Temperature =========== þ Oral temperatures - "Nearly 15 years ago, Dan Tandberg at Univ. of New Mexico published an elegant little study as a letter to the editor of NEJM. He showed persuasively that at respiratory rates over 18/minute there was significant and (most importantly) variable divergence of the usual and anticipated correlation of oral temperature with rectal temperature even in awake, alert adults." (S. Davidson, M.D.) þ Tympanic temperatures (some comments and references from H Louzon, MD) - Many studies have now confirmed that TM temperatures are inacurate, more often underestimating rather than overestimating the rectal temperature. One study found 96% specificity but 100% sensitivity under the age of 3 months but 100% sens/spec over 3 months. [Stewart JW, Webster D. Re-evaluation of the tympanic thermometer in the emergency department [see comments] Ann Emerg Med 1992;21(2):158-61.] Abstract: - In children less than 3 years old another study found a sensitivity of only 55% in detecting fever. [Muma BK, Treloar DJ, Wurmlinger K, Peterson E, Vitae A. Comparison of rectal, axillary, and tympanic membrane temperatures in infants and young children [see comments] Ann Emerg Med 1991;20(1):41-4.] Abstract: - In children aged 6 months to 6 years old TM measurements were 76% sensitive and 92% specific in detecting fever of 100.4 degrees F or more (and only 57% sensitive in the detection of 'high' fever > 102.9). [Brennan DF, Falk JL, Rothrock, SG Kerr RB. Reliability of infrared tympanic thermometry in the detection of rectal fever in children [see comments] Ann Emerg Med 1995; 25(1):21-30.] Abstract: - In children 2-71 months of age TM temps failed to detect fever in 33% of cases. [Hooker EA. Use of tympanic thermometers to screen for fever in patients in a pediatric emergency department [see comments] South Med J 1993; 86(8):855-8.] Abstract: - Cerumen impaction lowers TM temps by nearly 0.5 C compared to the opposite ear [Doezema D, Lunt M, Tandberg D. Cerumen occlusion lowers infrared tympanic membrane temperature measurement. Acad Emerg Med 1995;2(1):17-9.] - but not all studies have confirmed this. [Muma BK, Treloar DJ, Wurmlinger K, Peterson E, Vitae A. Comparison of rectal, axillary, and tympanic membrane temperatures in infants and young children [see comments] Ann Emerg Med 1991;20(1):41-4.] Abstract: - The presence of otitis media has slight (Kelly) or no (Muma) effect. [Kelly B, Alexander D, Effect of otitis media on infrared tympanic thermometry. Clin Pediatr (Phila) 1991; 30(4 Suppl):46-8; discussion 49.] Abstract: [Muma BK, Treloar DJ, Wurmlinger K, Peterson E, Vitae A. Comparison of rectal, axillary, and tympanic membrane temperatures in infants and young children [see comments] Ann Emerg Med 1991;20(1):41-4.] Abstract: - As JTG and others have pointed out, accurate readings are possible but are highly operator (technique) dependent. [Terndrup TE, Rajk J. Impact of operator technique and device on infrared emission detection tympanic thermometry. J Emerg Med 1992; 10(6):683-7.] Abstract: - Interestingly, although TM temperatures do not correlate as well as rectal temps do in predicting pulmonary artery temperature AVERAGE TM temps much more closely approximate pulmonary artery temp. [Milewski A, Ferguson KL, Terndrup TE. Comparison of pulmonary artery, rectal, and tympanic membrane temperatures in adult intensive care unit patients. Clin Pediatr (Phila);1991:30(4 Suppl):13-6; discussion 34-5.] Abstract: - This all indicates that when it's good...it's very very good but when it's bad....Of course of what possible significance could PA temps have when all studies done on health and disease have used rectal temps? The criteria for initiating a septic work up in a child less than 3 months of age is based on a RECTAL reading of 100.4 or greater. To be useful a temperature measurement in any other location would have to have a predictable relationship to rectal temperatues. The reference is: American Academy of Pediatrics and American College of Obstetricians and Gynecologists. 1988. Guidelines for Perinatal Care, 2nd ed. Elk Grove Village, Illinois. Naja McKenzie On Thu, 1 May 1997, DR BARNET ESKIN wrote: >I was recently told that the American Academy of Pediatrics has >published a policy statement that axillary temps are recommended for >infants less than 3 months of age because of the concern that taking >rectal temps in infants may lead to injury. However, despite my >contacting the Academy as well as searching for the actual policy, I >have been unable to find it. > >Anyone have the exact reference for this policy statement? As a Peds EM doc I recommend rectal for standardization out of the very first days of life. Some nurseries use rectal temp as test for imperforate anus. >> American Academy of Pediatrics and American College of Obstetricians and >> Gynecologists. 