The Efficacy of Tepid Sponge Bathing to
Reduce Fever in Young Children
JANE SHARBER, RN, MS, CEN
Tepid sponge baths distress febrile children, and their efficacy at
reducing fever has not been established. This study compared fever
reductionand with (1) acetaminophenalone and (2) acetaminophenplus a
15-minute tepid sponge bath. Twenty children, ages 5 to 68 months,
who presented to the emergency department or urgent care center with
fever of .::38.9'C were randomized to receive (1} acetaminophenalone or
(2) acetaminophen plus a 15-minute tepid sponge bath. All subjects
received a 15-mg/kg dose of acetaminophen.Tympanictemperaturewas
monitored every 30 minutes for 2 hours. Subjects were monitored for
signs of discomfort(crying, shivering, goosebumps). Sponge-bathed
subjectscooled faster duringthe firsthour, but there was no significant
temperature difference between the groupsover the 2-hour studyperiod
(P = .871). Subjects in the sponge bath group had significantlyhigher
discomfortscores (P = .009). (Am J Emerg Med 1997;15:188-192. Copy-
right© 1997 by W.B. Saunders Company)
Fever is one of the most common complaints in children
presenting to the emergency department (ED) and urgent
care center (UC). McCarthy1 reported 20% of children seen
in a pediatric ED were febrile. Complaints of fever also
accounted for 15% of after-hour calls to one pediatric
residency group and 19% of the visits to a sick child clinic.2•3
Although normal febrile responses are self-limiting, parents
may have undue concern over the danger fevers pose. Health
care providers may contribute to this fear with mixed
messages about the danger of fever and aggressive overtreat-
ment."?
Fever is a natural host response to infection or stressors.
Cytokines, such as interleukin-I (IL-1), released in reaction
to pathogens or tissue damage act at the anterior hypothala-
mus to raise the thermostatic set point, possibly through the
release of prostaglandins; heat-conserving and heat-produc-
ing effector mechanisms (shivering, vasoconstriction) are
activated.8 The neuropeptides vasopressin and o-melanocyte
stimulating hormone have been identified as possible endog-
enous antipyretics that downregulate fever by suppressing
thermostatic changes.9 Heat-dissipating effector mecha-
nisms (sweating, vasodilation) are activated during deferves-
ence.
In the ED or UC setting, antipyretic medications and tepid
From the College of Nursing, University of Arizona, Tucson.
Manuscript received May 8, 1995, returned June 20, 1995; revision
received December 13, 1995, accepted January 24, 1996.
FirstTemp Genius® tympanic thermometer provided by Sherwood
IMS, Carlsbad, CA.
This study was conducted toward completion of a Master of
Science degree at the University of Arizona, Tucson. Research was
conducted at Tucson Medical Center.
Address reprint requests to Ms Sharber, College of Nursing,
University of Arizona, 1305 North Martin Ave, Tucson, AZ 85721.
Key Words: Fever, sponge bath, tympanic thermometer, acetami-
nophen, childhood fever.
Copyright© 1997 by W.B. Saunders Company
0735-6757/97/1502-0022$5.00/0
188
sponge baths are commonly prescribed interventions for
children with fever. The efficacy of antipyretic medications
that reduce fever by acting on the hypothalamic set-point has
been well documented. However, the efficacy of externally
applied cooling measures, such as tepid sponge baths, for
reducing fever has not been established. Furthermore, sponge
baths are often distressing for febrile children and time-
consuming for staff to perform.
This article reports the results of a study that compared the
efficacy and the amount of discomfort between two tech-
niques to reduce fever in young children: (1) antipyretic
medication alone, and (2) antipyretic medication plus a tepid
sponge bath.'? Two null hypotheses were tested: (1) there is
no difference in overall temperature reduction between
febrile children treated with antipyretics alone, and those
treated with antipyretics and sponge bathing; (2) there is no
difference in discomfort between patients who receive
antipyretics alone, and those receive antipyretics and sponge
bathing.
