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Complementary, Holistic, and Integrative Medicine: Fever
Dere& 'ang" (ecilia )u&utu" Alison *hompson and Sunita +ohra
Pediatrics in Review #$$,-.$-!/
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Article complementary medicine
Complementary, Holistic, and
Integrative Medicine: Fever
Dere& 'ang"9
(ecilia )u&utu" PhD9
Alison *hompson" )4"
M4"9 Sunita +ohra" MD"
:2(P(" MSc9
Author Disclosure
Mr 'ang" Dr
)u&utu" and Ms
*hompson have
disclosed no financial
relationships relevant
to this
article. Dr +ohra has
disclosed receiving
salary support from
the Alberta ;eritage
:oundation for
Medical 2esearch
Population ;ealth
and (anadian
Institutes of ;ealth
2esearch. *his review
was funded in part by
PasseportSante< .net.
*his commentary does
contain a discussion
of an unapproved/
investigative use of a
commercial
product/device.
Introduction
:ever" commonly defined as a temperature of ,,./=: >.!./=(? or greater >a@illary? or
$$.%=: >.A.$=(? or greater >core?" is a common pediatric sign that has many causes >eg"
bacterial or viral infection?. Some of the causes are self1limiting and do not reBuire
treatment- others are serious underlying conditions reBuiring treatment. In children
>particularly infants?" see&ing medical attention for the evaluation" diagnosis" and treat1
ment of the underlying cause of fever is standard care. >? Some families see& to alleviate
fever and its associated symptoms >eg" discomfort" irritability" crying? through easily
accessible" ad3unctive self1care techniBues and complementary and alternative medicine
>(AM? therapies.
*his review discusses common (AM therapies that have been used to treat fever in
children and is limited to the following modalities" for which published scientific literature
is available: physical methods" natural health products >4;Ps?" and traditional (hinese
medicine >*(M?.
Physical Methods
Physical methods such as tepid sponging" bathing" fanning" and cooling blan&ets often are
used to treat fever. >#?>.? Although physical methods often are ine@pensive and readily
available" the efficacy of many of these methods has not been established through rigorous
research. >%?
A #$$7 systematic review of seven Buasi1randomiCed" controlled trials >2(*s? that
included children >n %7!? ages month to / years who had fever of a Dpresumed
infectious originE compared physical methods >eg" tepid sponging? with or without a drug
treatment >antipyretic? to a drug treatment" placebo" or no treatment. >%? 0f the seven
studies" three small trials had positive findings and demonstrated that tepid sponging
helped to reduce fever in children. ;owever" these findings were observed in children who
had already ta&en acetaminophen" so it is unclear whether the tepid sponging was
responsible for the observed reduction in fever. *he trials considered in this systematic
review had very small numbers and suffered from various methodologic limitations" such
as inadeBuate/unclear methods of sub3ect allocation and high dropout rates or
withdrawals. *he authors concluded that evidence to either support or discourage the
use of physical methods alone to treat fever is limited. >%?
Another systematic of $ Buasi12(*s" including the seven studies in the previously
cited review" also found minimal benefit from sponging in temperate climates and
concluded that evidence to support the routine use of sponging is lac&ing. >/? *his review
involved studies of febrile children between . months and 7 years of age who were not
critically ill.
In #$$$" a review e@amining the efficacy of tepid sponging for fever cited results from
four pediatric studies and reported little advantage to using tepid sponging in addition to
acetaminophen compared with using acetaminophen alone. :urthermore" acetaminophen
appeared to be a better tolerated treatment and was preferred by parents. >7?
(ommon adverse events >A5s? of physical methods of treating fever in general" and
9(omplementary and Alternative 2esearch and 5ducation >(A25? Program" Department of Pediatrics" Fniversity of
Alberta" 5dmonton" Alberta" (anada. 0n behalf of the American Academy of Pediatrics Section on (omplementary and
Integrative Medicine.
40*5: *he agents discussed in this series are designated as dietary supplements rather than drugs. Although dietary
supplements are regulated by the Fnited States :ood and Drug Administration >:DA?" their manufacturers may ma&e claims
with little evidence and need not prove safety prior to mar&eting. *he burden is on the :DA to monitor safety after the
product is on the mar&et. 2eaders are referred to the ,,% Dietary Supplement ;ealth and 5ducation Act >www.cfsan.fda.gov/
dms/dietsupp.html?.