1988. Guidelines for Perinatal Care, 2nd ed. Elk Grove >> Village, Illinois. >>I've heard this before, but despite having taken "zillions" of rectal >temps in infants over the years, I've never seen or heard of a >complication. Has anyone else on the list? What is your practice? Matthew J. Walsh, MD Asst Prof and Interim Chairman Dept of Emergency Medicine Texas Tech Univ Health Science Center --------------------------------------- Injury from rectal temp is rare: <1> Unique Identifier 92366053 Authors Brown PJ. Christmas BF. Ford RP. Institution Department of Paediatrics, Christchurch Hospital. Title Taking an infant's temperature: axillary or rectal thermometer?. Source New Zealand Medical Journal. 105(939):309-11, 1992 Aug 12. Local Messages Not owned by MCPHU Libraries Abstract AIM: to examine the validity of routine use of axillary thermometers to measure body temperature in infants. METHODS: comparison of 49 simultaneous paired axillary and rectal temperature recordings in infants between one and 11 months of age, who were considered afebrile by their clinicians. Regression analysis of the paired measurements, and a plot of the differences between the paired measurements against their means, were used to examine the limits of agreement of the two methods. RESULTS: the limits of agreement ranged from 0.2 to 1.6 degrees C difference between simultaneous paired measurements. As there was no consistent relationship between axillary and rectal temperatures, the use of a correction factor added to axillary values is invalid. The axillary thermometer may record almost the same as the rectal temperature or more than 1.5 degrees C lower at the same point in time. CONCLUSION: we question the validity of current clinical practice in assessing infant body temperature by using axillary thermometers, and we suggest that such measurement does not reflect the rectal temperature in a reliable or consistent fashion. If infant body temperature is sought, a rectal thermometer should be used. <2> Unique Identifier 92152945 Authors Morley CJ. Hewson PH. Thornton AJ. Cole TJ. Institution Department of Paediatrics, University of Cambridge. Title Axillary and rectal temperature measurements in infants [see comments]. Source Archives of Disease in Childhood. 67(1):122-5, 1992 Jan. Local Messages Currently received at CC + MOORE Abstract Rectal and axillary temperatures were measured during the daytime in 281 infants seen randomly at home and 656 at hospital under 6 months old, using mercury-in-glass thermometers. The normal temperature range derived from the babies at home was 36.7-37.9 degrees C for rectal temperature and 35.6-37.2 degrees C for axillary temperature. Rectal temperature was higher than axillary in 98% of the measurements. The mean (SD) difference between rectal and axillary temperatures was 0.7 (0.5) degrees C, with a range of 3 degrees C. When used in hospital to detect high temperature, axillary temperature had a sensitivity of 73% compared with rectal temperature. This is too insensitive for accurate detection of an infant's high temperature. Rectal temperature measurement is safer than previously suggested: perforation has occurred in less than one in two million measurements. If an infant's temperature needs to be taken, rectal temperature should be used. <3> Unique Identifier 89321748 Authors Maurage C. Belin MC. Robert M. Bremond M. Autret E. Rolland JC. Institution Service de Pediatrie R, Hopital Clocheville, CHR, Tours. Title [Rectal injury caused by a broken thermometer. Risks related to mercury]. [French] Source Archives Francaises de Pediatrie. 46(4):277-9, 1989 Apr. Local Messages Not owned by MCPHU Libraries Abstract This is a case of local mercury absorption caused by accidental rectal perforation during monitoring of temperature. This complication is only reported in cases of subcutaneous injury by a broken thermometer. Treatment necessitates complete excision of mercury deposits. When mercury remains, a clinical and biochemical follow-up is necessary but indication for chelation therapy is exceptional. <1> Unique Identifier 82067689 Authors Lau JT. Ong GB. Title Broken and retained rectal thermometers in infants and young children. Source Australian Paediatric Journal. 17(2):93-4, 1981 Jun.