METHODS
The study was conducted over a 3-month period in the ED and
UC of a large southwestern community hospital. The study was
approved by the institutional and university human subjects
committees, and written informed consent was obtained from the
parent or guardian of all subjects. Twenty subjects between 5 and
68 months of age were recruited. All subjects presented to the ED
or UC with a complaint of fever and a rectal temperature of
2'.38.9°C.Exclusion criteria included (1) illness requiring immedi-
ate antibiotic therapy, (2) antipyretic medication within 4 hours
prior to arrival, (3) nonpyrogenic fever (hyperthermia), and (4)
communication barrier which precluded obtaining informed con-
sent from the parent or guardian. The entry temperature reflected
the generally accepted threshold for treatment of fever." The age
range included children small enough to be bathed in a plastic tub
and excluded very young infants in whom febrile illnesses are
considered more serious.
The subjects were randomly assigned to receive either (1)
acetaminophen alone or (2) acetaminophen plus a tepid sponge
bath. Randomization was achieved by assigning subjects to the
treatment group specified by opening in order the next of 20 sealed,
serially numbered envelopes containing previously shuffled cards.
The treatment to be received was written on the card, and there
were 10 cards for each treatment group.
Procedure
The study period lasted 2 hours and the entire study protocol was
carried out by the investigator. Data recorded included age
(months), gender, height (cm), weight (kg), acetaminophen dose
(mg), body temperature (°C), discharge diagnosis, room tempera-
ture, and room humidity. After the initial temperature was taken,
subjects were undressed and weighed on identical scales (Olympic
Smart Scale Model 50; Olympic Medical, Seattle, WA). All
subjects then received a 15-mg/kg dose of acetaminophen on
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189 SHARBER • SPONGE BATHING FEBRILE CHILDREN
AMERICAN JOURNAL OF EMERGENCY MEDICINE• Volume 15, Number 2 • March 1997
189

approval of the ED or UC physician. The children were left RESULTS

undressed to their diaper for the duration of the study period and
oral fluids were freely encouraged. Body surface area (BSA) was Computerized analysis of the data was carried out using
calculated from a standard nomogram. The room temperature was SPSS statistical program. Descriptive statistics on demo-
adjusted to between 23.9°C and 27.2°C, and room temperature and graphic data were calculated for each treatment group.
humidity were measured using a sling psychrometer (Taylor Group equivalence was determined by Mann-Whitney U test
Thermometer Corporation of America, Fletcher, NC). for the variable of age, weight, BSA, initial temperature,
The subjects' temperatures were recorded initially and at 30- room temperature, and humidity, and by chi-square test of
minute intervals throughout the 2-hour study period using an independence for discharge diagnosis. Significance was set
infrared tympanic thermometer (First'Iemp Genius; Sherwood at P :::=; .05 for all analyses.
Intelligent Medical Systems, Carlsbad, CA). The thermometer was Hypotheses 1 and 2 were tested using a mixed design
calibrated by the manufacturer at the start of the study, and the analysis of variance (SPSS MANOVA procedure), with
same thermometer was used for all temperature readings through- treatment group as the between-subjects factor, and time as
out the study. The thermometer was set in the "tympanic" mode the within-subjects factor. A post hoc analysis was con-
and "core" equivalency setting. A pilot study had previously ducted when a significant group effect was detected to
established the stability of the tympanic thermometer readings. identify the specific treatment effect on temperature change,
Temperatures were taken by placing the probe over the outer or discomfort level. Equivalence of discomfort scale scores
opening of the ear canal, sealing the outer opening, with the tip of between the treatment groups was determined by Mann-
the probe directed toward the tympanic membrane. Whitney U test.