Pediatrics in Review +ol..$ 4o.# :ebruary #$$, !/
complementary medicine fever
sponging in particular" include shivering" having Dgoose
pimples"E crying" and having discomfort. *hese A5s are
the same fever1associated symptoms that sponging aims
to reduce. *hus" the efficacy of sponging in children is
arguable. 2are A5s reported after sponging with alcohol
include the loss of consciousness. >%?
atural Health Products
!raditional Her"al Medicine
Many popular 4;Ps used to treat fever >eg" gentian"
licorice root" peppermint" yarrow? have not been evalu1
ated scientifically through clinical studies. 0ne published
2(* assessed the efficacy of a Gapanese herbal medicine"
Mao1to" to treat fever and influenCali&e symptoms in 7$
children >ages / months to . years?. >!? Mao1to is a
combination of Ephedra Herba" Cinnamomi Cortex" Ar-
menicae Semen, and Glycyrrhizae Radix and is reported
to have antiviral and autoimmune effects. (hildren in the
study were randomiCed to ta&e either Mao1to alone
orally >$.$7 g/&g per dose three times daily?- a neur1
aminidase inhibitor" oseltamivir ># mg/&g per dose twice
daily? alone- or a combination of Mao1to and oseltamivir.
>!? *he group that received only Mao1to had a shorter
duration of fever after starting the medication >/ hours"
,/H confidence interval I(IJ ..# to ##." P
$.$? compared with the combination of Mao1to and
oseltamivir group >A hours" ,/H (I: /.# to #!.!"
P $.$/?" and the neuraminidase inhibitor1only group
>#% hours" ,/H (I: #../ to %..$" P $.$?. 4o A5s were
reported. *hese results suggest that Mao1to may be a
cost1effective control for fever due to type A influenCa in
children because it costs between one tenth and one
twentieth that of neuraminidase inhibitors. >!?
Kimitations of this study include lac& of true random1
iCation because patients younger than year of age were
assigned to the Mao1to1only group >they did not meet
the criteria for neuraminidase inhibitor treatment in Ga1
pan? and small sample siCe. >!? Study results suggest that
Mao1to could be a possible candidate for additional
A""reviations
A#: adverse events
A$RI: acute lower respiratory infection
CAM: complementary and alternative medicine
CI: confidence interval
HP: natural health product
RC!: randomiCed" controlled trial
!CM: traditional (hinese medicine
research outside of Gapan to assess the generaliCability of
efficacy and safety of the herb.
%inc or &itamin A 'upplementation
)oth Cinc and vitamin A are important for human growth
and immune function. >A? An 2(* e@amined the effects
of Cinc acetate and vitamin A supplementation on resolv1
ing fever in /. children >ages # to #% months? hospi1
taliCed in India who had severe acute lower respiratory
infection >AK2I?" including fever. (hildren received Cinc
acetate >$ mg twice daily for / days? plus vitamin
A placebo- vitamin A >$"$$$ mcg retinol twice daily for
% days? plus Cinc placebo- Cinc acetate plus vitamin A- or
Cinc and vitamin A placebos. :or boys supplemented
with Cinc acetate only" the resolution of fever was
.. times more rapid >P $.$$.? than seen in children
not supplemented with Cinc. 2eported A5s included
death >n ?" diarrhea >n /?" pyopneumothora@ >n %?"
and bulging fontanelle >n .?. *hese results suggest that
Cinc treatment reduces duration of fever due to AK2I for
boys" but not for girls" and that vitamin A treatment had
no benefit. >A?
)aseline evaluations of Cinc or vitamin A status were
not reported in this study for the Durban and peri1urban
poorE sub3ects" who may possess deficiencies >ie" suffer
from malnutrition? that may ma&e them much more
vulnerable to the onset of AK2I and its complications
and also might affect the resolution of fever" thereby
serving as confounders. (onclusions based on the re1
sults" therefore" are not generaliCable to other pediatric
populations" and research to determine the e@act mech1
anism of action for Cinc therapy is needed. Linc has
several A5s. 'hen ta&en in high doses over long periods"
it can decrease immunity and copper absorption" causing
copper deficiency that" in turn" increases the ris& of
anemia. Milder A5s associated with e@cessive Cinc inta&e
include headaches" stomach irritation" nausea" and vom1
iting.
!raditional Chinese Medicine
*(M is an ancient (hinese system of medicine that
includes meditation" herbal and nutritional therapy"
physical e@ercises" massage" and acupuncture. A paucity
of well1designed 2(*s e@ist that have investigated the
effectiveness of *(M remedies to treat fever. *hus" the
information presented in this section comes from case
reports that have several methodologic limitations. Such
findings should be viewed as being preliminary" incon1
clusive" and reBuiring additional research.
!7 Pediatrics in Review +ol..$ 4o.# :ebruary #$$,
complementary medicine fever
Cupping
In *(M" cupping involves the application of a vacuum to
a localiCed area of the s&in. >,? *his procedure is believed
to increase circulation in the treated area and theoreti1
cally eliminate to@ins trapped in the tissue. >$?
