Emergent Management of Pediatric Patients with Fever Updated: Apr 29, 2013

Overview
Patient History

The Physical Exam

Minimizing Patient Risk

Workup for Neonates

Workup for Children 5-8 Weeks Old

Workup for Children 2-24 Months Old

Workup for Children Older Than 24 Months

Urinalysis and Urine Culture

Stool Studies

Chest Radiographs

Lumbar Puncture

Prehospital Care

Emergency Department Care

Follow-up Care

Inpatient Care

Policy for Positive Culture Results

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Overview

Emergent management of pediatric patients with fever is a common challenge. Children with
fever account for as many as 20% of pediatric emergency department (ED) visits,[1] and the
underlying disorders in these cases range from mild conditions to the most serious of bacterial
and viral illnesses.[2, 3]

Infants younger than 2 months have unique risks for serious bacterial infections; as such, their
management is discussed separately from that of older children.

Clinical guidelines have been studied, reported, and scrutinized in major journals for the past 2
decades, yet definitive conclusions are sometimes still elusive and the application to each
individual case in the ED is sometimes even more frustrating for the clinician.[4] Inconsistent
treatment approaches exist even in the most experienced pediatric EDs.[5, 6]
Some of the fears and anxiety exhibited by parents are shared by ED staff as well. Myths and
misperceptions about children with temperature elevations are reported. Fever phobia is well
described as existing with both caregivers as well as medical providers.[7, 8, 9, 10]

Because pediatric fever is both a high-impact and a high-frequency chief complaint, the clinician
should be knowledgeable about febrile conditions that occur in a variety of age groups of
pediatric patients. ED guidelines for treating children with febrile illness are used in order to
standardize the approach to care.

This article discusses the appropriate ED management of young febrile children, particularly
those younger than 2 years. Neonates (< 28 days) and young infants (28-60 days) are discussed
as subsets of this group of pediatric febrile patients.

Patient History

Immunizations

Determine the patient's immunization status; see the 2011 immunization schedule.[11] Simply
asking whether the child is up to date with immunizations may not elicit enough information.
Ask how many doses of pneumococcal conjugate (PCV-7) and Haemophilus influenzae type B
(HIB) vaccines have been administered. It is also important to inquire about which
immunizations have been administered recently.

Some children may not be fully immunizedbecause of compliance, finances, or perceived

health risks,[12] and thus may be at risk for the infections covered by these vaccines. On the
other hand, recent vaccinations might have caused an elevation in the patient's temperature.

Temperature measurement at home

Some pediatric patients may have had a subjective determination of an elevated temperature by
their caregivers before coming to the hospital but are afebrile when they present to the ED.
Parents may report a temperature elevation in their child without having actually recorded the
temperature with a thermometer.

Parental reporting of fever on the basis of subjective information (eg, touching the child's torso
or extremities or feeling his or her forehead) is a reliable indicator of a fever having been present.
Studies have shown that the parental assessment of fever in this situation is usually accurate.[13]
On the other hand, one study found that the subjective history of fever in such infants may not
correlate with subsequent fever, whereas those with an elevated rectal temperature measured at
home had relatively high rates of serious bacterial infection.[14]

Home use of temporal artery thermometers have not been shown to be completely reliable
indicators of febrile children.[15]
Fever phobia

Parents may be overly concerned about possible outcomes of prolonged high temperature, or
they may believe that every fever requires antibiotic therapy.[16, 17] These usually unwarranted
fears have been shown to vary by race and ethnicity, as well as by the age of the child and
parental education level.[8, 18, 19]

Temperature elevation may not be the only sign of sepsis in neonates and infants. Other potential
signs and symptoms of sepsis unique to infancy should also be assessed. History taking is an
important part of clinical decision making.

The clinician should ask the patient's parents or caretakers about the following items when they
bring in a febrile or ill-appearing child:

Immunization history, such as recent vaccination or a history of inadequate

immunizations
History of exposure to sick contacts and treatments, such as antibiotics

Recent travel history

History of previous hospitalization, prolonged ICU stay, prematurity, or

immunocompromised diseases

History of change in mental status, change in eating and/or behavioral

patterns such as irritability, lethargy, or apnea

History of neglect or abuse

Documented fever at home, the duration of any fever, and the last treatment
(if any) for the fever

Environmental factors, such as being in the heat for a long time during the summer and being
overdressed during the winter, may indicate a risk for hyperthermia.

The neonate

The history of the neonate is explored for possible symptoms of poor feeding, vomiting, poor
social interaction, changes in the quality of crying, and possible apneic episodes. Any of these
findings are reasons to consider serious bacterial infection and may warrant further investigation
and laboratory evaluation.