The infrared tympanic thermometer was selected for this study
as the best reflection of core temperature, and as the most
Description of Sample
acceptable method to the children and parents for repeated
temperature measurements. The tympanic membrane is the least Two subjects were seen in the UC, and 18 subjects were
invasive site for clinical temperature measurement that accurately seen in the ED. An undocumented number of potential
reflects true core body temperature, the temperature at the hypothala- subjects were excluded from the study because of a recent
mus.12-15 Rectal temperature readings may be higher than actual antipyretic dose or communication barrier. The results of the
core temperature and lag behind core temperature fluctuations analyses of demographic data and room temperature and
because of stool in the rectum and the distance of the rectum from humidity are presented in Table 1. Gender was equally
the central nervous system and large central vessels.12 distributed between treatment groups, with 5 males and 5
Infrared tympanic thermometer readings are not significantly females in each group. The average bath water temperature
affected by otitis media, cerumen in the ear canal, or tympanostomy for the sponge baths was 33.0°C (range, 32.3°C to 33.3°C).
tubes.16-18 However, external heating or cooling of the head and Discharge diagnoses are described in Table 2; analysis of
neck can decrease tympanic membrane temperature readings. diagnostic categories demonstrated no significant between
Doyle et al19 reported that this effect lasted at least 20 minutes after
the two treatment groups. Some subjects had multiple
exposure to extreme ambient temperatures.
diagnoses.
Subjects in the sponge bath group were bathed 30 minutes after
the acetaminophen dose. Acetaminophen is absorbed from the
gastrointestinal tract within 10 to 60 minutes following oral Results of Hypothesis Testing
administration, and a noticeable temperature decrease occurs Results for the MANOVA procedure on hypothesis 1, no
within 30 minutes.P-" External cooling is predicted to be more difference in overall temperature change between groups,
comfortable and effective once normal heat-dissipating effector
mechanisms are activated. For the sponge bath, the child was
seated in a plastic tub in 2 inches of water at a temperature of TABLE 1. Descriptive Statistics and Mann-Whitney UTests for
31.1°C to 33.3°C (factory-calibrated Sunbeam liquid thermometer; Demographic Data by Group
Sunbeam, Wood Ridge, NJ). The child was continuously sponged Mean 2-Tailed
for 15 minutes using a washcloth to distribute the water over the Variable Group Mean SD Range Rank u p
head, trunk, and extremities.
The subjects were monitored for signs of discomfort (crying, Age (mo) 23.40 19.24 7.00-68.00 11.20 43.0 .6305
shivering, and "goosebumps") at 15-minute intervals throughout 2 16.90 9.67 5.00-33.00 9.80
the study period and at 5-minute intervals during the bathing Weight (kg) 11.41 3.82 8.20-20.28 11.60 39.0 .4359
procedure. At each observation, the occurrence of each symptom 2 9.84 2.01 6.62-12.30 9.40
was given a score of" I." Scores were totaled for each observation BSA(m2) 0.54 0.14 0.42-0.88 11.50 40.0 .4813
period with a possible discomfort score range of O to 3. These 2 0.49 0.08 0.37-0.58 9.50
symptoms have previously been cited in the literature as indicators Initial
of discomfort associated with the application of external cooling temp °C 39.77 0.54 39.0-40.8 10.95 45.5 .7394
measures.F-> All observations were made by a single observer; 2 39.75 0.67 38.9-41.0 10.05
temp °C
Room
therefore,and
intervals scoring
subjects.
was expected to be consistent across time
25.48 0.67 24.0-26.1 9.05 35.5 .2799
2 25.81 0.76 24.4-27.2 11.95
At the end of the bathing period, parents were asked to rate their
Room
perception of the child's discomfort. An anchored, O-to-10discom- humid% 34.00 3.13 27.0-37.0 8.70 32.0 .1903
concurrent
fort validity
scale was used, of theO observed
with labeled nodiscomfort.
discomfort,The
and discomfort
10 labeled NOTE: Group 1, acetaminophen only (n = 1 O); Group 2, acetamino-
2 38.40 6.69 31.0-51.0 12.30
extreme
scale wasdiscomfort.
not pilot-tested.
The discomfort scale was included to establish phen & spongebath (n = 10).
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190

TABLE 2. Discharge Diagnoses by Group Scores in the sponge-bathed group were significantly higher
at the .OS level (Table 4). A significant correlation was noted
Total Group 1 Group 2 between the observed discomfort scores and the discomfort
(N = 20) (N = 10) (N= 10)
scale scores (Spearman rho = .63, P = .00).
