16 International Journal of Nursing Care. January-June., 2013, Vol.1, No.

Warm Sponging Versus Tepid Sponging in Febrile

Children: Double Blind Randomized Controlled Trial of
efficacy

Athirarani M R
Assistant Professor, Govt. College of Nursing, Thiruvananthapuram, Kerala

ABSTRACT
Objective: To compare the efficacy of Warm Sponging with Tepid Sponging among children aged 6
months to 5 years with fever (>100oF to <104oF) and receiving syrup Paracetamol 15mg/kg body weight
in reducing body temperature by at least 20F or to normal temperature (98.6oF) at 30 minutes of
initiation of sponging
Materials and Method: The design adopted for the study was Parallel Group Double Blind Randomized
Controlled Trial
The participants consisted of 268 Children aged 6 months to 5 years of age and axillary temperature
100oF to 104oF were recruited from out patient department of a primary care setting and were screened
by review of medical history. Exclusion criteria were history of seizures, intake of antipyretics within 6
hrs, contraindications to paracetamol , dehydration and disorders of central nervous system. There
were two arms for the study i.e the Experimental group received Warm Sponging & paracetamol
(n=134) and Control group ;Tepid sponging & paracetamol, (n=134). The Outcome measure was
reduction of body temperature by at least 2oF or attaining normal temperature (98.6o F).
Results: There was a statistically significant difference in proportion of target temperature reduction
between Warm sponging and Tepid sponging groups . Chi square 21.145 at 1d(f) , P value 0.00001: The
achievement of target temperature in Warm sponging group was 49.25% and 22.39% in Tepid sponging
group, the difference in proportion between group is 26.86% ( 95% CI of 15.84% - 37.88%).
Conclusion: The study concluded that warm sponging along with oral paracetamol, was found to be
more effective than tepid sponging along with oral paracetamol in reducing temperature in febrile
children.

Keywords: Febrile Children, Paracetamol, Tepid Sponging, Warm Sponging

INTRODUCTION However, the efficacy of externally applied cooling

Fever is the commonest symptom of disease in
children(1). According to National Family Health
Survey III (2005-06), in India, 15 percent of children
under age three were ill with fever in the two weeks
prior to survey and among this 71% of children with
fever were taken to a health facility or to a provider(2) ..
Under normal circumstances, human body maintains
a normal range of internal body temperature that is
called the set point. It is not a specific temperature
but is a range of temperature (approximately 36.200 to
37.800C) above or below which compensatory warming
or cooling mechanisms are activated(3). The efficacy of
paracetamol as an antipyretic acting at the
hypothalamic set point is already established (4) .
measures for reducing fever has not been established(5)
Regarding external cooling measures, there are different
opinions about the use of sponging as an intervention.
The use of tepid sponging for reduction of fever has
been in practice for a long time. Recently it has been
claimed that warm sponging is better than tepid
sponging and that it has more physiological basis than
tepid sponging as a treatment for fever (6 ) (7) (8) . Globally
no study has been conducted to test the efficacy of warm
sponging compared to tepid sponging. Cochrane
Library on systematic review also recommends that it
would be helpful to compare warm sponging with tepid
sponging, with paracetamol in both arms, in a
randomized study (9)(10).

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 International Journal of Nursing Care. January-June., 2013, Vol.1, No. 1 17

MATERIALS & METHOD minutes, and then the back and the abdomen. The
procedure was repeated for 15 minutes. The
The children between the age group of 6 months to 5
temperature is again measured at 30 minutes of
years with fever (Temperature 100oF to 104oF) were
initiation of sponging (T30 minute).
recruited from the Out Patient Department of First
Referral Unit and were provided with the information Figure 1. CONSORT Flow chart
about study and given opportunity to participate. The
physician did the physical examination and prescribed
the medication. This study was conducted as per the
guidelines of Institutional Research & Human Ethics
Committee, Medical College, Thiruvananthapuram and
registered in Clinical Trials Registry of India (REFCTRI
- 2009 000666,19-08-2009). Informed consent was
obtained from the parents of all the participants.

