Non-pharmacological fever and hyperthermia management in children: an integrative review

Souza, Mariana Vieira de; Damião, Elaine Buchhorn Cintra; Buchhorn, Soraia Matilde Marques; Rossato, Lisabelle Mariano

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Acta Paulista de Enfermagem

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Review Article • Acta Paul Enferm. 34 • 2021 • https://doi.org/10.37689/acta-ape/2021AR00743 copy

Non-pharmacological fever and hyperthermia management in children: an integrative review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To identify non-pharmacological interventions for fever and hyperthermia in children indicated in the scientific literature.

Methods:

an integrative literature review carried out in the LILACS, PubMed and CINAHL databases and in the COCHRANE and SciELO libraries. Articles that addressed non-pharmacological interventions for fever and hyperthermia, published in Portuguese and English, from 2000 to 2019, have been included.

Results:

The sample consisted of 27 articles, which were grouped, according to their similarities, into seven categories. The interventions used were baths, warm compresses, sponging, encouraging fluid intake, ice packs, cooled blankets, and room ventilation. Different interventions were observed in non-pharmacological fever and hyperthermia management.

Conclusion:

Practicing non-pharmacological measures alone is not recommended for fever treatment in children, except for interventions that assist in the physiological responses of the body. The results highlight the recommendation of conducting further research that results in evidence to support the best care provided by pediatric nurses to children with fever.

