Thermometry in paediatric practice

Modelling metabolic performance in paediatric obstructive sleep disordered breathing: A case-control study

Paediatric obstructive sleep disordered breathing (OSDB) has a considerable impact on cardiovascular physiology, but the consequences on children's basal metabolism and response to exercise are far from being known. The objective was to propose model estimations for paediatric OSDB metabolism at rest and during exercise. A retrospective case-control analysis of data from children submitted to otorhinolaryngology surgery was performed. The heart rate (HR) was measured, while oxygen consumption (VO2) and energy expenditure (EE) at rest and during exercise were obtained using predictive equations. The results for the patients with OSDB were compared with controls. A total of 1256 children were included. A total of 449 (35.7%) had OSDB. The patients with OSDB showed a significantly higher resting heart rate (94.55 ± 15.061 bpm in OSDB vs. 92.41 ± 15.332 bpm in no-OSDB, p = 0.041). The children with OSDB showed a higher VO2 at rest (13.49 ± 6.02 mL min-1kg-1 in OSDB vs. 11.55 ± 6.83 mL min-1kg-1 in no-OSDB, p = 0.004) and a higher EE at rest (67.5 ± 30.10 cal min-1kg-1 in OSDB vs. 57.8 + 34.15 cal min-1kg-1 in no-OSDB, p = 0.004). At maximal exercise, patients with OSDB showed a lower VO2max (33.25 ± 5.82 mL min-1kg-1 in OSDB vs. 34.28 ± 6.71 in no-OSDB, p = 0.008) and a lower EE (166.3 ± 29.11 cal min-1kg-1 in OSDB vs. 171.4 ± 33.53 cal min-1kg-1 in no-OSDB, p = 0.008). The VO2/EE increment with exercise (Δ VO2 and Δ EE) was lower in OSDB for all exercise intensities (p = 0.009). This model unveils the effect of paediatric OSDB on resting and exercise metabolism. Our findings support the higher basal metabolic rates, poorer fitness performance, and cardiovascular impairment found in children with OSDB.

Fever assessment in children under five: Are we following the guidelines?

BACKGROUND

Fever is a common cause of medical consultation and hospital admission, particularly among children. Recently, the United Kingdom's National Institute for Health and Care Excellence (NICE) updated its guidelines for assessing fever in children under five years of age. The efficient assessment and management of children with fever are crucial for improving patient outcomes.

AIM

To evaluate fever assessment in hospitalized children and to assess its adherence with the NICE Fever in under 5s guideline.

METHODS

We conducted a retrospective cohort review of the electronic medical records of children under five years of age at the Department of Pediatrics, Salmaniya Medical Complex, Bahrain, between June and July 2023. Demographic data, vital signs during the first 48 h of admission, route of temperature measurement, and indications for admission were gathered. Fever was defined according to the NICE guideline. The children were divided into five groups according to their age (0-3 months, > 3-6 months, > 6-12 months, > 12-36 months, and > 36-60 months). Patients with and without fever were compared in terms of demography, indication for admission, route of temperature measurement, and other vital signs. Compliance with the NICE Fever in the under 5s guideline was assessed. Full compliance was defined as > 95%, partial compliance as 70%-95%, and minimal compliance as ≤ 69%. Pearson's χ2, Student's t test, the Mann-Whitney U test, and Spearman's correlation coefficient (rs) were used for comparison.

RESULTS

Of the 136 patients reviewed, 80 (58.8%) were boys. The median age at admission was 14.2 [interquartile range (IQR): 1.7-44.4] months, with the most common age group being 36-60 months. Thirty-six (26.4%) patients had fever, and 100 (73.6%) were afebrile. The commonest age group for febrile patients (> 12-36 months) was older than the commonest age group for afebrile patients (0-3 months) (P = 0.027). The median weight was 8.3 (IQR: 4.0-13.3) kg. Patients with fever had higher weight than those without fever [10.2 (IQR: 7.3-13.0) vs 7.1 (IQR: 3.8-13.3) kg, respectively] (P = 0.034). Gastrointestinal disease was the leading indication for hospital admission (n = 47, 34.6%). Patients with central nervous system diseases and fever of unknown etiology were more likely to be febrile (P = 0.030 and P = 0.011, respectively). The mean heart rate was higher in the febrile group than the afebrile group (140 ± 24 vs 126 ± 20 beats per minute, respectively) [P = 0.001 (confidence interval: 5.8-21.9)] with a positive correlation between body temperature and heart rate, r = 0.242, n = 136, P = 0.004. A higher proportion of febrile patients received paracetamol (n = 35, 81.3%) compared to the afebrile patients (n = 8, 18.6%) (P < 0.001). The axillary route was the most commonly used for temperature measurements (n = 40/42, 95.2%), followed by the rectal route (n = 2/42, 4.8%). The department demonstrated full compliance with the NICE guideline for five criteria: the type of thermometer used, route and frequency of temperature measurement, frequency of heart rate measurement, and use of antipyretics as needed. Partial compliance was noted for two criteria, the threshold of fever at 38 °C or more, and the respiratory rate assessment in febrile patients. Minimal compliance or no record was observed for the remaining three criteria; routine assessment of capillary refill, temperature reassessment 1-2 h after each antipyretic intake, and refraining from the use of tepid sponging.

CONCLUSION

This study showed that fever assessment in hospitalized children under five years of age was appropriate, but certain areas of adherence to the NICE guideline still need to be improved.

Correlation of temperature-sensing microchip and rectal temperature measurements in cats

Introduction

Rectal temperature (RT) is the reference standard for clinical evaluation of body temperature in mammals. However, the use of a rectal thermometer to measure temperature can cause stress and other problems, especially in cats. There is a need for clinical techniques that reduce both stress and defensive behavior as part of the provision of better medical care. Subcutaneous temperature-sensing identification microchips fulfil the current legal requirements and provide a reading of subcutaneous temperature (MT).

Methods

The clinical study tried to determine whether there is agreement between MT and RT in normal (n = 58), hospitalized (n = 26) and sedated/anesthetized (n = 36) cats. Three measurements were taken using both methods (MT and RT) in each cat. Correlation between MT and RT, and differences between MT and RT, were estimated for pairs of data-points from the same individual, and all data pairs in each group were considered overall.

Results

There was a strong positive correlation between MT and RT (r = 0.7 to 1.0) (p < 0.0005). The mean differences (d) were always negative and although statistically significant, these d values are likely of no biological importance. The overall d was ‑0.1°C in normal cats (p < 0.0005), -0.1°C in hospitalized cats (p = 0.001) and -0.1°C in sedated/anesthetized cats (p = 0.001). The limits of agreement between MT and RT appear narrow enough for MT to be acceptable estimate of RT. The overall limits of agreement (95%) were ‑0.71°C and 0.53°C (in normal cats); ‑0.51°C and 0.34°C (in hospitalized cats) and ‑0.60°C and 0.42°C (in sedated/anesthetized cats).

Discussion

MT may provide a good alternative to RT measurement in cats. However, this study was mostly performed in animals that were normothermic. Therefore, further studies in larger groups of cats under different conditions are needed to compare trends and assess variation with time.

Effect of Auricular Position on Body Temperature Measurement with Tympanic Thermometers: A Quasi Experimental Study

BACKGROUND

With the COVID-19 pandemic, body temperature measurement has begun to be widely used in the diagnosis of the coronavirus disease. When measuring body temperature, it is important to obtain the core temperature measurement. This study compared the results of body temperature obtained with the tympanic membrane thermometer-which is one of the methods that best reflect the body temperature-with or without positioning the auricle.

AIMS

The aim of this study was to investigate the effect of auricle position on body temperature measurements made with tympanic membrane thermometer in adult patients.

MATERIALS AND METHODS

A quasi-experimental design that employed a pre-test and a post-test was used in this study. A total of 143 patients who fit the inclusion criteria of the study were included in the sample. For analysis of the data, frequencies, percentages, means and standard deviations were calculated, and the significance of the difference between paired values was tested in order to investigate the effects of auricle position on measurement values. Statistical Package for the Social Sciences (SPSS) 22.0 was used in analyzing the data obtained in this study.

RESULTS

The difference between the values of measurement taken in these two separate positions was found to be 0.31 0C, and the Bland-Altman plot showed that the differences were distributed systematically around the value 0.31.

CONCLUSIONS

It was found in the comparison of two positions that there was a significant difference between the tympanic thermometer measurements made by positioning the auricle and those without positioning.