Diagnosis % % %
DISCUSSION
Otitis media 11 55 4 40 7 70
Respiratory tract infec- The study findings of no significant additional fever
tions* 6 30 5 50 10 reduction with tepid sponge bathing are similar to results
Viral syndrome/viremia 3 15 2 20 10 reported by two earlier studies evaluating fever reduction
Other+ 5 25 2 20 3 30
from antipyretics with and without sponge bathing. Hunter+
NOTES: Group 1 , acetaminophen only; Group 2, acetaminophen & and Newman26 reported tepid sponge bathing added no
sponge bath. f * N because of multiple diagnoses in some cases. significant additional reduction in fever beyond antipyretics
P= .263. alone. In contrast, Steele et al24 reported greater temperature
*Includes: URI, bronchitis, common cold, bronchiolitis, pharyngitis. reduction in subjects who received sponge bathing in
+lncludes: dehydration, stomatitis, febrile seizure, sinusitis. addition to antipyretics. Hunter, and Steele et al, sponge-
Reprinted with permlsslon'? bathed their subjects until a predetermined temperature was
are summarized in Table 3. Two cases from the sponge bath reached (up to 2 hours), but did not monitor temperatures
group were excluded from analysis because of errors in data after the bathing was stopped.22•24 In the current study,
collection at time 2 ( one temperature omitted, one taken 5 subjects experienced a rebound increase in body temperature
minutes into the bath). MANOVA results demonstrated after the bath. The body temperature immediately after the
significant temperature changes over time in both treatment bath is not known; therefore, the occurrence of afterfall
groups. However, post hoc one-way analysis contrasts cannot be inferred from this study data.
showed no significant difference in temperature between Mean temperatures by group are plotted in Figure I.
groups (P ::c; .01). The null hypothesis was supported. Subjects in the sponge bath group cooled more quickly; the
MANOVAresults for hypothesis 2, no difference between sponge bath group mean temperature was 0.77°C lower than
groups on measures of discomfort, are summarized in Table the acetaminophen-only group at 15 minutes after the bath.
3. Between-groups and within-groups results indicated sig- However, this difference was not statistically significant.
nificant difference in measures of discomfort because of The temperature readings may have been artificially low
treatment and time. Post hoc one-way analysis contrasts because external cooling to the face and head may have
were run on only 7 of the 11 observations to avoid a type II decreased tympanic membrane temperatures. 19
error (the significance level decreases with each additional Discomfort associated with the sponge bathing procedure
contrast). Significant differences between groups were found was clearly demonstrated in this study. Children in the
only for observations during the bathing period (P = .00). sponge bath group scored significantly higher on discomfort
The null hypothesis was rejected. scores during the bathing period only, and were rated higher
on discomfort by parents. Steele et al24 also reported
minimal discomfort in subjects who were not bathed and
Discomfort Scale
increasing discomfort with cooler bathing solutions. Caruso
The discomfort scale scores (parental rating of child's et al27 reported that warmer cooling blanket temperatures
discomfort) were compared using Mann-Whitney U test. were as effective and more comfortable than cool tempera-
tures for treating febrile adults.
TABLE 3. MANOVAfor Hypothesis I, Temperature; and Hypothesis
The results of the study can be explained by the physiol-
2,ObservedDiscomfort
ogy of temperature control and the mechanisms of fever.
Significance Body temperature is defended around the hypothalamic set
SS df F of F point by increasing or decreasing heat loss through changes
in peripheral blood flow and heat production from metabolic
Hypothesis 1: Temperature
activity.28•29 During fever, external cooling may produce heat
Between-Subjects Effect
Within Cells 20.30 16
loss, but may also activate heat-conserving and producing
Treatment Effects 0.30 1 0.03 .871 mechanisms. These mechanisms, vasoconstriction, shiver-
Within-Subjects Effect ing, and goosebumps, contribute to discomfort experienced
Within Cells 6.28 64 by children who are sponge bathed.
