The initial diagnosis of fever in a child is based almost entirely on the assessment by the caregivers [7]. The ability of caregivers to detect fever accurately in children by tactile examination is critical in preventing a first stage delay in the management of childhood illnesses [8]. The World Health Organization and United Nations Children’s Fund assume that mothers are able to assess their children by palpation for the presence of fever [9]. However, it is controversial about whether caregivers have the ability to accurately evaluate their children’ body temperature. Some studies suggest that there are significant inaccuracies in tactile assessment of body temperature, and objective measurement of temperature is recommended [8-10]. While findings in other studies showed that caregivers were able to provide accurate information about the presence or absence of fever in their children by palpation without the use of a thermometer [11-13]. Therefore, tactile assessment could be accept as a reliable screening tool for fever determination, and caregivers’ description of their children’ history of fever should be considered when giving medical decisions [11-13].

Teng, et al. [10] conducted a systematic review in 2007 about the accuracy of mother’s touch to detect fever in children. Many new studies have since been published in the topic. We, therefore, conducted this updated systematic review on the accuracy of palpation by caregiver to detect fever.

This systematic review was conducted according to the guidance of the Preferred Reporting Items for Systematic Review and Meta Analyses (PRISMA) Statement [14].

We searched the databases of Cochrane Library, Pub Med, Web of knowledge, EMBASE (Ovid), EBSCO and Google Scholar for diagnostic studies in English comparing tactile assessment of fever with objective method using a thermometer, without date restrictions. We used the following search terms: child or children, fever or febrile, palpate or palpation or touch or tactile or subjective assesment. Hand-search was performed after screening the reference lists of the retrived articles for pertinent publications. Abstracts were reviewed and full-text articles were obtained for studies that met the eligibility criteria.

Inclusion criteria: (a) published original papers in English; (b) evaluated the accuracy of palpation by parents as a method of detecting fever in children, compared with thermometer measurement; and (c) provided detailed information on the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of tactile assessment. We contacted the corresponding authors to obtain missing information when necessary.

Exclusion criteria: (a) tactile assessment was not done during the study, which means tactile assessment was done at a different time and could not be compared against thermometer measurement at the same time; (b) publication with only title and abstract, and full text could not be obtained after contacting the corresponding authors twice; and (c) duplications, letters and reviews.

Data were extracted independently through a standardized protocol by two reviewers. Disagreements between the two of them were recorded and resolved by consultation with a third author. We recorded characteristics of the study (author, design, year of publication, study country, and setting), study population (sample size, age range, inclusion and exclusion criteria, and prevalence of fever), reference standard (axillary temperature or rectal temperature or others, diagnostic cut-off), and index tests (definition, procedures, and link with inclusion criteria) on predefined forms. The diagnostic performance measure for index tests: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (–LR), negative likelihood ratio (–LR) were also collected.

We assessed the quality of selected studies and potential risk of bias with the 2011 revised version of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2), adapted to the review diagnostic accuracy studies, as recommended by the Cochrane Collaboration. This tool is composed of four domains that consider patient selection, index test, reference standard and flow of patients through the study, and timing of the index tests [15]. The quality assessment was done independently by two authors. Any disagreement was resolved through discussion and consensus.

Statistical analysis was performed using STATA software version12.0 (Stata Corporation, College Station, Texas, USA). Bivariate binomial mixed model was chosen and computed using the Midas program, as recommended by the Cochrane Collaboration for meta-analysis of diagnostic accuracy studies [16]. Meta-analytic integration of appointed studies was used for pooled estimated sensitivity, pooled estimated specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio and variations (Chi-square, I-square, LRT p) for heterogeneity assessment. A summary receiver operating characteristic (SROC) curve was drawn to identify diagnostic performance of tactile assessment from the area under the curve (AUC). Publication bias was explored using Egger’s test and Funnel plots.

The study selection process is displayed in Fig. 1. Eleven full-text articles [4,10,13,17-24] were included in the quantitative study and underwent quality assessment using　QUADAS-2(http://www.bristol.ac.uk/social-community-medicine/projects/quadas/quadas-2/). Table I summarizes the characteristics of the included studies. The 11 included studies were conducted in various countries/regions in the world and included a total of 3,625 children. Major variations in sensitivity, specificity, positive predictive value, negative predictive value existed in these studies Table II.