"The Fever Is Still There!": Workup and Management of Prolonged Fever

Fever is one of the most common chief complaints that brings pediatric patients to seek medical care. Although fever is, in most cases, a physiologic response to a pathogen that has alerted the immune system, prolonged fever can be challenging to work up for the treating pediatrician. In addition to assessing causes of fever, pediatricians must also address the fears that many caregivers may have surrounding elevations in body temperature and provide education as to when fever becomes a concern. Fever can be classified by its duration as well as the presence or absence of associated symptoms. Fever without a source is defined as a fever that has been present for 1 week without a clear cause. Fever of unknown origin is a fever that has been present daily for 8 days or more without an apparent source. This article will walk through considerations for a clinician evaluating a pediatric patient with prolonged fever. [Pediatr Ann. 2023;52(4):e124-e126.].

Early detection of cold stress to prevent hypothermia: A narrative review

Temperature monitoring is essential for assessing neonates and providing appropriate neonatal thermal care. Thermoneutrality is defined as the environmental temperature range within which the oxygen and metabolic consumptions are minimum to maintain normal body temperature. When neonates are in an environment below thermoneutral temperature, they respond by vasoconstriction to minimise heat losses, followed by a rise in metabolic rate to increase heat production. This condition, physiologically termed cold stress, usually occurs before hypothermia. In addition to standard axillary or rectal temperature monitoring by a thermometer, cold stress can be detected by monitoring peripheral hand or foot temperature, even by hand-touch. However, this simple method remains undervalued and generally recommended only as a second and lesser choice in clinical practice. This review presents the concepts of thermoneutrality and cold stress and highlights the importance of early detection of cold stress before hypothermia occurs. The authors suggest systematic clinical determination of hand and foot temperatures by hand-touch for early detection of physiological cold stress, in addition to monitoring core temperature for detection of established hypothermia, particularly in low-resource settings.

A Comparative Study of Forehead Temperature and Core Body Temperature under Varying Ambient Temperature Conditions

When the ambient temperature, in which a person is situated, fluctuates, the body's surface temperature will alter proportionally. However, the body's core temperature will remain relatively steady. Consequently, using body surface temperature to characterize the core body temperature of the human body in varied situations is still highly inaccurate. This research aims to investigate and establish the link between human body surface temperature and core body temperature in a variety of ambient conditions, as well as the associated conversion curves.

METHODS

Plan an experiment to measure temperature over a thousand times in order to get the corresponding data for human forehead, axillary, and oral temperatures at varying ambient temperatures (14-32 °C). Utilize the axillary and oral temperatures as the core body temperature standards or the control group to investigate the new approach's accuracy, sensitivity, and specificity for detecting fever/non-fever conditions and the forehead temperature as the experimental group. Analyze the statistical connection, data correlation, and agreement between the forehead temperature and the core body temperature.

RESULTS

A total of 1080 tests measuring body temperature were conducted on healthy adults. The average axillary temperature was (36.7 ± 0.41) °C, the average oral temperature was (36.7 ± 0.33) °C, and the average forehead temperature was (36.2 ± 0.30) °C as a result of the shift in ambient temperature. The forehead temperature was 0.5 °C lower than the average of the axillary and oral temperatures. The Pearson correlation coefficient between axillary and oral temperatures was 0.41 (95% CI, 0.28-0.52), between axillary and forehead temperatures was 0.07 (95% CI, -0.07-0.22), and between oral and forehead temperatures was 0.26 (95% CI, 0.11-0.39). The mean differences between the axillary temperature and the oral temperature, the oral temperature and the forehead temperature, and the axillary temperature and the forehead temperature were -0.08 °C, 0.49 °C, and 0.42 °C, respectively, according to a Bland-Altman analysis. Finally, the regression analysis revealed that there was a linear association between the axillary temperature and the forehead temperature, as well as the oral temperature and the forehead temperature due to the change in ambient temperature.

CONCLUSION

The changes in ambient temperature have a substantial impact on the temperature of the forehead. There are significant differences between the forehead and axillary temperatures, as well as the forehead and oral temperatures, when the ambient temperature is low. As the ambient temperature rises, the forehead temperature tends to progressively converge with the axillary and oral temperatures. In clinical or daily applications, it is not advised to utilize the forehead temperature derived from an uncorrected infrared thermometer as the foundation for a body temperature screening in public venues such as hospital outpatient clinics, shopping malls, airports, and train stations.

Clinical Accuracy of Non-Contact Forehead Infrared Thermometer Measurement in Children: An Observational Study

We evaluated the clinical reliability and utility of temperature measurements using no-contact forehead infrared thermometers (NCFITs) by comparing their temperature measurements with those obtained using infrared tympanic thermometers (IRTTs) in children. In this observational, prospective, and cross-sectional study, we enrolled 255 children (aged 1 month to 18 years) from the pediatric surgery ward at a tertiary medical center in Korea. The mean age of the children was 9.05 ± 5.39 years, and 54.9% were boys. The incidence rate of fever, defined as an IRTT reading of ≥38.0 °C, was 15.7%. The ICC coefficient for the assessment of agreement between temperatures recorded by the NCFIT and IRTT was 0.87, and the κ-coefficient was 0.83. The bias and 95% limits of agreement were 0.15 °C (−0.43 to 0.73). For an accurate diagnosis of fever (≥38 °C), the false-negative rate was much lower, but the false-positive rate was higher, especially in 6-year-old children. Therefore, NCFITs can be used to screen children for fever. However, a secondary check is required using another thermometer when the child’s temperature is >38 °C. NCFITs are proposed for screening but not for measuring the temperature. For the latter, an accurate and reliable thermometer shall be used.

Temperature change in children undergoing magnetic resonance imaging-An observational cohort study

AIM

An increasing number of children undergo magnetic resonance imaging requiring anesthesia or sedation to ensure their immobility; however, magnetic resonance imaging may increase body temperature whereas sedation or anesthesia may decrease it. We investigated changes in body temperature in children who underwent sedation or anesthesia for magnetic resonance imaging.

METHODS

Children aged 12 weeks-12 years undergoing anesthesia and magnetic resonance imaging were included in this prospective observational study. Tympanic body temperature was measured before and after magnetic resonance imaging, and the difference between measurements was calculated. Associations between the temperature difference and patient- or procedure-related factors were evaluated with linear and logistic regression analysis.

RESULTS

A total of 74 children were included, of whom 5 (7%) had a temperature increase ≥0.5°C. Mean temperature difference was -0.24°C (SD 0.48) for the entire group and -0.28°C for the youngest children (0-2 years). The temperature difference correlated positively with the duration of imaging (unadjusted coefficient 0.26, 95% confidence interval (CI), (0.01; 0.52)).

CONCLUSION

In this study of sedated or anesthetized children undergoing magnetic resonance imaging, clinically relevant increases in body temperature above 0.5°C were only found in a few patients. However, longer imaging duration tended to be associated with increased body temperature.

Human bocavirus and human metapneumovirus in children with lower respiratory tract infections: Effects on clinical, microbiological features and disease severity

BACKGROUND

We aimed to compare the clinical findings of human bocavirus (HBoV) and human metapneumovirus (HMPV) infections, and to analyze the effects of coinfections on clinical features and disease severity in children with HBoV and HMPV infections.

METHODS

Data were collected from 125 children with lower respiratory tract infections due to HBoV or HMPV, detected from nasal swap by real-time polymerase chain reaction (PCR) during the period from January, 2013 to December, 2017. In total, there were 101 HBoV (group 1) and 23 HMPV (group 2) infections in our data. The patients were further divided into four subgroups according to the coinfection status: HoBV only (subgroup 1, n = 41), HMPV only (subgroup 2, n = 19), HBoV and coinfection with other respiratory viruses (subgroup 3, n = 60), and HMPV and coinfection with other respiratory viruses (subgroup 4, n = 4).

RESULTS

The majority (88.8%) of the patients were aged 5 years or younger. Coinfections with other respiratory viruses were significantly more common in group 1 (P = 0.001). Among patients who had nosocomial pneumonia, patients with HBoV infections had significantly longer mean length of hospital stay (LOS) than those with HMPV infections (P = 0.032). The hospitalization and antibiotic requirements were significantly higher in subgroup 1 than subgroup 3 (P = 0.005, 0.039, resp.) According to the logistic regression analyses, the LOS increased by 21.7 times with HBoV infections (P = 0.006).

