2 out of the 5 studies that measured discomfort found with statistical significance that sponging caused more discomfort.

Comment(s)

2 articles that appeared relevant from the abstracts did not arrive in time (references below). The primary purpose for intervening should be to decrease the child's discomfort this is difficult to measure especially in the very young. It appears that sponging can have a role to play in conjunction with paracetamol so long as the child is not distressed by the intervention. It must be remembered that a fever is an immunologic response that needs intervention if the child is distressed it must not be reduced merely to reduce parental anxiety.

Clinical Bottom Line

A balance must be found between the need to decrease the febrile child's temperature and distress. Tepid sponging can have a role to play in fever reduction together with paracetamol but should not be used as a substitute.

References

1. Donahue, A.M Tepid sponging Journal of Emergency Nursing. 9(2) 1983, p78-82.
2. Clarita, R. & Pacis A comparison of 3 methods of temperature control. ANPHI Papers. Vol 21(2) 1986 Jul-Dec, p20-28.
3. Meremikwu, M. & Oyo-Ita, A Physical methods for treating fever in children (Review). The Cochrane Library. Issue 2 2006
4. Watts, R. Robertson, J. & Thomas, G Nursing management of fever in children: A systematic review. International Journal of Nursing Practice. Vol 9 2003, S1-8.