We examined the diagnostic accuracy of human touch (HT) method in assessing hypothermia against axillary digital thermometry (ADT) by a trained non-medical field investigator (who supervised activities of community health volunteers) in seven villages of Agra district, Uttar Pradesh, India. Body temperature of 148 newborns born between March and August 2005 was measured at four points in time for each enrolled newborn (within 48 h and on days 7, 30 and 60) by the field investigator under the axilla using a digital thermometer and by HT method using standard methodology. Total observations were 533. Hypothermia assessed by HT was in agreement with that assessed by ADT (<36.5
C) in 498 observations. Hypothermia assessed by HT showed a high diagnostic accuracy when compared against ADT (kappa 0.65–0.81; sensitivity 74%; specificity 96.7%; positive predictive value 22; negative predictive value 0.26). HT is a simple, quick, inexpensive and programmatically important method. However, being a subjective assessment, its reliability depends on the investigator being adequately trained and competent in making consistently accurate assessments. There is also a need to assess whether with training and supervision even the less literate mothers, traditional birth attendants and community health volunteers can accurately assess mild and moderate hypothermia before promoting HT for early identification of neonatal risk in community-based programs.

1. Brief Report
Human Touch vs. Axillary Digital Thermometry for Detection
of Neonatal Hypothermia at Community Level
by Siddharth Agarwal,a
Vani Sethi,b
Ravindra Mohan Pandey,c
and Dimple Kondalc
a
Urban Health Resource Centre, New Delhi 110057
b
Department of Food and Nutrition, Lady Irwin College, University of Delhi, New Delhi 110001
c
Department of Biostatistics, All India Institute of Medical Sciences, New Delhi 110029, India
Summary
We examined the diagnostic accuracy of human touch (HT) method in assessing hypothermia against
axillary digital thermometry (ADT) by a trained non-medical field investigator (who supervised
activities of community health volunteers) in seven villages of Agra district, Uttar Pradesh, India. Body
temperature of 148 newborns born between March and August 2005 was measured at four points in time
for each enrolled newborn (within 48 h and on days 7, 30 and 60) by the field investigator under the
axilla using a digital thermometer and by HT method using standard methodology. Total observations
were 533. Hypothermia assessed by HT was in agreement with that assessed by ADT (<36.5
C) in 498
observations. Hypothermia assessed by HT showed a high diagnostic accuracy when compared against
ADT (kappa 0.65–0.81; sensitivity 74%; specificity 96.7%; positive predictive value 22; negative
predictive value 0.26). HT is a simple, quick, inexpensive and programmatically important method.
However, being a subjective assessment, its reliability depends on the investigator being adequately
trained and competent in making consistently accurate assessments. There is also a need to assess
whether with training and supervision even the less literate mothers, traditional birth attendants and
community health volunteers can accurately assess mild and moderate hypothermia before promoting
HT for early identification of neonatal risk in community-based programs.
Introduction
Being simple, quick, inexpensive and programmati-
cally important human touch (HT) method has since
long been promoted for assessing neonatal hypother-
mia at community level [1–3]. However, there are
only a few community-based studies which have
examined the diagnostic accuracy of HT assessment
by health workers/mothers to detect neonatal
hypothermia compared to axillary thermometry
[4, 5] and practically none in rural Uttar Pradesh,
India. Hence, this study was undertaken to examine
the accuracy of HT method in assessing hypothermia
amongst infants (0–60 days) against axillary digital
thermometry by field workers for promoting its use
amongst community health volunteers (CHVs) in a
subsequent newborn care field trial in Agra district,
Uttar Pradesh.
Methods
The present study was conducted in seven villages of
Agra. Body temperature of 148 newborns born
between March and August 2005 was measured
at four points in time for each enrolled newborn
(within 48 h and on days 7, 30 and 60) during day
time by a trained non-medical field investigator
(who supervised the activities of CHVs) using two
methods under the axilla and by HT. Axillary
temperature was measured using a digital thermo-
meter (accuracy Æ 0.1
C) (Becton and Dickinson,
New Jersey). The thermometer’s tip was placed
high in the apex of the baby’s axilla, free from
moisture and the arm folded over the chest for
4 min as specified in the product specification and
instruction for use leaflet for this thermometer.
Newborns were classified as warm, mildly hypother-
mic and moderately hypothermic if their axillary
Acknowledgements
This study was supported by a Junior Research
Fellowship grant no. F. 11-14/2003 (SA-I) received
from University Grants Commission, New Delhi to
the second author of this article.
Correspondence: Dr Siddharth Agarwal, Urban Health
Resource Centre, F-9/4 Poorvi Marg, New Delhi 110057,
India. Tel: þ91-11-32455887. E-mail siddharth@uhrc.in.