The children with the history of seizures, Severely

dehydrated children, those with CNS disorders,
Chronic liver disorders, h/o allergy to Paracetamol and
children who had antipyretics within 6 hrs were
excluded from the study. A Written informed consent
was obtained from parents. The estimated sample size
was 134 participants in each arm & the total
participants were 268; The formula used for sample
size calculation for comparing two independent groups
using Pocock formula, with an effect size 15% , Z=
1.96 & Power 80%. The random numbers were generated
by the statistician and kept by the Head Nurse in charge
of the Out Patient Department. After checking the
physicians prescription the participants were
randomly assigned into one of the two treatment groups
(figure1). The randomization sequence was generated
using Random number table and using blocks of AB
& BA combinations to get an equal number of patients
in both groups; warm sponging or tepid sponging, 134
participants in each group.
The intervention begins with checking temperature
(recoded as T0 minute) & administering the Syrup
paracetamol 15mg/kg body weight. Tepid sponging
procedure was as follows, the articles used were a clean
tray containing Mackintosh, Basin with water, Bath
blanket, Sponge clothe, Small towel, Thermostat and
Chemical thermometer. After washing and drying
hands; a mackintosh was placed under child and
removed clothes and a bath blanket kept over body
exposing only the parts being sponged; put off fan.
Washcloths was immersed in water and squeeze to
remove dribbling water. Wiped the face and neck first
without touching the eyes and wiped down towards
fingers/ toes from outer aspect of each extremity and
move up from the inner aspect. Sponge cloths were kept
at each axilla & groin. A clockwise sequence was
followed for wiping the extremities each in turn for 5
For Warm sponging the water temperature was
34-37 oC (94-99o F) and done fast with long strokes. The
temperature of the water for warm is maintained with
the help of a thermostat. The temperature of the water
in thermostat is kept at a higher temperature i.e. at
45 o C (113 o F) than the required temperature of
34-37oC(93-99oF), based on the assumption of Newtons
law of rate of cooling. Because there will be reduction of
temperature while immersing a sponge clothe in water
& heat loss during the procedure. For Tepid sponging
the water temperature was 29-33oC (84-91oF) and done
with out long strokes or friction on the skin. Tap water
is used for tepid sponging, which collected in the
morning and kept in a separate basin & temperature of
the water is measured by a chemical (bath thermometer).
The procedure was done by the researcher; the
outcome assessment was done by the Research
Assistant. The Outcome Measures was proportion of
children with temperature reduction by 20F or attaining
normal temperature at 15 minutes after sponging,
measured by a digital thermometer. Digital thermometer
(Infi-Check, Model MT-219,CE 0044 with a,
Measurement range of 89.6oF to 109.4oF were used to
measure the temperature. Reliability of digital

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 18 International Journal of Nursing Care. January-June., 2013, Vol.1, No. 1

thermometers was ascertained by Intra Class
Correlation I.C.C. between Thermometer 1 &
thermometer 2 = 0.9680 and I.C.C. between Research
assistant I& Research assistant II = 0.9729
STATISTICAL ANALYSIS
Data were entered in the software were Microsoft
excel, data cleaned & statistical analysis was done using
the softwares SPSS 11 & Epi info. The first step in the
data analysis was to assess the descriptive statistics of
the baseline variables of the participants in the two
arms of treatment and to ensure the randomization was
proper. For quantitative variables mean and standard
deviations or Median and inter quartile range were
calculated. For qualitative variables, percentage was
calculated. Descriptive statistics were calculated for
baseline variables (table 1). Outcome was measured as
the proportion of children who achieved target
temperature reduction (tested by x2 test).A total of 268
patients, 139 girls (51.86%) and 129(48.13%) boys were
included. The median age of patients was 30.5 months.
The median initial temperature was 101.3oF in the
experimental Group & 101.1oF in the control group.