CONCLUSIONS

Human bocavirus and HMPV infections are serious pathogens mostly seen in children and usually requiring hospitalization regardless of co-infection status. The HBoV infections caused longer LOS than the HMPV infections in patients with nosocomial infections.

Hypothermia in Young Infants: Frequency and Yield of Sepsis Workup

OBJECTIVES

Serious bacterial infections (SBIs) in young infants can present with fever or hypothermia. There are substantial data on fever as a presentation for SBI that help to inform the clinical approach. In contrast, data on hypothermia are lacking, thus leaving clinicians without guidance. We aimed to describe the workup and findings, specifically the occurrence, of SBIs in infants younger than 60 days of life with hypothermia.

METHODS

We reviewed the medical records of infants younger than 60 days of life with rectal temperature of less than 36.5°C upon arrival to a children's hospital emergency department between January 2013 and December 2014. Comparisons were made between those who were found to have an SBI and those without. Serious bacterial infection was defined as bacteremia, bacterial meningitis, pneumonia, or urinary tract infection (UTI).

RESULTS

From the 414 patients identified, 104 (25%) underwent a sepsis evaluation of blood, urine, and/or cerebrospinal fluid culture. Serious bacterial infections were identified in 9 patients: 4 with UTI, 1 with pneumonia, 2 with bacteremia, 1 with pneumonia and UTI, and 1 with meningitis and bacteremia. Compared with patients with negative cultures, patients with SBI were older and had elevated absolute band counts and elevated immature-to-total neutrophil ratio.

CONCLUSIONS

Approximately a quarter of infants younger than 60 days with hypothermia were evaluated for SBI. Serious bacterial infection was identified in 9% of evaluated infants (2% of all hypothermic infants). Hypothermia can be a presenting sign of SBI.

The diagnostic accuracy of digital, infrared and mercury-in-glass thermometers in measuring body temperature: a systematic review and network meta-analysis

Not much is known about how accurate and reproducible different thermometers are at diagnosing patients with suspected fever. The study aims at evaluating which peripheral thermometers are more accurate and reproducible. We searched Medline, Embase, Scopus, WOS, CENTRAL, and Cinahl to perform: (1) diagnostic accuracy meta-analysis (MA) using rectal mercury-in-glass or digital thermometry as reference, and bivariate models for pooling; (2) network MA to estimate differences in mean temperature between devices; (3) Bland-Altman method to estimate 95% coefficient of reproducibility. PROSPERO registration: CRD42020174996. We included 46 studies enrolling more than 12,000 patients. Using 38 °C (100.4 ℉) as cut-off temperature, temporal infrared thermometry had a sensitivity of 0.76 (95% confidence interval, 0.65, 0.84; low certainty) and specificity of 0.96 (0.92, 0.98; moderate certainty); tympanic infrared thermometry had a sensitivity of 0.77 (0.60,  0.88; low certainty) and specificity of 0.98 (0.95, 0.99; moderate certainty). For all the other index devices, it was not possible to pool the estimates. Compared to the rectal mercury-in-glass thermometer, mean temperature differences were not statistically different from zero for temporal or tympanic infrared thermometry; the median coefficient of reproducibility ranged between 0.53 °C [0.95 ℉] for infrared temporal and 1.2 °C [2.16 ℉] for axillary digital thermometry. Several peripheral thermometers proved specific, but not sensitive for diagnosing fever with rectal thermometry as a reference standard, meaning that finding a temperature below 38 °C does not rule out fever. Fixed differences between temperatures together with random error means facing differences between measurements in the order of 2 °C [4.5 ℉]. This study informs practitioners of the limitations associated with different thermometers; peripheral ones are specific but not sensitive.

Assessment of Saudi Parents' Beliefs and Behaviors towards Management of Child Fever in Saudi Arabia-A Cross-Sectional Study

OBJECTIVE

Fever alone can lead to rare serious complications in children, such as febrile seizures. The aim of this study is to assess the knowledge, beliefs, and behavior of parents toward fever and its management.

METHODS

A cross-sectional study using an online questionnaire was applied over a period of 3 months, from January to March 2018, to parents who were living in Saudi Arabia. The inclusion criteria were a parent who is a resident of Saudi Arabia, with at least one child aged 6 years or less, while incomplete questionnaires, having a child aged more than 6 years, or parents who were not living in Saudi Arabia were excluded.

RESULTS

A total of 656 parents completed the questionnaire. More than two-thirds of the subjects were female, the majority of whom were aged between 25-33 years old. The best-reported place to measure the temperature of children was the armpit (46%), followed by the ear (28%) and the mouth (10.7%). More than half of the parents considered their children feverish at a temperature of 38 °C. The majority of parents (79.7%) reported that the most serious side effects of fever were seizure, brain damage (39.3%), coma (29.9%), dehydration (29.7%), and death (25%). The most common method used to measure a child's temperature was an electronic thermometer (62.3%). The most common antipyretic was paracetamol (84.5%).

CONCLUSIONS

Our study demonstrates the good knowledge of parents in identifying a feverish temperature using the recommended route and tools for measuring body temperature.

Fundamental Concepts of Human Thermoregulation and Adaptation to Heat: A Review in the Context of Global Warming

The international community has recognized global warming as an impending catastrophe that poses significant threat to life on earth. In response, the signatories of the Paris Agreement (2015) have committed to limit the increase in global mean temperature to <1.5 °C from pre-industry period, which is defined as 1850–1890. Considering that the protection of human life is a central focus in the Paris Agreement, the naturally endowed properties of the human body to protect itself from environmental extremes should form the core of an integrated and multifaceted solution against global warming. Scholars believe that heat and thermoregulation played important roles in the evolution of life and continue to be a central mechanism that allows humans to explore, labor and live in extreme conditions. However, the international effort against global warming has focused primarily on protecting the environment and on the reduction of greenhouse gases by changing human behavior, industrial practices and government policies, with limited consideration given to the nature and design of the human thermoregulatory system. Global warming is projected to challenge the limits of human thermoregulation, which can be enhanced by complementing innate human thermo-plasticity with the appropriate behavioral changes and technological innovations. Therefore, the primary aim of this review is to discuss the fundamental concepts and physiology of human thermoregulation as the underlying bases for human adaptation to global warming. Potential strategies to extend human tolerance against environmental heat through behavioral adaptations and technological innovations will also be discussed. An important behavioral adaptation postulated by this review is that sleep/wake cycles would gravitate towards a sub-nocturnal pattern, especially for outdoor activities, to avoid the heat in the day. Technologically, the current concept of air conditioning the space in the room would likely steer towards the concept of targeted body surface cooling. The current review was conducted using materials that were derived from PubMed search engine and the personal library of the author. The PubMed search was conducted using combinations of keywords that are related to the theme and topics in the respective sections of the review. The final set of articles selected were considered “state of the art,” based on their contributions to the strength of scientific evidence and novelty in the domain knowledge on human thermoregulation and global warming.

Systemic cytokines/chemokines associated to radiographic abnormalities in pneumonia in children

Community-acquired pneumonia (CAP) diagnosis remains a challenge in paediatrics. Chest radiography is considered gold standard for definition of pneumonia, however no previous study assessed the relationship between immune response and radiographic-confirmed-pneumonia. We assessed association between cytokines/chemokines levels and radiographic abnormalities in children with CAP. Children < 5-years-old hospitalized with CAP were investigated in a prospective study at the Federal University of Bahia Hospital, Brazil. On admission, clinical data and biological samples were collected to investigate 20 aetiological agents and determine serum cytokines/chemokines levels; chest radiographs were performed. Among 158 patients, radiographic diagnosis of pneumonia was confirmed in 126(79.7%) and 17(10.8%) had pleural effusion. Viral, bacterial and pneumococcal infection were detected in 80(50.6%), 78(49.4%) and 37(23.4%) cases. By comparing the median concentrations of serum cytokines/chemokines between children with or without pleural effusion, interleukin(IL)-6 was higher (26.6[18.6-103.7] vs 3.0[0.0-19.8]; p < 0.001) among those with pleural effusion; and between children with or without radiographic-confirmed-pneumonia, IL-6 was higher in the first subgroup (4.5[0.0-23.4] vs 0.0[0.0-3.6]; p = 0.02) after having excluded cases with pleural effusion. Stratified analyses according to aetiology showed IL-6 increase in the radiographic-confirmed-pneumonia subgroup inside the pneumococcal infection (28.2[5.9-64.1] vs 0.0[0.0-0.0]; p = 0.03) subgroup. By multivariable analysis, with IL-6 as dependent variable, pneumococcal infection and pleural effusion showed independent association with IL-6 elevation [respective OR: 5.071 (95%CI = 2.226-11.548; p < 0.001) and 13.604 (95%CI = 3.463-53.449; p = 0.0001)]. Considering the cases without pleural effusion, the area under the curve of IL-6 to predict pneumococcal infection was 0.76 (95%CI = 0.66-0.86; p < 0.001). IL-6 increase is a potential biomarker of pneumococcal infection among children with CAP without pleural effusion upon admission.