Keywords
Child; Fever; Pediatric nursing; Nursing care

Author(s)/Year	Level ^* * Oxford Evidence Level 1A: Systematic Review (with homogeneity) of Randomized Controlled Trials; 1B: Individual Randomized Controlled Trial (with narrow Confidence Interval); 2B: Individual cohort study (including Low Quality RCT); 5: Expert opinion without explicit critical appraisal, or based on physiology (lab or animal experiments)	Objective(s)	Method	Interventions	Conclusions
Pavithra C. 2018.⁽¹1. Pavithra C. Effect of Tepid Vs Warm sponging on body temperature and comfort among children with Pyrexia at Sri Ramakrishna hospital, Coimbatore. Int J Sci Applied Res. 2018;5(6):25-30.⁾	1B	To compare the effect of warm sponging with hot sponging in children with fever.	Randomized clinical trial	Warm sponging + antipyretic; hot sponging + antipyretic	Substantial reduction in body temperature with warm and hot sponging. Warm sponging causes mild discomfort when compared to hot sponging. Using hot sponging is recommended to reduce body temperature and promote comfort among children with fever.
Salgado PA, et al. 2015.⁽⁷7. Salgado PO, Silva LC, Silva PM, Paiva IR, Macieira TG, Chianca TC. [Nursing care to pacients with high body temperature: an integrative review]. Rev Min Enferm. 2015;19(1):212-9. Portuguese.⁾	5	To identify the evidence available in the literature on the best nursing care for patients with elevated body temperature.	Integrative review	Warm bath; warm compresses; combined therapy (physical + antipyretic method); ice packs; room ventilation	To treat children with a fever, fluid intake should be encouraged, excess clothing removed, air circulation in the environment and parents’ education. Although some studies in pediatrics demonstrate that using combination therapy is more effective in reducing body temperature than the administration of antipyretic alone.
Axelrod P. 2000.⁽¹⁵15. Axelrod P. External cooling in the management of fever. Clin Infect Dis. 2000 Oct;31(5 Suppl 5):S224-9.⁾	5	To assess external cooling measures for fever treatment	Literature review	Bath with alcohol; sponging; combined therapy (warm sponging + antipyretic); sponging with alcohol; icy sponging; refrigerated blankets	Children treated with warm sponging and antipyretics generally have greater discomfort than those treated with antipyretic alone. It is advised that physical methods are indicated only in hyperthermia treatment.
Thompson HJ et al. 2007.⁽¹⁶16. Thompson HJ, Kirkness CJ, Mitchell PH, Webb DJ. Fever management practices of neuroscience nurses: national and regional perspectives. J Neurosci Nurs. 2007;39(3):151-62.⁾	5	To determine whether there are trends in national practices in fever and hyperthermia management in neurologically vulnerable patients.	Quantitative study	Ice packs; refrigerated blankets; baths	Recommended interventions in fever and hyperthermia management: use of ice packs, refrigerated blankets and baths.
Casey G. 2000.⁽¹⁷17. Casey G. Fever management in children. Nurs Stand. 2000;14(40):36-40.⁾	5	To provide an explanation of the physiological mechanisms in controlling children's body temperature and how they change in fever.	Reflection study	Cold bath; warm sponging; combined therapy (warm sponging + antipyretic)	Warm sponging and bathing in cold water is not recommended, as they can increase discomfort, in addition to quickly reducing body temperature and causing a thermal shock.
Joanna Briggs Institute for Evidence Based Nursing and Midwifery. 2001.⁽¹⁸18. Joanna Briggs Institute for Evidence Based Nursing and Midwifery. Management of the child with fever. Best Practice. 2001;5(5):1-6.⁾	1A	To determine whether the available evidence supports the types and timing of the various nursing interventions commonly used for reduce fever in children.	Best practices guide	Warm sponging; combined therapy (sponging + antipyretic); cold bath; application of cold compresses; removing clothes; use of fans; encouraging fluid intake	Warm sponging is not indicated for fever treatment. It is recommended to encourage fluid intake, removal of excess clothes or sheets.
Watts R. 2012.⁽¹⁹19. Watts R, Robertson J. Non-pharmacological Management of Fever in Otherwise Healthy Children. JBI Library Syst Rev. 2012;10(28):1634-87.⁾	1A	To establish which non-pharmacological measures are effective in managing fever in healthy children from 3 months to 12 years of age.	Systematic review	Warm sponging; combined therapy (sponging + antipyretic); use of fans; rest and encouraging fluid intake	Warm sponging has no beneficial effect. It is recommended to encourage fluid intake, removal of excess clothing.
Purssel Edward. 2000.⁽²⁰20. Purssell E. Physical treatment of fever. Arch Dis Child. 2000;82(3):238-9.⁾	5	To assess the effectiveness of physical methods in fever treatment in children	Reflection study	Warm sponging; combined therapy (warm sponging + antipyretic); removal of excess clothing and ventilation of the environment.	Using combination therapy offers little advantage over the administration of antipyretic alone in treating febrile children.
