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Fever in Children
SPN NEWS
Position Statement for Measurement of Temperature/Fever in Children Cindy Asher, RN, CNS LaDonna K. Northington, DNS, RN, CCRN
INTRODUCTION/PROBLEM STATEMENT Temperature measurement in ill infants and children is a vital assessment parameter. Generally, the measurement of body temperature is used to determine the presence or absence of fever. Fever can be used to gauge the severity of illness by both parents and health care providers. However, many factors such as age, activity level, time of day, disease/illness, ambient temperature, and clothing can influence body temperature. According to the American Academy of Pediatrics (AAP) statement (December 2006), many fevers do not need treatment and are simply an indicator that the immune system has been activated as the result of a bacterial or viral illness. Fevers can actually help shorten a child's illness. A normal temperature is not a specific number but can range from 97 to 100.4 degrees Fahrenheit (AAP, 2006). The need for immediate assessment, septic workup, and treatment for infants less than 90 days old with fever must be recognized because the infant's condition can deteriorate quickly. The most accurate and appropriate method of measuring fever in children has been a topic of concern for many years. The use of the mercury thermometer has been phased out because of potential health problems associated with mercury. In addition to oral, rectal, and axillary methods, From the The Children's Medical Center of Dayton, OH, University of Mississippi Medical Center, Jackson, MS. 0882-5963/$ - see front matter doi:10.1016/j.pedn.2008.03.005
234
there are newer modes of measuring temperature such as tympanic and temporal artery methods, and the addition of these has increased the confusion. It is important that the nurse caring for infants and children, regardless of the setting, be aware of best practice implications for measuring temperature, or fever, in pediatric clients. One widely accepted and expert resource for parents and nurses on pediatric fever is the AAP Web site (www.aap.org), which offers public access to information and policy statements on common pediatric problems, including fever. In the AAP Parenting Corner (AAP, 2007), one can find what could be considered an expert definition of pediatric fever, as well as an overview of details regarding when and how to assess pediatric temperature using oral, rectal, tympanic, and axillary methods. RATIONALE/SUPPORTING INFORMATION For years, the measurement of temperature/fever via the rectal route was the “gold standard.” This was accomplished using a glass thermometer with mercury. The development of electronic and nonelectronic methods, which are faster and inexpensive, has created much discussion related to the best method for measuring temperature/fever in children. The pediatric nurse (regardless of setting) is commonly approached requesting advice on measuring fever in children. The nurse must be able to articulate and discuss common safe practices for use in home and health care settings.
Journal of Pediatric Nursing, Vol 23, No 3 (June), 2008
POSITION STATEMENT FOR MEASUREMENT OF TEMPERATURE/FEVER IN CHILDREN
Over the past decade, the newer and more convenient modes of measurement of temperature/ fever have spawned many studies regarding the most accurate and reliable method for measuring temperature in children. Although there have been no conclusive standardized results, the various studies each contribute to a better understanding of the fever measurement in children. Although there are several methods available for measuring temperatures, the goal is to use the most accurate method with the least degree of variance while still recognizing the comfort of the patient and ease of use for the health care provider. Because of a greater degree of variance accuracy, the temporal artery method should not be used with infants 90 days or younger who are ill, have a fever, or have an ill diagnosis. The rectal method should be used for these infants unless contraindicated by diagnosis (e.g., gastrointestinal/ rectal bleeding, prematurity, and oncology diagnosis). When the use of a rectal temperature method is contraindicated by diagnosis, the axillary method should be used. The temporal artery method can reliably be used in infants less than 90 days old without fever as well as for all patients greater than 3 months of age with or without fever, ill or well. In children 6 months of age or older, the tympanic or oral methods may be used with correct positioning of the ear (tympanic) and if the patient can cooperate (oral). Some of the studies that have been conducted include fever measurement in various settings (Jean Mary, Dicanzio, Shaw, & Bernstein, 2002; Martin & Kline, 2004; Maxton, Justin, & Gillies, 2004). Other studies approached fever management using various modes/methods (Barton, Gaffney, Chase, Rayens, & Piyabanditkul, 2003; Devrim et al., 2007; El Radhi & Barry, 2006; Lefrant et al., 2003; Molton, Blacktop, & Hall, 2001; Schuh, Komar, Stephens, Chu, Read, & Allen, 2004). Still other researchers approached the issue in terms of various ages of the children (Greenes & Fleisher, 2001; Leick-Rude & Bloom, 1998; Siberry, Diener-West, Schappell, & Karron, 2002). Limited studies have been conducted to analyze other studies (Craig,
235
Lancaster, Taylor, Williamson, & Smyth, 2002; Houlder, 2000).
