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Three Part Question

In [children <5 years old presenting to the Emergency Department with pyrexia] is [tympanic or oral thermometry] [more accurate at measuring the temperature]?

Clinical Scenario

A 2-year-old boy is brought into the Emergency Department one evening and his parents say he has been feeling hot the last 24 hours, and has a sore throat and is feeling irritable. They have measured his temperature at home using an oral thermometer and it read 39oC. You wonder if the tympanic thermometer in the Emergency Department is a more accurate way of measuring his temperature.

Search Strategy

OVID Medline <1966 – June Week 3 2005>
EMBASE <1980 – 2005 Week 26>
CINAHL <1982 – June Week 3 2005>
The Cochrane Library 2005 Issue 2.
Medline
(exp Fever/ OR fever$.mp. OR suspected fever$.mp. OR febrile.mp. OR pyrexia$.mp. OR exp TEMPERATURE/ OR exp Body Temperature/ OR exp Skin Temperature/ OR exp Body Temperature Regulation/ OR warm.mp. OR hot.mp. OR exp Seizures, Febrile/) AND (exp THERMOMETERS/ OR thermometer$.mp. OR exp Thermography/ OR temperature probe$.mp. OR mercury.mp. OR mercury thermometer$.mp. OR tympanic thermometer$.mp. OR tympanic probe$.mp. OR aural thermometer$.mp. OR aural probe$.mp. infrared thermometer$.mp. OR infrared probe.mp. OR ear thermometer$.mp. OR ear probe$.mp.) AND (exp THERMOMETERS/ OR thermometer$.mp. OR exp Thermography/ OR temperature probe$.mp. OR mercury.mp. OR mercury thermometer$.mp. OR oral thermometer$.mp. OR oral probe$.mp. OR sublingual thermometer$.mp. OR sublingual probe$.mp. OR mouth thermometer$.mp. OR mouth probe$.mp.) limit to (humans and english language and ("infant (1 to 23 months)" or "preschool child (2 to 5 years)"))
EMBASE
(exp FEVER/ OR fever$.mp. OR suspected fever$.mp. OR febrile.mp. OR pyrexia$.mp. OR exp TEMPERATURE/ OR exp Body Temperature/ OR exp Skin Temperature/ OR exp HIGH TEMPERATURE/ OR exp Febrile Convulsion/ OR warm.mp. OR hot.mp) AND (exp Temperature Measurement/ OR exp THERMOMETER/ OR thermometer$.mp. OR exp THERMOGRAPHY/ OR exp THERMOMETRY/ OR temperature probe$.mp. OR exp MERCURY/ or mercury thermometer$.mp.) AND (tympanic thermometer$.mp. OR tympanic probe$.mp. OR aural thermometer$.mp. OR aural probe$.mp. infrared thermometer$.mp. OR infrared probe.mp. OR ear thermometer$.mp. OR ear probe$.mp.) AND (oral thermometer$.mp. OR oral probe$.mp. OR sublingual thermometer$.mp. OR sublingual probe$.mp. OR mouth thermometer$.mp. OR mouth probe$.mp.) limit to human and English language and infant or preschool child <1 to 6 years>))
CINAHL
(exp FEVER/ OR fever$.mp. OR suspected fever.mp. OR febrile.mp. pyrexia$.mp. exp TEMPERATURE/ OR exp Body Temperature/ OR exp Skin Temperature/ OR BODY TEMPERATURE REGULATION/ OR exp ORAL BODT TEMPERATURE/ OR exp TYMPANIC BODY TEMPERATURE/ OR warm.mp. OR hot.mp. OR exp Convulsions, Febrile/) AND (exp Thermometers/ OR thermometer$.mp. OR exp THERMOGRAPHY/ OR thermometry.mp. OR temperature probe$.mp. OR exp Body Temperature Determination/ OR exp MERCURY/ OR mercury thermometer$.mp.) AND (exp Tympanic Thermometers/ OR tympanic thermometer$.mp. Or tympanic probe$.mp. OR aural thermometer$.mp. OR aural probe$.mp. OR infrared thermometer$.mp. OR infrared probe$.mp. OR ear thermometer$.mp. OR ear probe$.mp.) AND (exp Oral Thermometers/ OR oral thermometer$.mp. OR oral probe$.mp. OR sublingual thermometer$.mp. OR sublingual probe$.mp. OR mouth thermometer$.mp. OR mouth probe$.mp.) Limit to (English and (infant <1 to 23 months> or preschool child <2 to 5 years>))