McDougall P. 2014.⁽²¹21. McDougall P, Harrison M. Fever and feverish illness in children under five years. Nurs Stand. 2014;28(30):49-59.⁾	5	To increase the reader's understanding of the pathophysiology of fever in children and the identification of serious illness.	Literature review	Removing excess clothing; encouraging fluid intake; warm bath; cold bath; sponging	Cold or warm baths should not be given. Sponging or bathing at room temperature, encouraging fluid intake and removing excess clothing are recommended interventions.
Clarke P. 2014.⁽²²22. Patricia C. Evidence-based management of childhood fever: what pediatric nurses need to know. J Pediatr Nurs. 2014;29(4):372-5.⁾	5	To analyze the knowledge base of pediatric nurses in relation to fever in children.	Literature review	Sponging with alcohol; cold sponging	Sponging with alcohol is contraindicated in fever treatment. Guiding parents on encouraging the supply of fluids, removing excess clothing and watching for signs of seriousness.
Lava SAG, et al. 2012.⁽²³23. Lava SA, Simonetti GD, Ramelli GP, Tschumi S, Bianchetti MG. Symptomatic management of fever by Swiss board-certified pediatricians: results from a cross-sectional, Web-based survey. Clin Ther. 2012;34(1):250-6.⁾	5	To describe fever management in children.	Quantitative study	Warm sponging	Physical methods are not recommended due to insufficient clinical advantages.
Alves JG. 2008.⁽²⁴24. Alves JG, Almeida ND, Almeida CD. Tepid sponging plus dipyrone versus dipyrone alone for reducing body temperature in febrile children. Sao Paulo Med J. 2008;126(2):107-11.⁾	1B	To compare the effects of warm sponging and dipyrone with only dipyrone in fever treatment.	Randomized clinical trial	Combined therapy (warm sponging + antipyretic)	Adding warm sponging to the dipyrone promotes faster cooling.
Watts R. 2003.⁽²⁵25. Watts R, Robertson J, Thomas G. Nursing management of fever in children: a systematic review. Int J Nurs Pract. 2003;9(1):S1-8.⁾	1A	To determine the best available evidence that supports the types and timing of nursing interventions	Systematic review	Encouraging fluid intake; removing excess clothing; ventilation of the environment; warm sponging; combined therapy (warm sponging + antipyretic)	It is recommended to encourage fluid intake, removal of excess clothing or ventilation of the environment.
Moran P. 2012.⁽²⁶26. Moran P, Nicholson A. Management of fever in young children. WIN. 2012;20(9):40-4.⁾	5	To identify fever and signs of severity and provide guidance on fever management.	Literature review	Opening of windows and ventilation of the environment; warm sponging; combined therapy (warm sponging + antipyretic)	Lack of evidence to indicate the opening of windows or ventilation of the environment. Warm sponging does not offer significant advantages over the use of antipyretics alone.
Christie J. 2002.⁽²⁷27. Christie J. Managing febrile children: when and how to treat. Nurs N Z. 2002;8(4):15-7.⁾	5	To compare and evaluate the effectiveness of cooling methods and determine best practices based on evidence-based guidelines.	Literature review	Warm sponging; combined therapy (warm sponging + antipyretic); use of fans; removing clothes and blankets	Warm sponging is not recommended, as use of fans and removal of clothes are unnecessary interventions.
Thomas S et al. 2009.⁽²⁸28. Thomas S, Vijaykumar C, Naik R, Moses PD, Antonisamy B. Comparative effectiveness of tepid sponging and antipyretic drug versus only antipyretic drug in the management of fever among children: a randomized controlled trial. Indian Pediatr. 2009;46(2):133-6.⁾	2B	To compare the effectiveness of warm sponging and antipyretic drugs versus only antipyretic drugs in treatment of febrile children.	Randomized clinical trial	Combined therapy (warm sponging + antipyretic	Adding warm sponging to the administration of antipyretics does not offer any advantage in reducing the temperature and can result in discomfort.
Meremikwu MM. 2009.⁽²⁹29. Meremikwu MM, Oyo-Ita A. Physical methods versus drug placebo or no treatment for managing fever in children. Cochrane Database Syst Rev. 2003;(2):1-23.⁾	1A	To assess the benefits and harms of using physical cooling methods in fever management in children	Systematic review	Warm sponging; combined therapy (warm sponging + antipyretic)	Warm sponging associated with paracetamol achieves a better antipyretic effect than just the antipyretic; however, lack of evidence makes it difficult to conclude possible benefits and harms associated with this common practice.
Robertson J. 2002.⁽³⁰30. Robertson J. Management of the child with fever. Collegian. 2002;9(2):40-2.⁾	5	To identify the factors for treating fever; evaluate the value of interventions used to treat childhood fever and, provide information to parents that will allow them to safely manage their febrile child at home.	Reflection study	Warm sponging; combined therapy (warm sponging + antipyretic); encouraging fluid intake; removing excess clothing	It is recommended to encourage fluid intake and remove excess clothing.