Postion Statement/Recommendations One of the missions of Society of Pediatric Nurses (SPN) is to promote excellence in nursing care through research and the implementation of best practices based on education and research. To address the issue of the measurement of temperature/fever in children, SPN supports that the pediatric nurse 1. is aware that temperature/fever measurement is a common concern for health care providers and parents, 2. acknowledges the various modes/methods available for measuring temperature/fever in children, 3. uses appropriate documentation related to modes/methods of temperature measurement, 4. recognizes that temporal artery thermometry is accurate with infants older than 90 days without fever, as well as for all patients greater than 3 months of age with or without fever, ill or well, 5. recognizes that because of a degree of variance accuracy, the temporal artery method should not be used in infants 90 days or younger, who are ill, have a fever, or have an ill diagnosis. The rectal method should be used for these infants unless contraindicated by diagnosis, 6. recognizes that in children 6 months of age or older, the tympanic or oral methods may be used with correct positioning of the ear (tympanic) and if the patient can cooperate (oral), 7. uses assessment skills to determine etiologies that influence temperature/fever in children, 8. relies on evidence-based practice to determine the best method for evaluating temperature/ fever in any given setting, based on the age and condition of the client, and 9. uses evidence-based practice to determine best policies for his or her institution.
REFERENCES American Academy of Pediatrics. (2006). A minute for kids. Fever: A symptom, not a sickness. Retrieved December 11, 2007, from http://www.aap.org/sections/media/fever.htm. American Academy of Pediatrics (2007). Parenting corner Q&A: What's the best way to take a child's temperature? Retrieved December 11, 2007, from: http://www.aap.org/publiced/BR_Fever.htm.
Barton, S. J., Gaffney, R., Chase, T., Rayens, M. K., & Piyabanditkul, L. (2003). Pediatric temperature measurement and child/parent/nurse preference using three temperature measurement instruments. Journal of Pediatric Nursing, 18, 314−320. Craig, J. V., Lancaster, G. A., Taylor, S., Williamson, P. R., & Smyth, R. L. (2002). Infrared ear thermometry compared with
236
rectal thermometry in children: A systemic review. Lancet, 360, 603−609. Devrim, I., Kara, A., Ceyhan, M., Tezer, H., Uludag, A. K., Cengiz, A. B., et al. (2007). Measurement accuracy of fever by tympanic and axillary thermometry. Pediatric Emergency Care, 23, 16−19. El Radhi, A. S., & Barry, W. (2006). Thermometry in paediatric practice. Archives of Disease in Childhood, 91, 351−356. Greenes, D. S., & Fleisher, G. R. (2001). Accuracy of a noninvasive temporal artery thermometer for use in infants. Archives of Pediatrics & Adolescent Medicine, 155, 376−381. Houlder, L. C. (2000). The accuracy and reliability of tympanic thermometry compared to rectal and axillary sites in young children. Pediatric Nursing, 26, 311−314. Jean Mary, M. B., Dicanzio, J., Shaw, J., & Bernstein, H. H. (2002). Limited accuracy and reliability of infrared axillary and aural thermometers in a pediatric outpatient population. Journal of Pediatrics, 141, 671−676. Lefrant, J. Y., Muller, L., de La Coussaye, J. E., Benbabaali, M., Lebris, C., Zeitoun, N., et al. (2003). Temperature measurement in intensive care patients: A comparison of urinary bladder, oesophageal, rectal, axillary, and inguinal methods
ASHER AND NORTHINGTON
versus pulmonary artery core method. Intensive Care Medicine, 29, 414−418. Leick-Rude, M. K., & Bloom, L. F. (1998). A comparison of temperature taking methods in neonates. Neonatal Network, 17, 21−37. Martin, S., & Kline, A. (2004). Can there be a standard for temperature measurement in the pediatric intensive care unit? AACN Clinical Issues, 15, 254−266. Maxton, F. J. C., Justin, L., & Gillies, D. (2004). Estimating core temperature in infants and children after cardiac surgery: A comparison of six methods. Journal of Advanced Nursing, 45, 214−222. Molton, A., Blacktop, J., & Hall, C. M. (2001). Temperature taking in children. Journal of Child Health Care, 5, 5−10. Schuh, S., Komar, L., Stephens, D., Chu, L., Read, S., & Allen, U. (2004). Comparison of the temporal artery and rectal thermometers in children in the emergency department. Pediatric Emergency Care, 20, 736−741. Siberry, G. K., Diener-West, M., Schappell, E., & Karron, R. A. (2002). Comparison of temple temperatures with rectal temperatures in children less than 2 years of age. Clinical Pediatrics, 41, 405−414.