The birth history is explored to ascertain risk factors for underlying pathology, such as
prematurity, maternal infections (eg, group B Streptococcus, sexually transmitted diseases such
as genital herpes simplex), and congenital or chronic disease states. Neonates at risk for
congenital herpes are those born to mothers with a history of recent genital infection and high-
risk sexual activity; delivery-related risk factors include rupture of membranes for longer than 6
hours and use of a scalp electrode.
Neonates who present with irritability, seizures, respiratory distress, jaundice, or a characteristic
vesicular rash should be considered at risk for neonatal herpes. Note that 10-50% will not
develop skin lesions during the course of their illness.[20]

The history is also explored for previous diagnostic studies and their results.

The older child

The following questions might be helpful:

What is the timing of the current illness?

When did the fever start?

How long has the fever been present? Are there any related symptoms?

What is the patient's medical history? The history may not be applicable in all
cases, but it must be explored to reveal potential high risk or complicating
factors.

Has the child's activity significantly changed during the illness?

Is the child tolerating fluids at home? Has the child been less interested in
eating?

Have the stool patterns changed in consistency or frequency?

Has there been recent antibiotic use?

Has there been exposure to illness through babysitters, day care contacts, or
other caregivers? Are others at home sick?

Have the sleep patterns changed? Has the patient been snoring more at night
than usual?

Has there been any recent travel that might have exposed the child to
illnesses?

It can also be helpful to ask what has been done at home to help control the fever. Was an
antipyretic given at home? If so, what dose was given?

In some cases, the clinician finds that child received an inadequate does of antipyretic
medication. Over-the-counter medications may not clealry list the correct weight-based dose for
children younger than 2 years. Some product instructions simply state "call physician" or "seek
medical care." Parents should be educated that the steadily changing weight of their child will
result in a need to periodically update the correct dose of medication.[21, 22]

According to the 2003 clinical policy of the American College of Emergency Physicians
(ACEP), response to antipyretic medication does not change the likelihood of a child having a
serious bacterial infection and should not be used for clinical decision making.[23]
The Physical Exam

The physical examination of the febrile child is directed at locating a source of or reason for the
temperature elevation, with specific attention to potential serious bacterial illnesses.
Alternatively, an elevated temperature is not the only vital-sign irregularity that may indicate a
potential infectious problem. Hypothermia may be a presenting vital-sign abnormality in
septic neonates.

Thermometer use varies between oral, rectal, or axillary. Ear-probe thermometers may not be as
accurate as rectal thermometers in the neonate; some study results suggest that operator error is
the main reason. Axillary and rectal temperature measurements may also vary widely in
neonates.[24] A rectal-probe thermometer is probably most likely to result in an accurate
assessment of a neonate's temperature.[25, 26, 27]

Temperature elevation may not be the only sign of sepsis in neonates and infants. Other potential
signs and symptoms of sepsis unique to infancy should also be assessed.

The infant's or child's interactions with the parent or caregiver are easily observed while the
history is obtained. The following observations should be noted:

What is the quality of the cry? Is it abnormal, high pitched, or weak in effort?
Does the child appear fearful of the examiner? Beyond infancy, healthy young children
should fear strangers; the child who lies on the examination table without much
interaction or who is not disturbed by an examination may be more likely to have a more
serious illness
What is the skin color? Are there areas of cyanosis or jaundice? Are there any rashes
present?
What is the degree of hydration? Are tears present during crying? Is there moisture on
the oral mucosa/lips or tongue? For the neonate, a gentle palpation of the anterior
fontanelle may give a general indication to the fluid status; a sunken fontanelle indicates
possible hypovolemia/dehydration
What is the response to social overtures? Does the baby smile at the examiner? Does
the baby smile or appear interested in a small toy or other shiny object? Checking for a
social smile is a helpful component of the examination because it remains one of the
better predictors of well babies[28]

The capillary refill time is generally thought to be the quickest assessment of early
hypoperfusion. Capillary refill time is faster to obtain than a blood-pressure measurement and is
particularly helpful in a loud or busy ED. A delay in the capillary refill time (>2 seconds)
indicates hypoperfusion of the skin. Shunting of blood from the capillary beds in the skin is an
indication of increased systematic vascular resistance (SVR). An increase in SVR is generally
thought to occur early in the course of pediatric hypovolemia. Hypovolemia can result from
obvious conditions, such as blood loss and vomiting and diarrhea, or from more subtle reasons,
such as tachypnea and sweating.
The presence of dyspnea, tachypnea, grunting, flaring, and retractions is noted. These
findings suggest possible serious illness and require further exploration (eg, pulse oximetry,
chest radiography).[29]

Hydration status is documented to include specific signs of dehydration such as dry mucous
membranes, sunken fontanelle, absence of tears when crying, and/or a lack of urine output (by
history).

