Objective To evaluate the agreement between temperature measured at the axilla and rectum in children and young people. Design A systematic review of studies comparing temperature measured at the axilla (test site) with temperature measured at the rectum (reference site) using the same type of measuring device at both sites in each patient. Devices were mercury or electronic thermometers or indwelling thermocouple probes. Studies reviewed 40 studies including 5528 children and young people from birth to 18 years. Data extraction Difference in temperature readings at the axilla and rectum. Results 20 studies (n = 3201 (58%) participants) had sufficient data to be included in a meta-analysis. There was significant residual heterogeneity in both mean differences and sample standard deviations within the groups using different devices and within age groups. The pooled (random effects) mean temperature difference (rectal minus axillary temperature) for mercury thermometers was 0.25°C (95% limits of agreement − 0.15°C to 0.65°C) and for electronic thermometers was 0.85°C ( − 0.19°C to 1.90°C). The pooled (random effects) mean temperature difference (rectal minus axillary temperature) for neonates was 0.17°C ( − 0.15°C to 0.50°C) and for older children and young people was 0.92°C ( − 0.15°C to 1.98°C). Conclusions The difference between temperature readings at the axilla and rectum using either mercury or electronic thermometers showed wide variation across studies. This has implications for clinical situations where temperature needs to be measured with precision.

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BackgroundA lack of age-appropriate formulations can make it difficult to administer medicines to children. A manipulation of the dosage form may be required to achieve the required dose. This study aimed to describe medicines that are manipulated to achieve the required dose in paediatric practice.MethodA structured, undisguised observational study and postal survey. The observational study investigated drug manipulations occurring in clinical practice across three sites. The questionnaire, administered to a sample of paediatric nurses throughout the UK, surveyed manipulations conducted and nurses’ experiences and views.ResultsThe observational study identified 310 manipulations, of which 62% involved tablets, 21% were intravenous drugs and 10% were sachets. Of the 54 observed manipulations 40 involved tablets with 65% of the tablets being cut and 30% dispersed to obtain a smaller dose. 188 manipulations were reported by questionnaire respondents, of these 46% involved tablets, 12% were intravenous drugs, and 12% were nebuliser solutions. Manipulations were predominantly, but not exclusively, identified in specialist clinical areas with more highly dependent patients. Questionnaire respondents were concerned about the accuracy of the dose achieved following manipulations and the lack of practice guidance.ConclusionManipulations to achieve the required dose occur throughout paediatric in-patient settings. The impact of manipulations on the efficacy of the drugs, the accuracy of the dose and any adverse effects on patients is not known. There is a need to develop evidence-based guidance for manipulations of medicines in children.

A meta-analysis of diagnostic test studies provides evidence-based results regarding the accuracy of a particular test, and usually involves synthesizing aggregate data (AD) from each study, such as the 2 by 2 tables of diagnostic accuracy. A bivariate random-effects meta-analysis (BRMA) can appropriately synthesize these tables, and leads to clinical results, such as the summary sensitivity and specificity across studies. However, translating such results into practice may be limited by between-study heterogeneity and that they relate to some 'average' patient across studies.In this paper we describe how the meta-analysis of individual patient data (IPD) from diagnostic studies can lead to clinical results more tailored to the individual patient. We develop IPD models that extend the BRMA framework to include study-level covariates, which help explain the between-study heterogeneity, and also patient-level covariates, which allow one to assess the effect of patient characteristics on test accuracy. We show how the inclusion of patient-level covariates requires a careful separation of within-study and across-study accuracy-covariate effects, as the latter are particularly prone to confounding. Our models are assessed through simulation and extended to allow IPD studies to be combined with AD studies, as IPD are not always available for all studies. Application is made to 23 studies assessing the accuracy of ear thermometers for diagnosing fever in children, with 16 IPD and 7 AD studies. The models reveal that between-study heterogeneity is partly explained by the use of different measurement devices, but there is no evidence that being an infant modifies diagnostic accuracy.