Evolution of cytokines/chemokines in cases with community-acquired pneumonia and distinct etiologies

AIM

To compare the systemic cytokines/chemokines levels over time during the evolution of children hospitalized with community-acquired pneumonia (CAP) with and without pneumococcal infection.

METHODS

Children less than 5-years-old hospitalized with CAP were prospectively investigated in Salvador, Brazil. Clinical data and biological samples were collected to investigate 20 etiological agents and to determine serum cytokines/chemokines levels on admission and 2 to 4 weeks later. Cases with pneumococcal infection received this diagnosis irrespective of also having other etiologies.

RESULTS

A total of 277 patients were enrolled, however, serum sample was unavailable for cytokine measurement upon admission (n = 61) or upon follow-up visit (n = 36), etiology was undetected (n = 50) and one patient did not attend the follow-up visit. Therefore, this study group comprised of 129 cases with established etiology. The median (interquartile range) age and sampling interval was 18 (9-27) months and 18 (16-21) days, respectively. Established etiology was viral (52.0%), viral-bacterial (30.2%), and bacterial (17.8%). Pneumococcal infection was found in 31 (24.0%) patients. Overall, median interleukin-6 (IL-6; 10.6 [4.7-30.6] vs 21.0 [20.2-21.7]; P = .03), IL-10 (3.5 [3.1-4.5] vs 20.1 [19.8-20.4]; P < .001), and CCL2 (19.3 [12.4-23.2] vs 94.0 [67.2-117.8]; P < .001) were significantly higher in convalescent serum samples, whereas median CXCL10 (83.6 [36.4-182.9] vs 14.6 [0-116.6]; P < .001) was lower. Acute vs convalescent levels evolution of IL-10, CCL2, and CXCL10 did not differ among patients with or without pneumococcal infection. However, IL-6 decreased (27.8 [12.3-48.6] vs 20.8 [20.2-22.6]; P = .1) in patients with pneumococcal infection and increased (9.0 [4.2-22.6] vs 21.0 [20.2-21.7]; P = .001) in patients without it.

CONCLUSION

The marked increase of IL-6 serum levels during the acute phase makes it a potential biomarker of pneumococcal infection among children with CAP.

Parental Approach to the Management of Childhood Fever: Differences between Health Professional and Non-Health Professional Parents

Fever is responsible for 30% of pediatric consultations at primary care services. The aim of this study was to explore the parental approach to fever in children aged between 0 and 12 years old by both health professional and non-health professional parents. A qualitative study based on grounded theory was performed. Focus groups were conducted, segmented by sex, place of residence, and healthcare training, using a triangulated sample (theoretical and snowball sampling) of parents of children aged between 0 and 12 years who were treated for fever at primary care emergency services. The constant comparative method and a process of coding was used for the analysis. The study findings reveal that the health training of parents, their former experience, family pressures, the age of the child, and the parents' work outside the home, all influenced how they approached fever management. These findings could be incorporated into clinical practice to improve care and compliance with fever treatment.

A quarter of admitted poisoned patients have a mild poisoning and require no treatment: An observational study

BACKGROUND

Poisoned patients are frequently admitted following Emergency Department (ED) presentation, while the necessity of such admissions is hardly investigated. We determined the proportion and characteristics of poisoned patients who were admitted, but in retrospect had an uneventful admission.

METHODS

For this observational cohort study, all patients presented to the ED of a Dutch University Hospital with various poisonings during a 1.5-year period (January 2015-July 2016) were included. The uneventfulness of admissions, defined as patients with a low Poisoning Severity Score (PSS) who received no treatment, was determined in retrospect.

RESULTS

We included 417 patients who visited the ED for poisoning. 247 Patients were admitted: 30% to a general ward, 58% to a MCU, and 12% to the ICU. The poisoning severity scores of the admitted patients were none to mild in 38%, moderate to severe in 59%, and fatal in 2%. Upon admission, 60% of the patients received treatment. In retrospect, 77% of the admitted patients had a moderate, severe or fatal poisoning and/or required treatment. However, 23% of the admitted patients had a mild poisoning and required no treatment. This group involved younger patients (median age of 23 versus 42 years) and a higher proportion of patients reporting exposure to only one substance (65% versus 51%).

CONCLUSIONS

The majority of poisoned patients presented to the ED was admitted, while in retrospect, a quarter of these admissions were uneventful. Predictive parameters should be sought to identify patients who can be sent home safely.

Wheezing independently predicts viral infection in children with community-acquired pneumonia

AIM

To assess whether there was a difference in the frequency of symptoms and signs among children with community-acquired pneumonia (CAP) with viral or bacterial infection.

METHODS

A prospective cross-sectional study was conducted in Salvador, Brazil. Children less than 5-years-old hospitalized with CAP were recruited. Viral or only bacterial infection was diagnosed by an investigation of 11 viruses and 8 bacteria. Bacterial infection was diagnosed by blood culture, detection of pneumococcal DNA in acute buffy coat, and serological tests. Viral infection was diagnosed by detection of respiratory virus in nasopharyngeal aspirate and serological tests. Viral infection comprised only viral or mixed viral-bacterial infection subgroups.

RESULTS

One hundred and eighty-eight patients had a probable etiology established as only viral (51.6%), mixed viral-bacterial (30.9%), and only bacterial infection (17.5%). Asthma was registered for 21.4%. Report of wheezing (47.4% vs 21.2%; P = 0.006), rhonchi (38.0% vs 15.2%; P = 0.01), and wheezing detected on physical examination (51.0% vs 9.1%; P < 0.001) were the differences found. Among children with asthma, detected wheezing was the only different finding when children with viral infection were compared with those with only bacterial infection (75.0% vs 0%; P = 0.008). By multivariable analysis, viral infection (AdjOR [95% CI]: 9.6; 95%CI: 2.7-34.0), asthma (AdjOR [95% CI]: 4.6; 95%CI: 1.9-11.0), and age (AdjOR [95% CI]: 0.95; 95%CI: 0.92-0.97) were independently associated with wheezing on physical examination. The positive predictive value of detected wheezing for viral infection was 96.3% (95% CI: 90.4-99.1%).

CONCLUSION

Wheezing detected on physical examination is an independent predictor of viral infection.

Assessing the Usability of an Automated Continuous Temperature Monitoring Device (iThermonitor) in Pediatric Patients: Non-Randomized Pilot Study

BACKGROUND

Fever is an important vital sign and often the first one to be assessed in a sick child. In acutely ill children, caregivers are expected to monitor a child's body temperature at home after an initial medical consult. Fever literacy of many caregivers is known to be poor, leading to fever phobia. In children with a serious illness, the responsibility of periodically monitoring temperature can add substantially to the already stressful experience of caring for a sick child.

OBJECTIVE

The objective of this pilot study was to assess the feasibility of using the iThermonitor, an automated temperature measurement device, for continuous temperature monitoring in postoperative and postchemotherapy pediatric patients.

METHODS

We recruited 25 patient-caregiver dyads from the Pediatric Surgery Department at the Massachusetts General Hospital (MGH) and the Pediatric Cancer Centers at the MGH and the Dana Farber Cancer Institute. Enrolled dyads were asked to use the iThermonitor device for continuous temperature monitoring over a 2-week period. Surveys were administered to caregivers at enrollment and at study closeout. Caregivers were also asked to complete a daily event-monitoring log. The Generalized Anxiety Disorder-7 item questionnaire was also used to assess caregiver anxiety at enrollment and closeout.

RESULTS

Overall, 19 participant dyads completed the study. All 19 caregivers reported to have viewed temperature data on the study-provided iPad tablet at least once per day, and more than a third caregivers did so six or more times per day. Of all participants, 74% (14/19) reported experiencing an out-of-range temperature alert at least once during the study. Majority of caregivers reported that it was easy to learn how to use the device and that they felt confident about monitoring their child's temperature with it. Only 21% (4/9) of caregivers reported concurrently using a device other than the iThermonitor to monitor their child's temperature during the study. Continuous temperature monitoring was not associated with an increase in caregiver anxiety.

