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Comparison of Rectal, Axillary, Aural and non-contact thermometers in Febrile children

1 Assistant Professor, 2 Associate Professor, 3 Professor Department of Paediatrics, Government Vellore Medical College, Vellore Email: dr.ar.karthick@gmail.com, Mobile No. 9884201751 Corresponding Author Dr Luke Ravi Chelliah Abstract Introduction: Highest incidence of febrile illnesses occur in infancy and early childhood and it is essential to determine body temperature accurately, allowing rapid identification of potentially life threatening conditions. Rectal temperature is considered as ‘Gold standard’ but it is inconvenient. This study was designed to assess and compare the performance of three commercially available thermometers, a digital thermometer for axillary and rectal temperature measurement, a non-contact infrared thermometer for forehead temperature measurement and an infrared tympanic membrane thermometer. Methods and Materials: It was a descriptive study done in febrile children aged 3 months to 5 years, from September 2016 to February 2017 in Department of Paediatrics, Government Medical College and Hospital, Vellore, Tamil Nadu. Results: Mean rectal temperature was 38.96 o C ± 0.62 o C. Mean tympanic membrane temperature was 38.80 o C ± 0.64 o C. Mean axillary temperature was 38.04oC ± 0.62oC. Mean forehead temperature was 38.38 o C ± 0.65 o C. The co-efficient of correlation between mean rectal and tympanic membrane temperature was 0.958 and between mean rectal and axillary temperature was 0.907. The co-efficient of correlation between mean rectal and forehead temperature was 0.940. Conclusion: Children experienced more discomfort during rectal thermometry than with others. Amongst the three method, tympanic membrane temperature closely correlated and reflected the rectal temperature.


Introduction
Febrile illnesses have their highest incidence in infancy and early childhood, and fever is the leading symptom bringing children to the pediatrician. Fever may be the only objective indication of serious bacterial infection such as sepsis etc., which includes meningitis (1) . Accurate determination of body temperature is essential, allowing rapid identification of potentially life threatening conditions. The www.jmscr.igmpublication.org Impact Factor 5.84 Index Copernicus Value: 83.27 ISSN (e)-2347-176x ISSN (p) 2455-0450 DOI: https://dx.doi.org/10.18535/jmscr/v5i6.174 accepted method for accurate determination of body temperature in non-neonatal ambulatory children is by inserting a thermometer into the rectum to obtain a rectal temperature which is often considered the "gold standard" for clinical use. However, rectal temperature measurement is inconvenient, invasive, time consuming, potentially painful and not possible in children with diarrhoeal diseases (2) . The tympanic membrane shares the same vascular supply that perfuses the hypothalamus and is an excellent, readily accessible site for core temperature measurement. Infrared thermometers that enable temperature to be measured at the external ear canal have become available in the past 15 years and have been introduced into wide spread clinical use. Newer infrared thermometers have come which has enabled us to measure temperature by non-contact method (3) . This study was designed to assess and compare the performance of three commercially available thermometers, a digital thermometer for axillary and rectal temperature measurement, a noncontact infrared thermometer for forehead temperature measurement and the other an infrared tympanic membrane thermometer.