Time 37.70 4 96.07 .000 Heat loss depends on peripheral blood flow, BSA expo-
Treatment by Time 2.21 4 5.62 .001
Hypothesis
Discomfort
2: Observed
TABLE 4. Discomfort
Mann-Whitney UTest Scale Scores by Temperature Group:
Between-Subjects Effect
Within Cells 15.97 18 Mean Cases
Treatment Effects 7.64 1 8.61 .009 Rank (N)
Within-Subject Effect
Within Cells 29.13 180 Acetaminophen only 7.75 10
Time 15.11 10 9.34 .000 Acetaminophen & sponge bath 13.25 10
Treatment by Time 14.31 10 8.84 .000
NOTES: U, 2-tailed P, .0355; corrected for ties: Z, -2.1067; P, .0351.
JANE
191 SHARBER • SPONGE BATHING FEBRILE CHILDREN
AMERICAN JOURNAL
40.0
39.5
'iii'
.a
d"'i 39.0
~ ibuprofen, might give different results. Other areas for future
(l)
s-,
sponge
~ 38.5 bath
!
period
38.0
1·········
37.5
0 30 60 90 120
Time (minutes)
FIGURE 1. Mean temperature by group: mean and standard error
c•, acetaminophen only; 6, acetaminophen & sponge bath).
(Reprinted with perrnission.!")
sure, and the temperature gradient between the body and the
environment, and is maximized by increasing blood flow,
exposure, and the body-to-environment temperature gradi-
ent without activating heat conserving mechanisms.29 To
minimize activation of heat conserving mechanisms in this
study, time was allowed for the antipyretic to take effect
before bathing, warmer room and bath water temperatures
were used, and fluid intake was encouraged. Still, 7 of 10
children experienced goosebumps during the bath, and one
child had shivering.
Studies of hyperthermia suggest cool bathing solutions
are less effective at promoting heat loss than warmer
solutions because of peripheral vasoconstriction.P-" Dehy-
dration may also reduce heat loss by causing vasoconstric-
tion. Aynsley-Green and Pickering33 suggest that sponge
bathing may aggravate vasoconstriction in dehydrated fe-
brile children and result in increased core temperatures.
Dehydration was seen clinically more often than is reflected
in the discharge diagnoses. Six (30%) children consumed
from 240 mL to 720 mL of oral fluids during the study
period, and one (5%) child required 440 mL of intravenous
fluids. However, the effects of dehydration and fluid con-
sumption on fever reduction were not systematically evalu-
ated during this study.
Thomas et al34 called for research-based ED fever manage-
ment practices, and several researchers noted the need for
health care providers to provide reasonable intervention and
consistent parental education to reduce exaggerated fear of
fevers and avoid overtreatment.s-v"? The study results
suggest that a 15-minute sponge bath provides little addi-
tional fever reduction over antipyretic medication alone.
Initial management of a febrile child should ensure that the
child has received an adequate dose of an antipyretic and
that the child is adequately hydrated. If sponge bathing is
performed, warmer water and environmental temperatures
should be used, and the possibility of a rebound temperature
increase 30 to 60 minutes after the bath should be antici-
pated.
Febrile illnesses are common during childhood. Reassur-
OF EMERGENCY MEDICINE• Volume 15, Number 2 • March 1997
191
ance, accurate information about fever, and appropriate
management of febrile children by health care providers will
help relieve parental anxiety. The outcome of this study
should be verified by further research, because generalizabil-
ity is limited by the small sample size recruited from a single
facility. Similar studies with different antipyretics, such as
research include the mechanisms of fever and febrile
seizures, and the influence of hydration on fever and fever
reduction. Future advances in clinical thermometry will
improve the accuracy of core temperature measurements
with minimal invasiveness.
The author thanks Ida (Ki) M. Moore, RN, DNSc, Patricia Jones, PhD,
and Naja McKenzie, RN, MN, formerly of Sherwood IMS, and the
staff nurses at TMC ED and UC for their support and assistance.
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