CONCLUSIONS

The study results reveal that the iThermonitor is a highly feasible and easy-to-use device for continuous temperature monitoring in pediatric oncology and surgery patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02410252; https://clinicaltrials.gov/ct2/show/NCT02410252 (Archived by WebCite at http://www.webcitation.org/73LnO7hel).

Child fever management: A comparative study of Australian parents with limited and functional health literacy

Health literacy, or the ability to read and understand health information, is critical to the health of children. In this study, we compared the fever management knowledge of parents attending the emergency department with a child with fever. A cross-sectional survey of 33 parents/carers with limited health literacy and 122 with functional health literacy was undertaken. There were no differences in the overall proportion of correct responses to knowledge or management questions posed by the two scales between the two groups. Both groups presented with limited knowledge and poor practices (<60% correct in both scales) in relation to fever knowledge and management in their children. Although health literacy impacts health utilization, we did not find any differences in these groups. Inappropriate practices, such as when to give medications, were evident. Educational programs, responsive to health literacy, are urgently needed to address these information needs for parents. An assessment of parents' health literacy level can guide the selection of information that can be easily read, understood, and acted upon to deliver the best health outcomes for children.

Predictive power of a single body temperature at different cutoff values for neonates in the nursery transferring to special care nursery

The aim of this study was to identify the clinical parameters indicative of serious etiology of neonatal hyperthermia and to determine the appropriate cutoff value of body temperature (BT) for predicting the need to transfer the newborn to the special care (SC) nursery.The nursery records of newborns diagnosed with hyperthermia between 2007 and 2013 were retrospectively reviewed. The clinical characteristics of newborns with hyperthermia remained in the nursery were compared with those transferred to the SC nursery. In addition, the receiver operating characteristic analysis was used to determine the appropriate cutoff BT for predicting further septic workup in the SC nursery.Among the 92 newborns with hyperthermia evaluated, 30 (32.6%) were transferred to the SC nursery and 62 (67.4%) remained in the nursery. Clinical characteristics associated with transfer to the SC nursery included the highest BT, BT at first measurement during hyperthermia, frequency of hyperthermia, duration of hyperthermia, irritable crying, decreased appetite, poor activity, vomiting with abdominal distension, tachypnea, and tachycardia (all P < .05). BT for predicting the need for transferring newborns with hyperthermia to the SC nursery had an area under the curve of 0.976 (P < .001). A BT of 38 °C was determined as the optimal cutoff value for predicting the need to monitoring for suspicious clinical symptoms (sensitivity (Sn), 93%; specificity (Sp), 87%). Furthermore, BT≥38.2 °C (Sn, 70%; Sp 100%) and BT≤37.8 °C (Sn, 100%; Sp, 61%) respectively were determined as the cutoff values for transferring newborns to the SC nursery or allowing them to remain in the regular nursery.Our results suggest a BT of 38 °C represents the optimal cutoff indicating newborns for close monitoring for suspicious clinical presentations including irritable crying, decreased appetite, poor activity, vomiting with abdominal distension, tachypnea, and tachycardia. Newborns with BT < 37.8 °C may remain in the nursery but should be transferred to the SC nursery for septic workup and empiric antibiotics if the BT is above 38.2 °C.

Axillary and Tympanic Temperature Measurement in Children and Normal Values for Ages

AIM

The aim of the study was define the normal values of tympanic and axillary body temperature in healthy children.

METHODS

This observational cross-sectional study was performed in healthy children aged 0 to 17 years who visited the ambulatory general pediatric of Istanbul Medical Faculty.

RESULTS

Of 1364 children, 651 (47.7%) were girls and 713 were boys, the mean (SD, range) age was 72.5 (53.6, 1-204) months. The mean (SD) axillary body temperature was 36.04°C (0.46°C; minimum, 35.0°C; maximum, 37.6°C). The 95th and 99th percentiles were 36.8°C and 37.0°C, respectively. The mean (SD) tympanic body temperature was 36.91°C (0.46°C; minimum, 35.15°C; maximum, 37.9°C). The 95th and 99th percentiles were 37.6°C and 37.8°C, respectively. There were statistically significant differences between sexes for only tympanic body temperatures. Both axillary and tympanic body temperatures were statistically higher in 0 to 2 months compared with other age groups. For this age group, the 99th percentile was 37.5°C for axillary and 37.85°C for tympanic temperature.

CONCLUSIONS

Axillary and tympanic body temperatures should be considered as fever when they are more than 37.0°C and 37.8°C, respectively. For 0 to 2 months, fever is 37.5°C and 37.85°C in axillary and tympanic temperatures, respectively.

Serologically diagnosed acute human bocavirus 1 infection in childhood community-acquired pneumonia

AIM

To assess the role of human bocavirus 1 (HBoV1) as a causative agent of non-severe community-acquired pneumonia (CAP) in children.

METHODS

Patients aged 2-59 months with non-severe CAP (respiratory complaints and radiographic pulmonary infiltrate/consolidation) attending a University Hospital in Salvador, Brazil were enrolled in a prospective cohort. From 820 recruited children in a clinical trial (ClinicalTrials.gov NCT01200706), nasopharyngeal aspirate (NPA), and acute and convalescent serum samples were obtained from 759 (92.6%) patients. NPAs were tested for 16 respiratory viruses by PCR. Acute HBoV1 infection was confirmed by measuring specific IgM and IgG responses in paired serum samples.

RESULTS

Respiratory viruses were detected in 693 (91.3%; 95%CI: 89.1-93.2) CAP cases by PCR. HBoV1-DNA was detected in 159 (20.9%; 95%CI: 18.2-24.0) cases. Of these 159 PCR positive cases, acute HBoV1 infection was confirmed serologically in 38 cases (23.9%; 95%CI: 17.8-31.0). Overall, acute HBoV1 infection was confirmed in 5.0% (38/759) of non-severe CAP patients. HBoV1 was detected in 151 cases with at least one other virus making 31.7% of all multiple virus (n = 477) detections. Among all 759 cases, 216 had one respiratory virus detected, and sole HBoV1 was detected in only 8 (3.7%). Acute HBoV1 infection was serologically diagnosed in 34 (22.5%) HBoV1-DNA-positive cases with another virus, compared to 4 (50.0%) cases with sole virus detection (p = 0.09).

CONCLUSION

HBoV1 was detected by PCR in one fifth of the children with non-severe CAP and acute HBoV1 infection was serologically confirmed in one quarter of these cases.

Systemic cytokines and chemokines on admission of children hospitalized with community-acquired pneumonia

Community-acquired pneumonia (CAP) is the main cause of death in children under-5 years worldwide and Streptococcus pneumoniae is the most common bacterial agent. However, it is difficult to identify pneumococcal infection among children with CAP. We aimed to assess association between any cytokine/chemokine and pneumococcal infection in childhood CAP. Furthermore, we evaluated the diagnostic value of cytokine/chemokine for pneumococcal infection. This prospective study was conducted at an Emergency Room, in Salvador, Brazil. Children <5-years-old hospitalized with CAP in a 21-month period were evaluated. On admission, clinical and radiological data were collected along with biological samples to investigate 20 etiological agents and determine serum cytokines (interleukin (IL)-8, IL-6, IL-10, IL-1β, IL-12, TNF-α, IL-2, IL-4, IL-5, γ-interferon), and chemokines (CCL2, CCL5, CXCL9, CXCL10) concentration. From 166 patients with etiology detected, pneumococcal infection was detected in 38 (22.9%) cases among which the median IL-6(pg/ml) was 31.2 (IQR: 12.4-54.1). The other 128 cases had other causative agents detected (Haemophilus influenzae, Moraxella catarrhalis, atypical bacteria and viruses) with the median IL-6 concentration being 9.0 (IQR: 4.1-22.0; p < 0.001). The area under the ROC curve for IL-6 to predict pneumococcal CAP was 0.74 (95%CI: 0.65-0.83; p < 0.001). By multivariate analysis, with pneumococcal CAP as dependent variable, IL-6 was an independent predictor for pneumococcal infection (OR = 5.56; 95%CI: 2.42-12.75, cut-off point = 12.5 pg/ml; p = 0.0001). The negative predictive value of IL-6 under 12.5 pg/ml for pneumococcal infection was 90% (95%CI: 82-95%). Independently significant difference was not found for any other cytokines/chemokines. Serum IL-6 concentration on admission is independently associated with pneumococcal infection among children under-5 years hospitalized with CAP.

