A5V4d

Antipyretic interventions
9.2 Physical and drug interventions to reduce body
temperature
Review question
What, if any, antipyretic interventions are effective in reducing body temperature in children with
fever?
There are a number of interventions that can be undertaken to reduce temperature, both
pharmacological and physical; however, it is not clear whether these treatments are either beneficial
or necessary, or what the indications for the treatment of fever should be. Consequently, there is wide
variation in practice, both with the use of interventions, and the outcomes that are aimed for. Some
healthcare professionals aim to reduce temperature to what they consider to be normal, while others
aim simply to reduce temperature. Although the circumstances under which interventions are used
will vary, it is important that the possible benefits and harms of treating fever are understood. This
includes any adverse effects from the interventions.
Elevations in body temperature result from rising levels of substances such as prostaglandins in the
hypothalamus. This has the effect of resetting the hypothalamic temperature set-point and increasing
temperature. Paracetamol and no steroidal anti-inflammatory agents such as ibuprofen inhibit the
action of the cyclooxygenase enzymes involved in the production of prostaglandins, and this is the
basis of their antipyretic activity, although inflammatory mediators other than prostaglandins may also
be potential drug targets. Peripherally, the production of pyrogenic cytokines is also suppressed and
the production of endogenous anti-inflammatory compounds is promoted.
Physical treatments such as tepid sponging cool the part of the body being sponged but do not
reduce the levels of prostaglandins and so the temperature of the whole body is not reduced.
Furthermore, because the hypothalamus is still set at a higher temperature level, physical treatments
may cause shivering and other adverse effects as the body aims to meet the hypothalamic set-point
temperature, which continues to be raised. Shivering with a high temperature is sometimes referred to
as a rigor.
Physical interventions
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.
Narrative evidence
Two reviews 208,209 with EL 1+ and EL 2+ ratings, respectively, due to the nature of the included
studies, were found. These compared tepid sponging with antipyretic drugs. One systematic review
(SR) 210 which evaluated the benefits and harms of sponging techniques was also found. One further
study compared undressing with paracetamol and tepid sponging. 211 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. 209 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. 212 Discomfort was also
significant, a finding that is supported by some studies of tepid sponging in children. 213
GDG translation
Physical methods of temperature reduction do not treat the cause of fever, which is the action of
circulating pyrogens 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
197