Kiu assessed the efficacy of cupping therapy in $.
individuals from ! to /A years of age who had high fever
due to upper respiratory tract infection. >? *he inter1
vention was described as Dfire1insertion cuppingE for / to
/ minutes over three pressure points on the head. *he
author defined the outcomes as: ? cured" if the body
temperature dropped to the normal range and was still
normal after % hours or #? effective" if the body temper1
ature dropped to the Dnormal rangeE >not defined? and
was no more than $$.%=: >.A=(? % hours later or if the
temperature dropped to between ,,..= and $$.%=:
>.!.%= and .A=(? and rose by no more than $.%=(
% hours later. >? A total of . study participants were
described as cured" and results in 7A cases were termed
effective- the outcomes from the remaining four cases
and any A5s were not mentioned.
Although the authors reported a high success rate
>,7H? with this method" this study suffers from ma3or
methodologic inadeBuacies" including lac& of informa1
tion on the method of diagnosing upper respiratory tract
infection" Dblinding"E randomiCation" and a control
group. Study results need verification through larger and
better designed 2(*s. :urthermore" because this re1
search was conducted in a predominantly adult popula1
tion" the findings may not be generaliCable to children.
Several mild A5s from the use of cupping have been
reported" including circular ecchymotic lesions >bruis1
ing?. >$? 0ccasionally" cupping can cause panniculitis
>inflammation of subcutaneous fatty and muscle tissue?
or thermal in3ury. >$?
Acupuncture
Acupuncture is a method of healing developed in (hina
at least #"$$$ years ago that describes a family of proce1
dures involving stimulation of anatomic points on the
body by a variety of techniBues. *he acupuncture tech1
niBue that has been scientifically studied most involves
penetrating the s&in with thin" solid" metallic needles that
are manipulated by the hands or that carry electrical
stimulation. >#?
A (hinese study investigated whether fever caused by
the common cold could be treated with application of
acupuncture needles at three pressure points on the head.
>.? Participants >n /!? ages 7 to 7A years suffering
from the common cold were recruited from a local
hospital. 0f these" %/ individuals had received medica1
tion more than % hours earlier" and # had received none.
Patients were as&ed to rest Buietly for $ to / minutes
before the acupuncture. *he author reported statistically
significant changes in ob3ective indicators after treat1
ment >eg" body temperature" respirations" heart rate"
blood pressure" temperature at the three pressure points
on the head where acupuncture needles were applied?.
*he freBuency of these measures was not described" and
no correlations between them were discussed.
(linical effects were described as being effective in
%7 of /! cases for a total efficacy rate of A$.!H. >.?
:inally" a comparison of morbidity scores before
>A.// $.%.? and after >..A/ $.##? treatment showed a
statistically significant difference. Although this study
observed positive effects of acupuncture in treating fever
and associated symptoms in patients suffering from the
common cold" influenCa" acute tonsillitis" and acute
bronchitis" poor study design limits the validity of the
findings. Methodologic limitations include lac& of a con1
trol group" poor reporting of outcomes" and Buestion1
able primary outcome measures >due to combining ob1
3ective and sub3ective measures into one score?. 4o A5s
were reported. Additional research in this area is needed
to clarify the efficacy and safety of needle acupuncture to
reduce fever.
Acupuncture therapy rarely results in serious A5s.
>%? 5vidence from # prospective studies of more than
million treatments estimates the ris& of a serious A5
occurring from acupuncture therapy to be $.$/ per
$"$$$ treatments and $.// per $"$$$ individual pa1
tients in the general population. >%? *he most common
serious A5s included pneumothora@" in3ury to the cen1
tral nervous system" transmission of hepatitis )" and s&in
infections. >%?
Conclusion
2eviews of available evidence have concluded that phys1
ical methods of cooling" such as tepid sponging" cannot
be considered effective in reducing childhood fever due
to the lac& of clear and verifiable findings. *he rationale
for and physiologic mechanisms of the herbal medicine
Mao1to and Cinc supplementation for treating fever are
not well understood- they should be viewed with caution
when considered as treatments for children. Preliminary
evidence for the efficacy of *(M >cupping and needle
acupuncture? in treating fever comes from three inade1
Buately described case series. *hese studies have meth1
odologic shortcomings and do not provide sufficient
evidence to support the use of these (AM therapies. *he
need for more rigorous studies to evaluate the efficacy of
(AM therapies in children suffering from fever is clear.
Pediatrics in Review +ol..$ 4o.# :ebruary #$$, !!
complementary medicine fever
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!A Pediatrics in Review +ol..$ 4o.# :ebruary #$$,
Complementary, Holistic, and Integrative Medicine: Fever
Dere& 'ang" (ecilia )u&utu" Alison *hompson and Sunita +ohra
Pediatrics in Review #$$,-.$-!/
D0I: $./%#/pir..$1#1!/
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