Bernath VF. 2002.⁽³¹31. Bernath VF, Anderson JN, Silagy CA. Tepid sponging and paracetamol for reduction of body temperature in febrile children. Med J Aust. 2002;176(3):130.⁾	5	To assess the effectiveness of warm sponging in relation to the combined use of paracetamol with warm sponging in reducing body temperature.	Literature review	Warm sponging; combined therapy (warm sponging + antipyretic)	Warm sponging is effective in treating febrile children in the first 30 minutes and has an additive effect when combined with paracetamol.
National Institute for Health and Care Excellence: Clinical Guidelines. 2013.⁽³²32. Davis T. NICE guideline: feverish illness in children—assessment and initial management in children younger than 5 years. Arch Dis Child Educ Pract Ed. 2013;98(6):232-5.⁾	5	To present the recent clinical guideline on fever management in children.	Best practices guide	Warm sponging; removing excess clothing	Warm sponging is not recommended for fever treatment. It is recommended to remove excess clothing and blankets, encourage fluid intake and breastfeed for babies.
Roberts S. 2008.⁽³³33. Roberts S. The feverish child: knowing what to do. BJSN. 2008;3(06):290-2.⁾	5	To explore issues related to fever in young children, how to recognize it and discuss different forms of treatment.	Reflection study	Warm sponging; use of fans	Warm sponging is not recommended. Use of fans to cool the environment should be indicated, as long as feverish children do not show tremors.
Edwards H et al. 2007.⁽³⁴34. Edwards H, Walsh A, Courtney M, Monaghan S, Wilson J, Young J. Improving paediatric nurses’ knowledge and attitudes in childhood fever management. J Adv Nurs. 2007;57(3):257-69.⁾	5	To present assessment of an education program effectiveness for the development of evidence-based knowledge aimed at fever management.	Quantitative study	Encouraging fluid intake; warm sponging	It is recommended to encourage fluid intake and warm sponging 30 minutes after antipyretic administration.
Beard RM. 2008.⁽³⁵35. Beard RM, Day MW. Fever and hyperthermia: learn to beat the heat. Nursing. 2008;38(6):28-31.⁾	5	To distinguish between fever and hyperthermia, assess and intervene appropriately.	Reflection study	Encouraging fluid intake; cold sponging; use of ice packs.	Recommended methods for the duration of the antipyretic: cold sponging on the forehead, use of ice packs on the groin and armpits and encouraging fluid intake.
Thompson HJ. 2011.⁽³⁶36. Thompson HJ, Kagan SH. Clinical management of fever by nurses: doing what works. J Adv Nurs. 2011;67(2):359-70.⁾	5	To define fever from the nurses ‘perspective, report nurses’ decision making regarding fever management, and report barriers to evidence-based practice.	Qualitative study	Blanket removal; opening windows; use of fans; ice packs; refrigerated blankets; baths	Lack of creation of multidisciplinary protocols. Nurses use interventions based on empirical experience, there is no evidence-based recommendation on the best method.
Aluka TM et al. 2013.⁽³⁷37. Aluka TM, Gyuse AN, Udonwa NE, Asibong UE, Meremikwu MM, Oyo-Ita A. Comparison of cold water sponging and acetaminophen in control of Fever among children attending a tertiary hospital in South Nigeria. J Family Med Prim Care. 2013;2(2):153-8.⁾	1B	To investigate the effectiveness of cold sponging compared to oral use of paracetamol in treatment of febrile children.	Randomized clinical trial	Cold sponging	Discomfort triggered by cold sponging should not limit using this intervention, considered a safe technique, it should be encouraged, including in order to avoid seizures.
Chiappini E et al. 2009.⁽³⁸38. Chiappini E, Principi N, Longhi R, Tovo PA, Becherucci P, Bonsignori F, et al.; Writing Committee of the Italian Pediatric Society Panel for the Management of Fever in Children. Management of fever in children: summary of the Italian Pediatric Society guidelines. Clin Ther. 2009;31(8):1826-43.⁾	5	To provide guidance on managing the signs and symptoms of fever in children.	Literature review	Warm sponging; exposure to cold air; refrigerated blankets; ice packs and sponging with alcohol	Physical methods are not recommended to reduce fever, only to treat hyperthermia.
Bridgwater K et al. 2008.⁽³⁹39. Bridgwater K, Fletcher M, Hatter E, Houghton J, Mason C, Monaghan J. Managing fever. Paediatr Nurs. 2008;20(8):27.⁾	5	To provide guidance on best evidence-based practices to assist nurses in providing care to children and adolescents with fever.	Best practices guide	Warm sponging; removing excess clothing; encouraging fluid intake	Using tepid sponging for fever management is not recommended, it is only recommended to remove excess clothing and encourage fluid intake.

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[1] Corresponding author Mariana Vieira de Souza, E-mail: mariana.ee@usp.br