Acta Pædiatrica ISSN 0803-5253

REGULAR ARTICLE

Accuracy of tympanic and forehead thermometers in private paediatric

practice
J Teller1*, M Ragazzi2*, GD Simonetti (giacomo.simonetti@insel.ch)2, SAG Lava2,3
1.Private Paediatric Practice, Langnau i.E., Switzerland
2.Division of Paediatric Nephrology, University Children’s Hospital Bern, University of Bern, Bern, Switzerland
3.Department of Paediatrics, Ospedale Regionale Bellinzona e Valli, Bellinzona and University of Bern, Bern, Switzerland

Keywords ABSTRACT
Children, Fever, Infrared forehead, Infrared tympanic, Aim: To compare infrared tympanic and infrared contact forehead thermometer
Thermometer
measurements with traditional rectal digital thermometers.
Correspondence
Methods: A total of 254 children (137 girls) aged one to 24 months (median 7 months)
GD Simonetti, MD, Division of Paediatric
Nephrology, University Children’s Hospital, consulting a private paediatric practice because of fever were prospectively recruited. Body
Inselspital and University of Bern, Freiburgstrasse temperature was measured using the three different devices.
3010 Bern, Switzerland.
Tel: +41 31 632 95 12 |
Results: The median and interquartile range for rectal, tympanic and forehead
Fax: +41 31 632 94 20 | thermometers were 37.6 (37.1–38.4)°C, 37.5 (37.0–38.1)°C and 37.5 (37.1–37.9)°C,
Email: giacomo.simonetti@insel.ch respectively (p < 0.01). The limits of agreement in the Bland-Altman plots were 0.73 to
Received +1.04°C for the tympanic thermometer and 1.18 to +1.64°C for the forehead
24 July 2013; revised 7 September 2013; thermometer. The specificity of both the tympanic and forehead thermometers for
accepted 10 October 2013.
detecting fever above 38°C was good, but sensitivity was low. Forehead measurements
DOI:10.1111/apa.12464 were susceptible to the use of a radiant warmer.
*These authors contributed equally to this work. Conclusion: Both the tympanic and forehead devices recorded lower temperatures than
the rectal thermometers. The limits of agreement were particularly wide for the forehead
thermometer and considerable for the tympanic thermometer. In the absence of valid
alternatives, because of the ease to use and little degree of discomfort, tympanic
thermometers can still be used with some reservations. Forehead thermometers should
not be used in paediatric practice.

INTRODUCTION study, performed more than 20 years ago (6), investigated

Fever is a frequent symptom in childhood and one of the
most common reasons for taking a child to the doctor (1).
Ideally, temperature measurement techniques should be
safe, easy to perform, noninvasive, cost-effective and time-
efficient and should accurately reflect core body tempera-
ture (2,3). Traditionally, body temperature has typically
been taken orally in older children and adults and rectally
in infants and young children. Rectal measurement, the gold
standard in young children (3), is reliable and accurately
reflects the body’s core temperature. However, the proce-
dure is invasive and not well accepted among children and
parents. Therefore, alternative measurement methods are
needed (2,4).
In infants younger than 4 weeks, axillary measurement is
extremely accurate (2,4). In older children and adults,
however, this method, although easy to perform and
generally well tolerated, showed variable sensitivity. Fur-
thermore, although an axillary reading is generally 0.5°C
lower than a rectal reading, an exact conversion factor
cannot be established (2). Tympanic measurements using
infrared thermometers have also been repeatedly investi-
gated, with conflicting results (5). Furthermore, only one
tympanic thermometers in the setting of a private paediatric
practice. More recently, infrared cutaneous contact ther-
mometers that can assess forehead temperature have
appeared on the market. So far, only a few published
studies have examined the validity of these thermometers
and none have been performed in a private paediatric
practice (2,3,7).
Key notes
 Our study of 254 children presenting with fever in a
private paediatric practice compared readings from
infrared tympanic, infrared contact forehead and tradi-
tional rectal digital thermometers.
 We found that tympanic and forehead thermometers
recorded lower temperatures than digital rectal ther-
mometers, and their limits of agreement were partic-
ularly wide.
 The findings suggest that tympanic thermometers can
be used with some reservations, but forehead ther-
mometers should not be used in paediatric practice.