Alternating Acetaminophen and Ibuprofen versus Monotherapies in Improvements of Distress and Reducing Refractory Fever in Febrile Children: A Randomized Controlled Trial

BACKGROUND

No evidence can be found in the medical literature about the efficacy of alternating acetaminophen and ibuprofen treatment in children with refractory fever.

OBJECTIVE

Our objective was to assess the effect of alternating acetaminophen and ibuprofen therapy on distress and refractory fever compared with acetaminophen or ibuprofen as monotherapy in febrile children.

METHODS

A total of 474 febrile children with axillary temperature ≥38.5 °C and fever history ≤3 days in a tertiary hospital were randomly assigned to receive either (1) alternating acetaminophen and ibuprofen (acetaminophen 10 mg/kg per dose with shortest interval of 4 h and ibuprofen 10 mg/kg per dose with shortest interval of 6 h and the shortest interval between acetaminophen and ibuprofen ≥2 h; n = 158), (2) acetaminophen monotherapy (10 mg/kg per dose with shortest interval of 4 h; n = 158), or (3) ibuprofen monotherapy (10 mg/kg per dose with shortest interval of 6 h; n = 158). The mean Non-Communicating Children's Pain Checklist (NCCPC) score was measured every 4 h, and axillary temperatures were measured every 2 h.

RESULTS

In total, 471 children were included in an intention-to-treat analysis. No significant clinical or statistical difference was found in mean NCCPC score or temperature during the 24-h treatment period in all febrile children across the three groups. Although the proportion of children with refractory fever for 4 h and 6 h was significantly lower in the alternating group than in the monotherapy groups (4 h: 11.54% vs. 26.58% vs. 21.66%, respectively [p = 0.003]; 6 h: 3.85% vs. 10.13% vs. 17.83%, respectively [p < 0.001]), the mean NCCPC score of children with refractory fever for 4 or 6 h was not lower than those in either of the monotherapy groups. The number of patients who developed persistent high body temperature was consistent across all study groups.

CONCLUSIONS

Alternating acetaminophen and ibuprofen can reduce the proportion of children with refractory fever, but if one cycle of alternating therapy cannot reduce febrile distress as defined by NCCPC score, two or more cycles of alternating therapy may have minimal to no clinical efficacy in some cases. The trial was registered with the Chinese Clinical Trial Registry as ChiCTR-TRC-13003440 and the WHO Registry Network as U1111-1146-6714.

Cost minimisation analysis of thermometry in two different hospital systems

INTRODUCTION

Temperature monitoring can be accomplished by various methods, including oral (OT), rectal (RT), axillary (AT), tympanic membrane (TMT) and temporal artery (TAT) thermometry, with varying amounts of cost incurred by healthcare systems.

METHODS

The potential thermometry cost savings in two hospital systems-University Hospital Centre Zagreb (UHCZ), which uses TMT (device Covidien Genius 2) and University of Michigan Hospitals (UMH), which relies on OT, RT and AT (device Welch Allyn suretemp plus 692)-were analysed to evaluate institution-wide TAT (device Exergen TAT-5000) implementation. Two scenarios were developed: scenario 1, comparing costs for a period of 1, 3 and 5 years; scenario 2, calculation of the number of measurements per device for TAT to be cost-effective.

RESULTS

At UHCZ, use of TAT would bring budget savings regardless of the number of devices per bed and the number of years observed. Savings would range from US$0.08 million (one device per bed, impact for 1 year) to US$1.8 million (one device per 10 beds, impact for 5 years). At UMH, use of TAT would lead to budget savings if one device per 10 beds were acquired, but only over a period of 3 or 5 years. Other TAT scenarios were associated with budget costs at UMH even after a period of 5 years.

CONCLUSIONS

Sensitivity analyses showed that the price of current consumables had the highest impact on the model in both hospital settings, with TAT up to 10 times cheaper in that regard over TMT at UHCZ, potentially leading to considerable budget savings within a year of hospital-wide implementation.

Digital Axillary and Non-Contact Infrared Thermometers for Children

Axillary digital thermometers (ADTs) and non-contact (infrared) forehead thermometers (NCIFTs) are commonly used in pediatric settings, where an incorrect body temperature measurement may delay treatments or lead to incorrect diagnoses and therapies. Several studies comparing ADT or NCIFT with other methods have found conflicting results. To investigate whether ADT and NCIFT can be used interchangeably, a comparative observational study was conducted involving 205 children aged 0 to 14 years who were consecutively admitted to the pediatric emergency department. The Bland–Altman plot illustrated agreement between the two methods. A total of 217 pairs of measurements were compared; axillary measurements showed average values significantly higher than forehead measurements (37.52°C and 37.12°C; t = 7.42, p = .000), with a mean difference of 0.41°C between the two methods (range = −1.80 and +2.40). In this setting and population, ADT and NCIFT cannot be used interchangeably.

Respiratory syncytial virus a and b display different temporal patterns in a 4-year prospective cross-sectional study among children with acute respiratory infection in a tropical city

Respiratory syncytial virus (RSV) is one of the most common etiological agents of childhood respiratory infections globally. Information on seasonality of different antigenic groups is scarce. We aimed to describe the frequency, seasonality, and age of children infected by RSV antigenic groups A (RSVA) and B (RSVB) among children with ARI in a 4-year period.Children (6-23 months old) with respiratory infection for ≤7 days were enrolled in a prospective cross-sectional study, from September, 2009 to October, 2013, in Salvador, in a tropical region of Brazil. Upon recruitment, demographic, clinical data, and nasopharyngeal aspirates (NPA) were collected. A multiplex quantitative real-time polymerase chain reaction (RT-PCR) with a group-specific primer and probeset for RSVA and RSVB was used. Seasonal distribution of infection by RSV different antigenic groups was evaluated by Prais-Wisten regression.Of 560 cases, the mean age was 11.4 ± 4.5 months and there were 287 (51.3%) girls. Overall, RSV was detected in 139 (24.8%; 95% CI: 21.4%-28.5%) cases, RSVA in 74 (13.2%; 95% CI: 10.6%-16.2%) cases, and RSVB in 67 (12.0%; 95% CI: 9.5%-14.9%) cases. Two (0.4%; 95% CI: 0.06%-1.2%) cases had coinfection. RSVA frequency was 9.6%, 18.4%, 21.6%, and 3.1% in 2010, 2011, 2012, and 2013, respectively. RSVB frequency was 19.2%, 0.7%, 1.4%, and 35.4% in the same years. RSVA was more frequently found from August to January than February to July (18.2% vs. 6.4%, P < 0.001). RSVB was more frequently found (P < 0.001) between March and June (36.0%) than July to October (1.0%) or November to February (1.6%). RSVB infection showed seasonal distribution and positive association with humidity (P = 0.02) whereas RSVA did not. RSVA was more common among children ≥1-year-old (17.8% vs. 1.8%; P = 0.02), as opposed to RSVB (11.5% vs. 12.2%; P = 0.8).One quarter of patients had RSV infection. RSVA compromised more frequently children aged ≥1 year. RSVA predominated in 2011 and 2012 whereas RSVB predominated in 2010 and 2013. In regard to months, RSVA was more frequent from August to January whereas RSVB was more often detected between March and June. Markedly different monthly as well as yearly patterns for RSVA and RSVB reveal independent RSV antigenic groups' epidemics.

Diagnostic Yield of Timing Blood Culture Collection Relative to Fever

BACKGROUND

Conventional practice involves obtaining a blood culture during or immediately after a fever to increase diagnostic yield. There are no data to support this practice in children.

METHODS

Retrospective single-center case-control study of children (0-18 years) who had blood cultures performed as part of routine care. Cases had an a priori defined pathogen isolated from blood culture (n = 410) and were age-matched with contemporaneous controls with a sterile blood culture (n = 410). The predictive value of fever (before and after blood culture), C-reactive protein and hematologic indices were analyzed by multivariate regression and area under the receiver operating characteristic curves (AUCs) in neonatal, general pediatric and pediatric oncology patients.