Position Statement for Measurement of Temperature/Fever in Children Cindy Asher, RN, CNS LaDonna K. Northington, DNS, RN, CCRN
INTRODUCTION/PROBLEM STATEMENT Temperature measurement in ill infants and children is a vital assessment parameter. Generally, the measurement of body temperature is used to determine the presence or absence of fever. Fever can be used to gauge the severity of illness by both parents and health care providers. However, many factors such as age, activity level, time of day, disease/illness, ambient temperature, and clothing can influence body temperature. According to the American Academy of Pediatrics (AAP) statement (December 2006), many fevers do not need treatment and are simply an indicator that the immune system has been activated as the result of a bacterial or viral illness. Fevers can actually help shorten a child's illness. A normal temperature is not a specific number but can range from 97 to 100.4 degrees Fahrenheit (AAP, 2006). The need for immediate assessment, septic workup, and treatment for infants less than 90 days old with fever must be recognized because the infant's condition can deteriorate quickly. The most accurate and appropriate method of measuring fever in children has been a topic of concern for many years. The use of the mercury thermometer has been phased out because of potential health problems associated with mercury. In addition to oral, rectal, and axillary methods, From the The Children's Medical Center of Dayton, OH, University of Mississippi Medical Center, Jackson, MS. 0882-5963/$ - see front matter doi:10.1016/j.pedn.2008.03.005
234
there are newer modes of measuring temperature such as tympanic and temporal artery methods, and the addition of these has increased the confusion. It is important that the nurse caring for infants and children, regardless of the setting, be aware of best practice implications for measuring temperature, or fever, in pediatric clients. One widely accepted and expert resource for parents and nurses on pediatric fever is the AAP Web site (www.aap.org), which offers public access to information and policy statements on common pediatric problems, including fever. In the AAP Parenting Corner (AAP, 2007), one can find what could be considered an expert definition of pediatric fever, as well as an overview of details regarding when and how to assess pediatric temperature using oral, rectal, tympanic, and axillary methods. RATIONALE/SUPPORTING INFORMATION For years, the measurement of temperature/fever via the rectal route was the “gold standard.” This was accomplished using a glass thermometer with mercury. The development of electronic and nonelectronic methods, which are faster and inexpensive, has created much discussion related to the best method for measuring temperature/fever in children. The pediatric nurse (regardless of setting) is commonly approached requesting advice on measuring fever in children. The nurse must be able to articulate and discuss common safe practices for use in home and health care settings.
Journal of Pediatric Nursing, Vol 23, No 3 (June), 2008
POSITION STATEMENT FOR MEASUREMENT OF TEMPERATURE/FEVER IN CHILDREN
Over the past decade, the newer and more convenient modes of measurement of temperature/ fever have spawned many studies regarding the most accurate and reliable method for measuring temperature in children. Although there have been no conclusive standardized results, the various studies each contribute to a better understanding of the fever measurement in children. Although there are several methods available for measuring temperatures, the goal is to use the most accurate method with the least degree of variance while still recognizing the comfort of the patient and ease of use for the health care provider. Because of a greater degree of variance accuracy, the temporal artery method should not be used with infants 90 days or younger who are ill, have a fever, or have an ill diagnosis. The rectal method should be used for these infants unless contraindicated by diagnosis (e.g., gastrointestinal/ rectal bleeding, prematurity, and oncology diagnosis). When the use of a rectal temperature method is contraindicated by diagnosis, the axillary method should be used. The temporal artery method can reliably be used in infants less than 90 days old without fever as well as for all patients greater than 3 months of age with or without fever, ill or well. In children 6 months of age or older, the tympanic or oral methods may be used with correct positioning of the ear (tympanic) and if the patient can cooperate (oral). Some of the studies that have been conducted include fever measurement in various settings (Jean Mary, Dicanzio, Shaw, & Bernstein, 2002; Martin & Kline, 2004; Maxton, Justin, & Gillies, 2004). Other studies approached fever management using various modes/methods (Barton, Gaffney, Chase, Rayens, & Piyabanditkul, 2003; Devrim et al., 2007; El Radhi & Barry, 2006; Lefrant et al., 2003; Molton, Blacktop, & Hall, 2001; Schuh, Komar, Stephens, Chu, Read, & Allen, 2004). Still other researchers approached the issue in terms of various ages of the children (Greenes & Fleisher, 2001; Leick-Rude & Bloom, 1998; Siberry, Diener-West, Schappell, & Karron, 2002). Limited studies have been conducted to analyze other studies (Craig,
235
Lancaster, Taylor, Williamson, & Smyth, 2002; Houlder, 2000).