e80 ©2013 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. e80–e83
Teller et al.
The aim of this noncommercially sponsored study was to
compare infrared tympanic and infrared contact forehead
thermometer measurements with those from traditional
rectal digital thermometers within a large sample of infants
and toddlers presenting at a private paediatric practice.
PATIENTS AND METHODS
In this prospective study, infants and toddlers between one
and 24 months of age with no underlying chronic illness or
known pathology and presenting to the private paediatric
practice because of fever were eligible to participate.
Participants were consecutively recruited between Novem-
ber 1, 2011 and April 2, 2012.
Age and gender were recorded for each patient, and
temperature measurements were collected as part of the
routine clinical diagnostic procedure. After explaining the
purpose of temperature measurement, informed consent
was obtained from the parents. No data are available on
those who declined to consent. After having created a quiet
atmosphere, during the physical examination, taking care of
avoiding any haste, a licensed paediatrician on the project
(JT) took the three temperature measurements, each of
which was performed at room temperature (22–24°C). All
three measurements were taken within 3 min.
Each patient’s rectal temperature was measured using the
Microlife MT1961TM (Microlife, Widnau, Switzerland) con-
ventional digital thermometer. Infrared tympanic tempera-
ture was measured using the ThermoScan 6022TM (Braun,
Kronberg, Germany) thermometer, and infrared skin fore-
head temperature was measured using the VoiceThermo
wdc 6603 BTM (Wellness-design-company, Du € sseldorf,
Germany) thermometer. All the thermometers (always the
same device for each type of thermometer) were used
strictly according to the manufacturers’ manuals.
The use of an infrared radiant warmer was sometimes
necessary. Its use was annotated, and its influence on
measurements was evaluated.
Power calculation was performed to determine sample
size. At least 198 children were needed to achieve a study
power of 80%, with a error = 0.05, estimating a potential
difference between the two methods of 0.2°C and a
standard deviation of 1°C (8). Normal distribution of
variables was tested using the D’Agostino–Pearson omnibus
test for normality. Not normally distributed data are
presented as median and interquartile range (IQR). Vari-
ables were compared by the nonparametric Friedman
analysis of variance test, and the Dunn’s post-test procedure
was used to compare the different measurements. The
Fisher exact test was used to compare dichotomous
variables; sensitivity, specificity, positive predictive value
and negative predictive value were calculated, using rectal
temperature of 38.0°C, as the generally used cut-off point
for rectally measured fever (3,9). Moreover, receiver oper-
ating characteristics (ROC) curve analysis was performed to
establish the best threshold in determining the presence of
rectally measured fever (≥38°C) for tympanic and forehead
thermometers. Concordance among the different methods
©2013 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. e80–e83
Accuracy of thermometers in paediatric practice
was examined using Bland–Altman plots, which display the
mean differences and 95% limits of agreement (10). Statis-
tical significance was assigned at p < 0.05.
RESULTS
Our final sample included 254 children (117 boys and 137
girls) ranging in age from one to 24 months, with a median
of 7.0 (5.0–11.0) months.
Figure 1 shows the temperature readings from the three
types of thermometers investigated. The medians and IQR
for the rectal, tympanic and forehead thermometers were
37.6 (37.1–38.4)°C, 37.5 (37.0–38.1)°C and 37.5 (37.1–
37.9)°C, respectively. The tympanic and forehead measure-
ments were 0.1°C ( 0.1–0.4, p < 0.01) and 0.15°C ( 0.3–
0.7; p < 0.05) lower than the rectal measurements, respec-
tively (Fig. 1). However, tympanic and forehead measure-
ments were not significantly different from each other
(Fig. 1). Using Bland–Altman plots, the 95% limits of
agreement were 0.73 to +1.04°C (Fig. 2, upper panel) for
the tympanic measurements and 1.18 to +1.64°C (Fig. 2,
lower panel) for the forehead measurements.
While the specificity in detecting temperatures above
38°C was good, the sensitivity was low when using either
the tympanic or the forehead thermometer (Table 1).
Similarly, the positive predictive value was good (ranging
from 88% to 95%), and the negative predictive value was
adequate (ranging from 71% to 84%, Table 1). Calculating
the ROC curve, we found that the best threshold for
detecting rectal temperature ≥38°C was 37.55°C for both
the tympanic and the forehead thermometers. In particular,
for a tympanic temperature of 37.55°C sensitivity was
93.1% (95% CI: 86.4–97.2%) and specificity 83.5% (95% CI:
76.7–89.0%) with an area under the curve of 0.94 (95% CI:
Figure 1 Box plot of temperatures measured with the 3 different devices. The
boundary of the box closest to zero indicates the 25th percentile, the line within
the box marks the median, and the boundary of the box farthest from zero
indicates the 75th percentile. Whiskers (error bars) above and below the box
indicate the 90th and 10th percentiles. (ns = not significant).
e81
Accuracy of thermometers in paediatric practice Teller et al.