RESULTS

One thousand one hundred seventy-two (6.7%) of 17,607 blood cultures were positive, of which 410 (35%) cultured pathogen(s). Three hundred and twenty four (79%) cases and 275 (67.1%) controls had a fever (≥37.5°C) during the 12 hours pre- or post-collection. Fever 2-6 hours before a blood culture was neither sensitive nor specific for predicting bacteremia in neonatal or pediatric patients and marginally predictive in oncology patients (AUC 0.59-0.63). Cultures obtained 2-6 hours before fever were nonpredictive in neonates (AUC 0.56-0.59), marginally predictive in pediatric patients (AUC 0.64-0.67) and moderately predictive in oncology patients (AUC 0.70). C-reactive protein was marginally predictive in neonates (AUC 0.60). Hematologic indices were nonpredictive in all groups.

CONCLUSIONS

Fever before obtaining blood culture was neither sensitive nor specific for culture positivity; timing of pediatric blood cultures relative to fever is unimportant. Bacteremia precedes a fever, but this is of limited clinical applicability.

Temperature measurements with a temporal scanner: systematic review and meta-analysis

OBJECTIVES

Systematic review and meta-analysis on the diagnostic accuracy of temporal artery thermometers (TAT).

DESIGN

Systematic review and meta-analysis. The index test consisted of temperature measurement with TAT. The reference test consisted of an estimation of core temperature.

PARTICIPANTS

Clinical patients as well as healthy participants, with or without fever.

INTERVENTIONS

Literature search in PubMed, Embase, Cinahl and Web of Science. Three reviewers selected articles for full-text reading after which a further selection was made. Risk of bias was assessed with QUADAS-2. Pooled difference and limits of agreement (LoA) were estimated with an inverse variance weighted approach. Subgroup and sensitivity analyses were performed. Sensitivity and specificity were estimated using hierarchical models. Quality of evidence was assessed according to the GRADE system.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was measurement accuracy expressed as mean difference ± 95% LoA. A secondary outcome was sensitivity and specificity to detect fever. If tympanic thermometers were assessed in the same population as TAT, these results were recorded as well.

RESULTS

37 articles comprising 5026 participants were selected. Pooled difference was -0.19 °C (95% LoA -1.16 to 0.77 °C), with moderate quality of evidence. Pooled sensitivity was 0.72 (95% CI 0.61 to 0.81) with a specificity of 0.94 (95% CI 0.87 to 0.97). The subgroup analysis revealed a trend towards underestimation of the temperature for febrile patients. There was a large heterogeneity among included studies with wide LoA which reduced the quality of evidence.

CONCLUSIONS

TAT is not sufficiently accurate to replace one of the reference methods such as rectal, bladder or more invasive temperature measurement methods. The results are, however, similar to those with tympanic thermometers, both in our meta-analysis and when compared with others. Thus, it seems that TAT could replace tympanic thermometers with the caveat that both methods are inaccurate.

TRIAL REGISTRATION NUMBER

CRD42014008832.

Skin Temperature Over the Carotid Artery, an Accurate Non-invasive Estimation of Near Core Temperature

BACKGROUND

During anesthesia, continuous body temperature monitoring is essential, especially in children. Anesthesia can increase the risk of loss of body temperature by three to four times. Hypothermia in children results in increased morbidity and mortality. Since the measurement points of the core body temperature are not easily accessible, near core sites, like rectum, are used.

OBJECTIVES

The purpose of this study was to measure skin temperature over the carotid artery and compare it with the rectum temperature, in order to propose a model for accurate estimation of near core body temperature.

PATIENTS AND METHODS

Totally, 124 patients within the age range of 2 - 6 years, undergoing elective surgery, were selected. Temperature of rectum and skin over the carotid artery was measured. Then, the patients were randomly divided into two groups (each including 62 subjects), namely modeling (MG) and validation groups (VG). First, in the modeling group, the average temperature of the rectum and skin over the carotid artery were measured separately. The appropriate model was determined, according to the significance of the model's coefficients. The obtained model was used to predict the rectum temperature in the second group (VG group). Correlation of the predicted values with the real values (the measured rectum temperature) in the second group was investigated. Also, the difference in the average values of these two groups was examined in terms of significance.

RESULTS

In the modeling group, the average rectum and carotid temperatures were 36.47 ± 0.54°C and 35.45 ± 0.62°C, respectively. The final model was obtained, as follows: Carotid temperature × 0.561 + 16.583 = Rectum temperature. The predicted value was calculated based on the regression model and then compared with the measured rectum value, which showed no significant difference (P = 0.361).

CONCLUSIONS

The present study was the first research, in which rectum temperature was compared with that of skin over carotid artery, to find a safe location with easier access and higher accuracy for estimating near core body temperature. Results obtained in this study showed that, using a model, it is possible to evaluate near core body temperature in children, by measuring skin temperature over carotid artery.

Axillary temperature measurement: a less stressful alternative for hospitalised cats?

Rectal temperature measurement (RTM) can promote stress and defensive behaviour in hospitalised cats. The aim of this study was to assess if axillary temperature measurement (ATM) could be a reliable and less stressful alternative for these animals. In this prospective study, paired rectal and axillary temperatures were measured in 42 cats, either by a veterinarian or a student. To assess the impact of these procedures on the cat's stress state, their heart rate was checked and a cat stress score (CSS) was defined and graded from 1 (relaxed) to 5 (terrified). A moderate correlation was found between RTM and ATM (r=0.52; P<0.0001). RTM was on average 0.9 °C (1.6 °F) higher than ATM (P<0.0001), although a wide variation was found in the difference between these two measurements (-2.1 °C to 3.6 °C (-3.8 °F to 6.5 °F)). ATM failed to identify hypothermia in 25 per cent of the cases and hyperthermia in 19 per cent of the cases but may be considered less stressful than RTM. Indeed, RTM induced a mildly greater increase in heart rate (+6 bpm; P=0.01) and in CSS (+0.2; P=0.001) than ATM. The results were not affected by operator type. In conclusion, RTM should remain the standard method to obtain accurate temperatures in cats.

Differences upon admission and in hospital course of children hospitalized with community-acquired pneumonia with or without radiologically-confirmed pneumonia: a retrospective cohort study

Background

The use of chest radiograph (CXR) for the diagnosis of childhood community-acquired pneumonia (CAP) is controversial. We assessed if children with CAP diagnosed on clinical grounds, with or without radiologically-confirmed pneumonia on admission, evolved differently.

Methods

Children aged ≥ 2 months, hospitalized with CAP diagnosed on clinical grounds, treated with 200,000 IU/Kg/day of aqueous penicillin G for ≥ 48 h and with CXR taken upon admission, without pleural effusion, were included in this retrospective cohort. One researcher, blinded to the radiological diagnosis, collected data on demographics, clinical history and physical examination on admission, daily hospital course during the first 2 days of treatment, and outcome, all from medical charts. Radiological confirmation of pneumonia was based on presence of pulmonary infiltrate detected by a paediatric radiologist who was also blinded to clinical data. Variables were initially compared by bivariate analysis. Multi-variable logistic regression analysis assessed independent association between radiologically-confirmed pneumonia and factors which significantly differed during hospital course in the bivariate analysis. The multi-variable analysis was performed in a model adjusted for age and for the same factor present upon admission.

Results

109 (38.5 %) children had radiologically-confirmed pneumonia, 143 (50.5 %) had normal CXR and 31 (11.0 %) had atelectasis or peribronchial thickening. Children without radiologically-confirmed pneumonia were younger than those with radiologically-confirmed pneumonia (median [IQR]: 14 [7–28 months versus 21 [12–44] months; P = 0.001). None died. The subgroup with radiologically-confirmed pneumonia presented fever on D1 (33.7 vs. 19.1; P = 0.015) and on D2 (31.6 % vs. 16.2 %; P = 0.004) more frequently. The subgroup without radiologically-confirmed pneumonia had chest indrawing on D1 (22.4 % vs. 11.9 %; P = 0.027) more often detected. By multi-variable analysis, Fever on D2 (OR [95 % CI]: 2.16 [1.15-4.06]) was directly and independently associated with radiologically-confirmed pneumonia upon admission.

Conclusion

The compared subgroups evolved differently.

Sociodemographic and Clinical Determinants of Time to Care-Seeking Among Febrile Children Under-Five in North-Central Nigeria

OBJECTIVES

Our study sought to determine the time parents of febrile children under the age of five took to seek competent medical care. We also looked at the possible sociodemographic/ clinical factors that influenced this presentation.

METHODS

Four hundred and nine under-fives presenting at the emergency unit with a history of fever in the last 48 hours along with their mothers were recruited over four months. Relevant sociodemographic information as well as symptoms and duration of illness were obtained. Multinomial regression analysis was performed to determine the predictors of early and late presentation.