Fig. 1 Flow diagram of the study selection process.

TABLE I  Characteristics of Included Diagnostic Studies

Fig. 2 Forest plot for sensitivity and specificity of tactile assessment.

Quality assessment: Risk of bias and applicability of the included studies are displayed in Table III. Overall the 11 studies were rated with an average acceptable applicability. The majority of the included studies were at low risk for two categories with respect to applicability, including the patient and index test. Most studies used convenience samples, leading to high risk of bias in the patient section domain.

TABLE II  The Diagnostic Parameters of Tactile Assessment in the Included Studies

Notes: TP: true positive; FP: false positive; TN: true negative; FN: false negative; 
Sen: sensitivity; Spe: specificity; PLR: positive likelihood ratio; NLR:negative 
likelihood ratio; DOR: diagnostic odds ratio; n: number of  children. 

TABLE III	Bias and Applicability: The Relative Level Bias Assessment of Bias Risk and Applicability 
Concerns Across the Included Studies 

Forest plot for sensitivity and specificity of tactile assessment is showed in Fig. 2. The funnel plot and the test indicates no publication bias (P=0.11).

The SROC curve of sensitivity vs. specificity of tactile assessment suggests diagnostic cut-off located in the point where sensitivity was 0.88 and specificity 0.55. It also indicates that there was no threshold effect. Area under curve was 0.82 (95% CI 0.7 to 0.85), predicting moderate diagnostic value (Fig. 3). When looking at the likelihood ratios (measures that are more meaningful for clinical decisions), pooled estimates of positive likelihood ratio were 1.93 (95% CI 1.39 to 2.67), and pooled estimates of negative likelihood ratio were 0.23 (95% CI 0.15 to 0.36).

Fig. 3 SROC curve of sensitivity versus specificity of tactile assessment.

This systematic review and meta-analysis documented that tactile assessment of fever by caregiver in children had moderate diagnostic value. The reasonably high sensitivity and low negative likelihood ratio indicated that caregivers’ assessment of ‘no fever’ were quite accurate. When a child had no fever, the caregiver can perhaps accurately judge it by palpation. On the other hand, the specificity and the positive likelihood ratio were not good enough, meaning thereby that caregivers’ assessment of ‘fever’ was not that reliable and confirmation was needed. Tactile assessment was therefore more useful to exclude fever rather than to confirm fever.

There are some limitations of this review. First, six potentially relevant articles could not be included because of missing information [25-30]. In the abstract of four of these studies, it was stated that caregivers’ assessment of fever was reliable [25-27,30] with relatively high sensitivity. Abstracts of the other two articles could not be found [28,29]. Second, the quality of the results was moderate to low. Also there was significant heterogeneity among the chosen studies for the meta-analysis. Although bivariate binomial mixed model allowing for heterogeneity was used in our analysis [31], the heterogeneity could not be eliminated through statistical methods. The heterogeneity was supposed to be caused by the significant differences in educational background, severity of pyrexia, age of child, methods of temperature recording, fever threshold and research design in the included studies.

The results of our study were similar to the findings of a previous systematic review [10]. The diagnostic odds ratio was different from that of the earlier review, but the 95% confidence level was still above one. We added area under curve to indicate diagnostic value, which is more convincing when the diagnostic cut-off is different.

As a subjective method, tactile assessment of fever had not reached a uniform standard so far. There were only few studies exploring the effect of different palpation method (site used, part of hand used) on reliability of tactile assessment. Odinaka’s study [17] revealed that palpation with the palmar surface of the hand using multiple sites improves the reliability of tactile assessment of fever. Since detecting fever by touch has some value for reference, we can explore some techniques to improve the reliability of this method and carry out relevant education to caregivers.

Contributors: YWL: conceptualized and designed the study, carried out the analyses, interpreted the data, drafted the initial manuscript, and approved the final manuscript as submitted; LSZ: conceptualized and designed the study, assisted in the interpretation of the results, revised the manuscript, and approved the final manuscript as submitted; XL: assisted in data extraction and the interpretation of the results, and approved the final manuscript as submitted.

Funding: None; Competing interest: None stated.

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