Search Outcome

Medline: 220 papers found, 5 were relevant.
Embase: 114 papers found, no new papers.
CINAHL: 3 papers found, none relevant.
Cochrane Library - no relevant papers found.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Pontious SL, Kennedy A, Chung KL, Burroughs TE, Libby LJ and Vogel DW. 1994. USA.	172 children who presented to an emergency department during a 5-month period. 89 were febrile and 83 were afebrile. Comparing TempaDOT (oral and axillary) with FirstTEMP (tympanic) and Genius (tympanic).	Clinical trial.	Accuracy	TempaDOT was most accurate, followed by FirstTEMP and Genius. Most accurate sites were oral, axillary, tympanic and rectal.	No basic data on the patients regarding their temperatures or ages.
			Sensitivity to temperatures <37.5oC.	TempaDOT is most sensitive.
			Sensitivity to temperatures >37.5oC	FirstTEMP is most sensitive.
			Precision	TempaDOT is most precise, followed by FirstTEMP and Genius. Most precise sites were oral, tympanic, rectal and axillary.
Talo H, Macknin ML and Medendorp SV. 1991. USA.	137 children in a hospital setting.	Controlled clinical trial.	Correlation coefficients between right and left ears.	Significantly large (p<0.01) correlation coefficients (0.92).	Data derived from abstract only.
			Correlation coefficients between oral and mean ear.	Significantly large (p<0.01) correlation coefficients (0.68).
			Temperature difference between mean ear and oral.	-0.20oC (+/- 0.59oC)
Rhoads FA and Grandner J. 1990 USA	48 children aged 1 month to 10 years old in a hospital outpatient setting.	Cohort study.	Comparison between oral and tympanic measurement	40/48 (88.5%) of oral measurements were higher than tympanic measurements.	Data available from abstract only.
			Range of temperature differences.	-0.7oC to +2.5oC.
			Correlation between tympanic and oral measurements.	0.75
			Sensitivity to temperatures of 39oC.	0/3 patients with oral temperature of 39oC were detected by tympanic thermometer.
			Sensitivity to temperatures of 38oC or higher..	3/8 (37.5%) of patients with oral temperature 38oC or higher were detected by tympanic thermometer.
Kelly B and Alexander D. 1991. USA.	84 children with unilateral suppurative or non-suppurative otitis media.	Cohort study.	Mean temperature difference between infected and uninfected ears.	For 67 children with unilateral suppurative otitis media, mean temperature in infected ear was 0.38o Fahrenheit higher than in uninfected ear (p=0.005). For 17 children with unilateral non-suppurative otitis media, no statistically significant difference between temperatures of infected and uninfected ears.	Data derived from abstract only.
			Temperature difference between infected or uninfected ears and oral measurement.	No significant difference.
Chamberlain JM, Grandner J, Rubinoff JL, Klein BL, Waisman Y and Huey M. 1991 USA	Children in a paediatric emergency department. Comparing tympanic thermometer to oral thermometer.	Controlled clinical trial.	Sensitivity in detecting temperatures of 38oC.	Tympanic thermometer is 80% sensitive.	Data derived from abstract only.
			Specificity in detecting temperatures of 38oC.	Tympanic thermometer has 93% specificity.
			Sensitivity in detecting temperatures of 38.5oC.	Tympanic thermometer is 80% sensitive.
			Specificity in detecting temperatures of 38.5oC.	Tympanic thermometer has 95% specificity.

Comment(s)

Only one of the five papers could be obtained in full. As much relevant data as possible was derived from the abstracts of the other papers. Two papers suggested that oral thermometry was more accurate than tympanic thermometry. One paper found that there was no statistically significant difference between oral and tympanic thermometer readings and one paper found that the presence of otitis media has no significant impact on the accuracy of tympanic thermometer readings.

Clinical Bottom Line

Oral thermometry appears to be more accurate and precise than tympanic thermometry, but tympanic thermometry is more sensitive at temperature above 37.5oC and can be trusted in the presence of otitis media.

References

1. Pontious SL, Kennedy A, Chung KL, Burroughs TE, Libby LJ and Vogel DW. Accuracy and reliability of temperature measurement in the emergency department by instrument and site in children. Pediatric Nursing. 1994 Jan-Feb; 20(1):58-63.
2. Talo H, Macknin ML and Medendorp SV. Tympanic membrane temperatures compared to rectal and oral temperatures. Clinical Pediatrics. 1991 Apr; 30 (4):30-3
3. Rhoads FA and Grandner J. Assessment of an aural infrared sensor for body temperature measurement in children. Clinical Pediatrics. 1990 Feb; 29(2):112-5
4. Kelly B and Alexander D. Effect of otitis media on infrared tympanic thermometry. Clinical Pediatrics 1991 Apr; 30 (4): 46-8
5. Chamberlain JM, Grandner J, Rubinoff JL, Klein BL, Waisman Y and Huey M. Comparison of a tympanic thermometer to rectal and oral thermometers in a pediatric emergency department. Clinical Pediatrics. 1991 Apr; 30(4):24-9.