RESULTS

Over half (57%) of patients presented within 24 hours of onset of fever. The mean age of the children and mothers were 22±15 months and 30±5 years, respectively. High social class (odds ratio (OR) 6.5, 95% CI 1.6-26.4), Hausa ethnic group (OR 19.3, 95% CI 5.7-65.6), convulsions (OR 3.2, 95% CI 1.6-6.5) and appearance of other symptoms (OR 6.0, 95% CI 3.0-12.0) were significant predictors of early presentation. Secondary school education, belonging to another ethnic group, and non-resolution of fever were significant predictors of late presentation.

CONCLUSION

The majority of febrile under-fives came to the hospital to seek competent medical care within the first 24 hours of illness. However, there is a need for more parental education on early hospital presentation for parents of low socioeconomic status and educational background.

Methylphenidate intoxications in children and adults: exposure circumstances and evidence-based dose threshold for pre-hospital triage

CONTEXT

Methylphenidate intoxications mostly have a relatively mild course, although serious complications can occur.

OBJECTIVE

We aimed to characterize methylphenidate exposures and reassess our current dose threshold for hospital referral (2 mg/kg).

METHODS

In a prospective follow-up study, we analysed 364 consecutive methylphenidate exposures that were reported to the Dutch Poisons Information Center. Patients and/or physicians were surveyed by telephone using standardized questionnaires. Three physicians independently scored the observed severity of the intoxication of each patient as 'no/mild' (observation at home) or 'moderate/severe' (hospital referral necessary).

RESULTS

Unintentional exposures (40%) mostly occurred at home involving the patients' own medication or those from a family member. Compared to unintentionally exposed patients, intentionally exposed patients were exposed to relatively high methylphenidate doses (3.1 vs 1.6 mg/kg), more often used immediate release methylphenidate formulations (62 vs 34%) and more frequently had concomitant exposures (71 vs 17%). Severe symptoms like convulsions or coma were reported only in patients with concomitant exposures. Following exposure to methylphenidate only (i.e. no concomitant exposures), the most commonly reported symptoms were dry mucosa, headache, agitation, sleepiness and tachycardia. Our results show that the reported methylphenidate dose is predictive of the observed severity of the intoxication and can therefore aid in pre-hospital triage.

CONCLUSION

We increased our current dose threshold for hospital referral from 2 to 3 mg/kg. In addition, we will refer patients at lower doses when clinical symptoms indicate the need for hospital referral. Application of this new dose threshold optimizes triage, thereby reducing unnecessary hospital referral and thus costs, without jeopardising patient safety.

Accuracy of infrared tympanic thermometry used in the diagnosis of Fever in children: a systematic review and meta-analysis

BACKGROUND

Accurate determination and detection of fever is essential in the appropriate treatment of pediatric population. It is widely known that improper definitions of fever can cause grave and dangerous consequences in medical procedures. Infrared tympanic thermometry seems a relatively new and popular alternative for traditional measurement in the diagnosis of pediatric fever. However, its accuracy in the diagnosis of fever remains a major concern.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, Ovid, Elsevier, Google Scholar, and Cochrane library.

STUDY SELECTION

Cross-sectional, prospective design.

DATA EXTRACTION

Two investigators independently assessed selected studies and extracted data. Disagreements were resolved by discussion with other reviewers.

RESULTS

A total of 25 articles were included in our meta-analysis. The summary estimates revealed that the pooled sensitivity was 0.70 (95% confidence interval [CI] = 0.68-0.72), pooled specificity was 0.86 (95% CI = 0.85-0.88), and pooled diagnostic odds ratio was 47.3 (95% CI = 29.76-75.18), for the diagnosis of fever using infrared tympanic thermometry. Additionally, the area under the summary receiver operating characteristic curve was 0.94, and Q* value was 0.87.

CONCLUSION

A total of 25 articles that encompassing 31 studies were analyzed. Based on our meta-analysis, accuracy of infrared tympanic thermometry in diagnosing fever is high. We can cautiously make conclusion that infrared tympanic thermometry should be widely used as fever of thermometer.

Effect of wearing an N95 respirator on infrared tympanic membrane temperature measurements

To determine the impact of wearing an N95 filtering facepiece respirator (N95 FFR) on tympanic temperature measurements. TMT measurements, with and without wearing an N95 filtering facepiece respirator (N95 FFR) were obtained at the onset and termination of 1 h of treadmill exercise in 21 subjects, and at staggered time intervals (0, 20, 40, 60 min) during combined sedentary activity and exercise of another 46 subjects, to determine any effect on TMT. A total of 877 TMT measurements were obtained that demonstrated a mean TMT increase of 0.05 °C in the first study group (p = 0.04) and a 0.19 °C decrease in the second study group (p < 0.001) with the wearing of an N95 FFR, both of which were lower than controls. Wearing an N95 FFR for 1 h, at different levels of activity, results in significantly lower TMT values than not wearing an N95 FFR, but the magnitude of the changes would likely have minimal clinical significance.

[Systematic review and meta-analyses of diagnostic accuracy of infrared thermometer when identifying fever in children]

PURPOSE

Infrared thermometers are increasingly used as a convenient, non-invasive assessment method for febrile children. However, the diagnostic accuracy of the infrared thermometer for children has been questioned, particularly in relation to sensitivity and specificity. The aim of this study was to evaluate diagnostic accuracy of infrared thermometers in febrile children.

METHODS

Articles published between 1966 and 2012 from periodicals indexed in the Ovid Medline, Embase, CINAHL, Cochrane, KoreaMed, NDSL, KERIS and other databases were selected, using the following keywords: 'infrared thermometer'. The QUADAS-II was applied to assess the internal validity of the diagnostic studies. Selected studies were analyzed using meta-analysis with MetaDisc 1.4.

RESULTS

Nineteen diagnostic studies with high methodological quality, involving 4,304 children, were included. The results of meta-analysis showed that the pooled sensitivity, specificity and AUC (Area Under the Curve) of infrared tympanic thermometers in children over 1 year were 0.80 (95% CI 0.78, 0.81), 0.94 (95% CI 0.93, 0.95) and 0.95 respectively. However the diagnostic accuracy of infrared tympanic thermometers in children with hyperthermia was low.

CONCLUSION

The diagnostic accuracy of infrared tympanic thermometer was similar to axillary and rectal thermometers indicating a need for further research to substantiate these findings in children with hyperthermia.

Fever after redo Nissen fundoplication with hiatal hernia repair

BACKGROUND

Fevers often arise after redo fundoplication with hiatal hernia repair. We reviewed our experience to evaluate the yield of a fever work-up in this population.

METHODS

We performed a retrospective review of children undergoing redo Nissen fundoplication with hiatal hernia repair between December 2001 and September 2012. Temperatures and fever evaluations of those children receiving a mesh repair were compared with those without mesh. A fever defined as temperature ≥38.4°C.

RESULTS

Fifty one children received 46 laparoscopic, 4 open, and 1 laparoscopic converted to open procedures. Biosynthetic mesh was used in 25 children whereas 26 underwent repair without mesh. A fever occurred in 56% of those repaired with mesh compared with 23.1% without mesh (P = 0.02). A fever evaluation was conducted in 32% of those with mesh compared with 11.5% without mesh (P = 0.52). A urinary tract infection was identified in one child after mesh use and an infection was identified in two children without mesh, one pneumonia and one wound infection (P = 1). In those repaired with mesh, there was no significant difference in maximum temperature.

CONCLUSIONS

Fever is common after redo Nissen fundoplication with hiatal hernia repair and occurs more frequently, and with higher temperatures in those with mesh. Fever work-up in these patients is unlikely to yield an infectious source and is attributed to the extensive dissection during the redo procedure.

Determining fever in children: the search for an ideal thermometer

Body temperature measurement is most commonly taken to confirm the presence or absence of fever. Many decisions concerning the investigation and treatment of children are based on the results of temperature measurement alone. Determining the presence of fever in young children is particularly important. A missed fever is serious, but a false-positive fever reading can result in unnecessary septic workups. The axillary, rectal, oral and tympanic membrane sites are most commonly used to record body temperature, and electronic and infrared thermometers are the devices most commonly used. Each site and device has numerous advantages and disadvantages, which are described in this article. The search for the means of measuring body temperature that best combines accuracy, speed, convenience, safety and cost-effectiveness goes on. The infrared thermometer and the tympanic site appear to offer such a combination. Electronic thermometers are also suitable when used orally or at the axilla in newborn babies.