DISCUSSION
This study demonstrates that both tympanic and forehead
thermometers devices record lower temperatures than
rectal thermometers. This can frequently underestimate
the core temperature. Although both devices showed
excellent specificity and positive predictive values, sensitiv-
ity was low, and the negative predictive values were
suboptimal. With a lower threshold of 37.55°C for both
the tympanic and forehead thermometers, derived from a
ROC curve, sensitivity slightly improved, particularly for the
tympanic thermometer.
The forehead thermometer showed clear inconsistency,
with limits of agreement encompassing a range of almost
3°C. While the tympanic thermometer showed a slightly
better degree of agreement, its range of almost 2°C is
clinically inappropriate (11,12). These results are consistent
with previous data (13–15). More importantly, a well-
performed systematic review of studies comparing rectal
and tympanic thermometers found acceptable mean differ-
ences but similarly wide limits of agreement (5).
In addition, the present results indicate that forehead
measurements were susceptible to the use of a radiant
warmer, explaining at least in part their insufficient accu-
racy, as well as supporting the conclusion that these devices
are not appropriate for use in a private paediatric practice.
Figure 2 Bland–Altman plots, which display the difference between two
There are two innovative aspects of this study. First, the
measurements against their average. The data plotted should ideally scatter measurements were performed in the real-world setting of a
around a difference of zero across the range of means: the smaller the scatter is private paediatric practice using modern devices. Children
away from the mean (solid line), the greater the agreement. The scatter is presenting to a private paediatric practice represent the vast
quantified by calculating the limits of agreement (dotted lines), which are majority of feverish children cared for by paediatricians.
estimated by the mean difference and 2 standard deviations of the difference. Nonetheless, only one study, performed more than 20 years
Upper panel: Bland–Altman plot of tympanic measurements. The mean
ago, analysed tympanic thermometer measurements in this
difference is 0.15°C, and the 95% limits of agreement range from 0.73 to
+1.04°C. Lower panel: Bland–Altman plot of the forehead thermometer. The setting (6). Second, we assessed the influence of external
mean difference is 0.23°C, and the 95% limits of agreement range from 1.18 factors on recorded temperatures, such as the use of a
to +1.64°C. radiant warmer. Although the negative effect of radiant
heaters on temperature measurement might appear evident,
our data demonstrate that rectal and tympanic readings are
not affected by the presence of a radiant warmer and can
Table 1 Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) therefore be rated as robust. On the other side, forehead
with 95% confidence interval for detecting rectal fever (≥38.0°C) with the tympanic thermometers are extremely dependent on external vari-
and infrared skin thermometers ables and are therefore even more unreliable as already
Thermometer Sensitivity Specificity PPV NPV shown by their wide limits of agreement.
Another significant strength of the present study is the
Tympanic 0.72 0.97 0.95 0.84
(0.62–0.80) (0.93–0.99) (0.87–0.99) (0.77–0.89)
inclusion of children with a febrile illness. In contrast, most
Infrared skin 0.42 0.96 0.88 0.71 thermometer studies have utilised a mixed sample of
(0.32–0.52) (0.92–0.99) (0.75–0.95) (0.64–0.77) healthy and sick patients, without a clear selection based
on the pretest probability of finding a feverish temperature.
Moreover, infrared cutaneous contact thermometers have
only been commercially available for a few years, and data
0.91–0.97, p < 0.0001). On the other side, for a forehead on their use in a private paediatric practice are lacking.
temperature of 37.55°C sensitivity was 80.4% (95% CI: The present study has some limitations. First, only one
71.4–87.6%) and specificity 73.0% (95% CI: 65.2–79.9%) model for each type of thermometer was analysed; thus, our
with an area under the curve of 0.83 (95% CI: 0.78–0.88, results cannot be generalised to other models. Second, only
p < 0.0001). children 24 months of age or less were included. Thus, no
A radiant warmer was used in 117 children, but not conclusions for older children can be drawn. Thirdly,
documented in 42 children. Subgroup analyses indicated that sensitivity, specificity, positive predictive value and negative
the radiant warmer only influenced forehead measurements. predictive value are computed from children presenting

e82 ©2013 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. e80–e83
Teller et al.
with fever; therefore, these data should be interpreted with
respect to the study design. Fourthly, we did not evaluate
the reproducibility of measurements performed by each 3.
type of thermometer. However, the high number of partic-
ipants included in the study should have minimised the 4.
impact of measurement imprecision. Finally, our results
might not be automatically generalised to inpatients or to
children presenting to a paediatric emergency department. 5.
In conclusion, according to the results of the present
study, a reliable and valid alternative to invasive rectal
6.
temperature measurement is still lacking. Forehead ther-
mometers similar to that investigated in the present study
should not be used in private paediatric practice because of 7.
their wide limits of agreement along with their vulnerability
to the influence of external factors such as a radiant
warmer. In the absence of valid alternatives, and consider-
8.
ing that tympanic thermometers are easy to use, create little
discomfort and are the preferred method of physicians and
nurses at several institutions, such thermometers can be
employed but with some reservations. Their lack of sensi- 9.
tivity and negative predictive value, together with their wide
limits of agreement, render them suboptimal as a screening 10.
tool, in contrast to some recently proposed data (16).
11.
According to other studies, axillary measurement might
represent a better screening tool (15). This notion is also
supported by the recently published update of the Italian
Guidelines on Fever Management (17). Finally, very 12.
recently, a temporal artery thermometer was also shown
to perform very well, with limits of agreement in a range of
approximately 0.5°C (18).
13.
Patient history and a careful clinical examination remain
the most important criteria for the evaluation of a feverish
child. The clinical assessment and suspicion should guide 14.
diagnostic and therapeutic decisions, rather than tempera-
ture readings (19). As already suggested more than 40 years
ago by Smith, it is the child that should be treated, not the 15.
thermometer (20).
16.
CONFLICT OF INTEREST
None. 17.
ACKNOWLEDGEMENTS
18.
No support from any organisation for the submitted work.
19.
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