Materials and Methods
Five hundred children with fever in the age group between 3 months to 5 years, who attended the Department of Pediatrics, Government Vellore Medical College, Vellore, were included in the study. They were randomized. Children with suppurative Otitis media, otitis externa, large amount of wax, anal fissure and those with diarrhoeal diseases were excluded from the study. A cutoff of 38˚C was kept to define a febrile patient. Informed written consent was obtained from the caretakers / parents of the children. Rectal temperature was obtained by using a digital electronic thermometer. Axillary and Rectal temperature measurements were taken using OMRON MC-246 digital thermometer. A probe cap was initially mounted over the tip and water soluble lubricant jelly was applied over the probe.
They were positioned properly (child in left lateral position, in supine position) and the buttocks were separated and thermometer was inserted without force to a distance of 1 -1.5 cm into the rectum. When the reading was ready, the thermometer would emit a [beep-beep-beep] sound three times. Ear temperature was measured by using Chicco infrared ear thermometer. A probe cap was housed on the thermometer case as instructed in operation manual. The center of the probe cap was aligned with the center of the probe. Ear was pulled back slightly to straighten the ear canal (for children under 1 yearpinna was gently pulled backwards and for children over 1 years of age pinna was gently pulled upwards and backwards). "Scan" button on the right side of the thermometer was pressed and the beep signal was taken as end point and the reading was noted. The same procedure was repeated in the other ear. Separate probe caps were used for each child. Forehead temperature was measured by using Equinox Touchfree infrared thermometer. The forehead was made free of sweat and hairs if any were moved aside. Power button was pressed to turn on the thermometer. The scan button was pressed and held down and the thermometer was gently moved towards the temporal area at distance of about 4 -6 cm. The scan button would then be released and a short beep was heard which indicated end of measurement. The temperature displayed instantly was measured. Two readings were taken in time gap of 30 seconds. The instruments were pre-calibrated. Attempts were made to take all readings in patients within ten minutes and in following order: forehead temperature  ear temperature  axillary temperature  rectal temperature. After measurements, parental and patient preference was assessed for all the techniques. FLACC pain scale was used to assess the level of discomfort experienced by children during each procedure. Relevant investigation for the diagnosis was done as and when and appropriate treatment was initiated.
The data were analyzed using SPSS ver. 18.0 and following statistical methods were applied.
 Descriptive statistic which includes mean, standard deviation and range to know the nature of sample, age and group wise.  Product moment correlation to find out the relationship between temperature recorded among different age groups.
 Graphical representation of two temperature considering x and y axis.

Results
A total of 500 children admitted with fever during the period September 2016 to February 2017 were enrolled in the study. The mean age of children is found to be around 23 -24 months i.e., around 2 years. When 't' test is applied to these values, a non-significant difference existed between males and females.  The mean values of the readings taken in both ears is nearly equal and the difference exists in the 2 nd decimal point. The intra patient correlation between the two readings on right ear (r = 0.993) and that between the two readings on the left side (r = 0.994) were highly significant (p<0.0001) indicating that there was high reliability in the measurement of first and second readings of the temperature of respective ears. Comparatively the mean temperature from both ears is nearly the same. The difference exists in the third decimal and it is totally negligible. The mean temperature difference between the two ears is 0.002 o C. The intra patient correlation between the readings of right and left ears was highly significant (r=0.994, p<0.0001). The mean values of the readings taken in forehead is nearly the same. The paired't' test revealed a correlation value of 0.997 and p value of 0.397 (P>0.05) and no significant difference exists between the two readings.   It is evident that measurement of temperature by rectal thermometer was more painful when compared to that of other methods and Forehead thermometer which has mean value of 2.92 is the least painful procedure.

Conclusion
Fever is an important indicator of infection in children. The height of the fever correlates with the likelihood of serious bacterial infection and occult bacteremia. With the technology of today, patterns of fever are seldom used to narrow a differential diagnosis. It is important to be able to detect and document fever accurately. Ear and forehead are potentially convenient sites for paediatric temperature measurement and in this study it has been shown that ear temperature correlates well with "core" body temperature than the axillary or forehead method. It is also well accepted by children and parents. Compared to oral, axillary and rectal thermometry, ear thermometry has advantages, which include ease of use, rapidity of results, safety, non-invasiveness, patient and health care provider convenience, lack of influence by factors known to spuriously affect oral temperature (tachypnea, recent oral intake, crying etc.) and reliability over a wide range of temperatures. Rectal thermometry, along with the risk of perforation, has also been shown to lag behind in a dynamic situation where temperature is changing rapidly. It is also not possible to use in case of co-existing diarrheal diseases. Temperature recording is particularly upsetting for the younger child and it is time to consider whether tympanic thermometry can take over from traditional methods of temperature measurement.