ß The Author [2007]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org 1 of 2
doi:10.1093/tropej/fmm098
Journal of Tropical Pediatrics Advance Access published December 21, 2007

2. temperature was in the range of 36.5–37.5
C,
36–36.4
C and 36
C, respectively [1]. The field
investigator used dorsum of hands to assess newborn’s
skin temperature at abdomen (just below the umbili-
cus) and soles of feet. Newborns were classified as
warm, mild hypothermic and moderately hypothermic
if both abdomen and soles were warm, abdomen warm
and soles cold, both abdomen and soles were cold,
respectively [1,3]. The investigator was not informed
about the hypothermia classification by axillary
method until data collection completion to prevent
any subjective bias while recording. Data was analysed
using STATA 9.1 (STATA Corporation, college
station, TX, USA). For comparing the two methods,
each observation was considered as one unit, axillary
method was considered the gold standard and tests
for diagnostic accuracy were applied [6].
Results
The point prevalence of hypothermia (mild and
moderate) during the period 0–60 days was 14%.
During this period, by HT method, 86.5%, 12.9%
and 0.6% infants were identified as warm, mildly and
moderately hypothermic. The percentage of infants
adjudged warm, mildly and moderately hypothermic
by axillary method was 85.5%, 13.3% and 1.2%,
respectively. No infant had axillary temperature
32
C or was perceived to have ‘extremely cold’
abdomen by human touch method.
Hypothermia assessed by HT was in agreement
with hypothermia assessed by axillary method
(36.5
C) in 498 out of the 533 observations. There
were only 35 (6.7%) mismatched measurements.
Kappa value of 0.73 (95% confidence interval 0.65–
0.81) showed a good agreement between the two
tests. The sensitivity and specificity of HT method to
correctly identify hypothermic (true positive) and
non-hypothermic babies (true negative) was 74% and
96.7%, respectively. A positive and negative like-
lihood ratio of 22 (cut off 9) and 0.26 (cut off 0.5),
respectively, also indicated that HT had a high
diagnostic accuracy (Table 1).
Out of six babies which were identified moderately
hypothermic by axillary method (36
C), HT
identified two (33.3%) as moderately hypothermic
and identified four as mildly hypothermic. Out of
71 babies that were identified mildly hypothermic
by axillary method (36–36.4
C), 51 (71.8%) were
identified mildly hypothermic and 20 identified as
warm by HT. Out of the 456 babies identified as
warm by axillary method (!36.5
C), HT identified
441 babies were identified warm and 15 as mildly
hypothermic (false positive), respectively.
Discussions
Studies comparing the accuracy of HT method against
axillary thermometry in identifying hypothermia
(axillary temperature 36.5
C) show that it is 96%,
34.4% and 23.4% sensitive when assessed by paedia-
tricians [3], CHVs [5] and mothers [5], respectively.
However, being a subjective assessment the reliability
of HT method depends on the investigator being
adequately trained and competent in making consis-
tently accurate assessments. Large-scale community-
based studies are hence needed to assess whether
with training and supervision even the less literate
mothers, traditional birth attendants and CHVs can
accurately assess mild and moderate neonatal
hypothermia using HT method. Based on experiential
learning and evidence from such studies if found
reliable the use of HT method could be promoted for
early identification of neonatal risk in community-
based programs.
References
1. WHO. Hypothermia in the newborn. Thermal
Protection of the Newborn: A Practical Guide. Geneva,
WHO press, 1997; pp. 5–10.
2. Daga SR. Sole is the mirror of newborn’s health. J Trop
Pediat 1992;38:41.
3. Singh M, Rao G, Malhotra AK, Deorari AK.
Assessment of newborn baby’s temperature by human
touch: a potentially useful primary care strategy. Indian
Pediatr 1992;29:449–52.
4. Ellis M, Manandhar D, Hunt L, Barnett S, Azad K.
Touch detection of neonatal hypothermia in Nepal.
Arch Dis Child Fetal Neonatal Ed. 2006;91:F367–8.
5. Kumar R, Agarwal AK. Accuracy of maternal percep-
tion of neonatal hypothermia. Indian Pediatr
1996;33:583–5.
6. Landis RJ, Koch GG. The measurement of observer
agreement for categorical data. Biometrics
1977;33:159–74.
TABLE 1
Diagnostic accuracy of human touch method in
identifying hypothermia (N ¼ 533)
Axillary Method (Gold Standard)
Human touch
method result
Hypothermia No
hypothermia
Total
Positive 57 (True) 15 (False) 72
Negative 20 (False) 441 (True) 461
Total 77 456 533
Prevalence ¼ 14%; sensitivity ¼ 74%; specificity ¼
96.7%; PVþ ¼ 79.0%; PVÀ ¼ 95.6%; LRþ ¼ 22.5;
LRÀ ¼ 0.26; ROC Area (95% C.I.) ¼ 0.85 (0.80–0.90),
where PV is the predictive value, LR the Likelihood ratio
and ROC the receiver operating area.
S. AGARWAL ET AL.
2 of 2 Journal of Tropical Pediatrics