Postion Statement/Recommendations One of the missions of Society of Pediatric Nurses (SPN) is to promote excellence in nursing care through research and the implementation of best practices based on education and research. To address the issue of the measurement of temperature/fever in children, SPN supports that the pediatric nurse 1. is aware that temperature/fever measurement is a common concern for health care providers and parents, 2. acknowledges the various modes/methods available for measuring temperature/fever in children, 3. uses appropriate documentation related to modes/methods of temperature measurement, 4. recognizes that temporal artery thermometry is accurate with infants older than 90 days without fever, as well as for all patients greater than 3 months of age with or without fever, ill or well, 5. recognizes that because of a degree of variance accuracy, the temporal artery method should not be used in infants 90 days or younger, who are ill, have a fever, or have an ill diagnosis. The rectal method should be used for these infants unless contraindicated by diagnosis, 6. recognizes that in children 6 months of age or older, the tympanic or oral methods may be used with correct positioning of the ear (tympanic) and if the patient can cooperate (oral), 7. uses assessment skills to determine etiologies that influence temperature/fever in children, 8. relies on evidence-based practice to determine the best method for evaluating temperature/ fever in any given setting, based on the age and condition of the client, and 9. uses evidence-based practice to determine best policies for his or her institution.
REFERENCES American Academy of Pediatrics. (2006). A minute for kids. Fever: A symptom, not a sickness. Retrieved December 11, 2007, from http://www.aap.org/sections/media/fever.htm. American Academy of Pediatrics (2007). Parenting corner Q&A: What's the best way to take a child's temperature? Retrieved December 11, 2007, from: http://www.aap.org/publiced/BR_Fever.htm.
Barton, S. J., Gaffney, R., Chase, T., Rayens, M. K., & Piyabanditkul, L. (2003). Pediatric temperature measurement and child/parent/nurse preference using three temperature measurement instruments. Journal of Pediatric Nursing, 18, 314−320. Craig, J. V., Lancaster, G. A., Taylor, S., Williamson, P. R., & Smyth, R. L. (2002). Infrared ear thermometry compared with
236
rectal thermometry in children: A systemic review. Lancet, 360, 603−609. Devrim, I., Kara, A., Ceyhan, M., Tezer, H., Uludag, A. K., Cengiz, A. B., et al. (2007). Measurement accuracy of fever by tympanic and axillary thermometry. Pediatric Emergency Care, 23, 16−19. El Radhi, A. S., & Barry, W. (2006). Thermometry in paediatric practice. Archives of Disease in Childhood, 91, 351−356. Greenes, D. S., & Fleisher, G. R. (2001). Accuracy of a noninvasive temporal artery thermometer for use in infants. Archives of Pediatrics & Adolescent Medicine, 155, 376−381. Houlder, L. C. (2000). The accuracy and reliability of tympanic thermometry compared to rectal and axillary sites in young children. Pediatric Nursing, 26, 311−314. Jean Mary, M. B., Dicanzio, J., Shaw, J., & Bernstein, H. H. (2002). Limited accuracy and reliability of infrared axillary and aural thermometers in a pediatric outpatient population. Journal of Pediatrics, 141, 671−676. Lefrant, J. Y., Muller, L., de La Coussaye, J. E., Benbabaali, M., Lebris, C., Zeitoun, N., et al. (2003). Temperature measurement in intensive care patients: A comparison of urinary bladder, oesophageal, rectal, axillary, and inguinal methods
ASHER AND NORTHINGTON
versus pulmonary artery core method. Intensive Care Medicine, 29, 414−418. Leick-Rude, M. K., & Bloom, L. F. (1998). A comparison of temperature taking methods in neonates. Neonatal Network, 17, 21−37. Martin, S., & Kline, A. (2004). Can there be a standard for temperature measurement in the pediatric intensive care unit? AACN Clinical Issues, 15, 254−266. Maxton, F. J. C., Justin, L., & Gillies, D. (2004). Estimating core temperature in infants and children after cardiac surgery: A comparison of six methods. Journal of Advanced Nursing, 45, 214−222. Molton, A., Blacktop, J., & Hall, C. M. (2001). Temperature taking in children. Journal of Child Health Care, 5, 5−10. Schuh, S., Komar, L., Stephens, D., Chu, L., Read, S., & Allen, U. (2004). Comparison of the temporal artery and rectal thermometers in children in the emergency department. Pediatric Emergency Care, 20, 736−741. Siberry, G. K., Diener-West, M., Schappell, E., & Karron, R. A. (2002). Comparison of temple temperatures with rectal temperatures in children less than 2 years of age. Clinical Pediatrics, 41, 405−414.