Table 1. Baseline Characteristics of the two groups

Serial Variable Warm Sponging Tepid Sponging

No. (N=134) (N=134)
1 Age in months
Median(IQR) 30 (24.5) 36 (32.25)
2 Sex
Girls 72 (53.7%) 67 (50%)
Boys 62 (46.3%) 67 (50%)
3 Religion
Hindu 110 (82.1%) 114 (85.1%)
Christian 7 (5.2%) 3 (2.2%)
Muslim 17 (12.7%) 17 (12.7%)
4 Type of family
Nuclear 57(42.5%) 67(50%)
Joint 56 (41.8%) 61(45.5%)
Extended 21(15.7%) 16(11.9%)
5 Place of residence
Urban 2(1.5%) 5(3.7%)
Rural 128(95.5%) 126(94%)
Costal 4(3%) 3(2.2%)
6 Income
APL 38(28.4%) 33(24.6%)
BPL 96(71.6%) 101(75.4%)
7 Education of Mother
Primary school 29(21.6%) 19(14.2%)
High School 77(57.5%) 78(58.2%
Higher secondary& above 28(20.9%) 37(27.6%)
8 Education of father
Primary school 33(24.6%) 32(23.9%)
High School 87(64.9) 86(64.2%)
Higher secondary &above 13(9.7%) 16(11.9%)
9 Birth weight
Under weight 20(14.9%) 25(18.7%)
Normal 114(85.1%) 109(81.3%)
10 Immunization
Complete 123(91.8%) 129(96.3%)
Incomplete 11(8.2%) 5(3.7%)
11 Initial temperature
Median(IQR) 101.3(1.85) 101.1(1.70)
101.3(1.85) 101.1(1.70)

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 International Journal of Nursing Care. January-June., 2013, Vol.1, No. 1 19
RESULT
Proportion of children with temperature reduction
by 20F or attaining normal temperature at 15 minutes
after sponging, measured by a digital thermometer was
the outcome measure. The reduction of at least 20F or to
normal temperature (98.60F) at 30 minutes of initiation
of sponging was the target, in warm sponging group it
Table 2: Comparison of proportion of children who achieved temperature reduction by x2 test
Treatment
Warm sponging
+Syrup Paracetamol
15mg/Kg body wt
Temperature reduction attained 66
Temperature reduction not attained 68
134
DISCUSSION
In the available literature there are two studies
compared the efficacy the warm sponging. Study by
Edward Purssel (Arch Dis Child 2000;82:238-239)
compared Paracetamol 5-10 mg/kg body weight + tepid
sponging+ sponging time 20 minutes versus
Paracetamol 15mg/kg body weight + Warm
sponging(water temperature 31-33oC) + sponging time
15minutes. The mean temperature difference in fist
group was 0.2 oF & in warm sponging group it was
0.8oF.Another study by Kinmonth A (BMJ Vol 305,7
Nov,1992) compared the fever clearing time ; there were
three arms Syrup paracetamol Vs. Syrup paracetamol
+ warm sponging Vs Warm sponging .The fever clearing
time in these groups were Syrup paracetamol (65
minutes) Syrup paracetamol + warm sponging (31.1
minutes) and Warm sponging (20 minutes).
CONCLUSIONS
It is concluded that warm sponging along with
oral paracetamol, is clearly more effective than tepid
sponging along with oral paracetamol in reducing
temperature in febrile children.
ACKNOWLEDGEMENTS
The author is thankful to Dr.Rajamohanan k. Prof
of paediatrics, SAT Hospital Thiruvananthapuram, Dr
4. athirarani-16-20.pmd 19
was 49.25% (66/134) and attainment of target
temperature in Tepid sponging group was 22.39%
(30/134). Thus the effect size i.e. the difference in
proportion of the warm sponging group and the tepid
sponging group was 26.86% with a 95% confidence
interval of 15.84% - 37.88%. x2 is 21.145 at 1d(f).The p
value obtained is 0.00001.Thus the effect of warm
sponging was highly significant(table 2).
Total Significance
Tepid sponging
+Syrup Paracetamol
15mg/Kg body wt
30 96 x2 =21.145
104 172 P =.00001 Significant
134 268
MKC Nair, Director, Child Development Centre
Thiruvananthapuram, Prof.Prasanna Kumari.Y,
Deputy Director of Nursing Education, Dr RM
Panda,HOD, Dept of Biostatistics, All India Institute of
Medical Sciences and all the faculty of Clinical
Epidemiology Research and Training Centre,
Government Medical College, Thiruvananthapuram,
Kerala,
Conflict of Interest
There were no conflicts of interest reported.
FUNDING
There was no financial assistance from any
governmental/non governmental funding agency.
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