Persistent irritability despite feeding or inability of parents to console the child is concerning.
True irritability and lethargy are physical signs traditionally associated with an ill child.
Lethargy is defined as a decrease in the level of consciousness, some examples of which are
failure of the child to recognize parents or caregivers, absent eye contact with the examiner,
or failure to interact with the environment at an age-appropriate level.

Toxicity is defined as a clinical syndrome with the following: lethargy with (1) poor
perfusion as evidenced by delayed capillary refill or (2) cyanosis or other signs of
respiratory distress. Cold hands and feet, limb pain, and pale or mottled skin are
considered "red flag" manifestations of septicemia.[30]

The presence or absence of meningeal signs is documented in older children. Clinicians should
bear in mind that in some infants and younger children (perhaps younger than 12-15 months)
who develop meningitis, specific meningeal signs, such as the Kernig or Brudzinski sign, may
not be present.

A hemorrhagic rash is classically described as resulting from overwhelming systemic bacterial

infection due to meningococcemia but may be due to other (usually serious) infections. The
presence of petechiae or purpura in febrile children indicates the need for prompt evaluation and
therapy.

Clinical observation scales have been developed to aid in the determination of the degree of
illness.[31] Clinical observation by house staff and seasoned clinicians has produced inconsistent
results over the reliability and consistency of clinical observation scales. Regardless of the
clinical scale used, one predictor of overall wellness of a child is the presence of a smile.[28]

A physical finding of an isolated bacterial illness, such as otitis media or pneumonia, should not
preclude the clinician from possibly pursuing a more extensive workup to exclude sepsis in the
neonate.

Minimizing Patient Risk

Discharging a child from the emergency department (ED) with an unrecognized serious bacterial
infection is a potential medicolegal risk for the ED physician. The risk is minimized by
performing and documenting an appropriate history, physical examination, and, when indicated,
a workup, as well as ensuring effective follow-up care.[32]
Several factors indicate an increased risk of bacteremia and/or sepsis, including age less than 2
months, an immunocompromised state (eg, neutropenic or underlying malignancy), being
unvaccinated or undervaccinated, hypothermia (core temperature < 36.8C, or 98F), and
hyperthermia (core temperature >40.5C, or 105F).[33]

Some pediatric patients may be potentially at a higher risk for bacterial illness than their age-
matched counterparts. Special consideration for these populations should include appropriate
evaluation in the ED, documentation of consultation with specialists, and chart documentation
related to special needs.

Patients with inserted medical devices (eg, foreign bodes) may be at increased risk for infection
related to the device. A documented discussion with an appropriate consultant may be indicated.
Examples of such devices include the following:

Recently inserted cardiac pacemaker

Ventriculoperitoneal shunts

Central lines or other long-term intravenous access

Patients with sickle cell disease are considered functionally asplenic. Asplenic patients are at
exceptional high risk of sepsis due to encapsulated organisms, such as Streptococcus
pneumoniae. If these patients present with fever, they are considered at higher risk for occult
bacteremia and treated accordingly. Blood cultures, CBCs, and differentials are assessed.
Parenteral antibiotics against encapsulated organisms are given early.

Patients who are absolutely or relatively immunocompromised (eg, patients with underlying
malignancy, patients undergoing chemotherapeutic regimens) must be evaluated for possible
occult bacterial infection. Fever and neutropenia should be considered, and a consultation with
the oncologist may be indicated.[34]

The approach to patients with HIV infection should be aggressive enough to determine presence
of serious bacterial illness. History includes the parents or patient's knowledge of their level of
CD4 cells and viral load. A sepsis workup is usually indicated in HIV-positive patients presenting
with fever. Early consultation with the primary care provider or infectious disease specialist is
indicated in the care of these patients.

Infants who were born prematurely may be at risk for infections, such as bronchiolitis or other
complications (eg, necrotizing enterocolitis). Consultation with the primary care provider or
high-risk neonatologist may be indicated.

Patients with cystic fibrosis are especially susceptible to pneumonia and should be liberally
evaluated for such. Consultation with a pulmonologist may be indicated.

Ideally, the decision to admit or discharge these patients is established by a written protocol or
guidelines previously established in conjunction with the department of pediatrics. A documented
discussion with the specialist may be indicated.
Patients with febrile seizures

The evaluation of patients presenting with a simple febrile seizure focuses on determining the
cause of the fever. In children aged 2-24 months with simple febrile seizures, the risk for occult
bacteremia is about the same as that of patients with fever alone.

In children who remain ill appearing and/or who have signs of toxicity, the possibility of
meningitis might be considered.[35] Young children with febrile seizures, especially those younger
than 12 months may not always reliably demonstrate physical signs of meningitis.

The child with a febrile seizure should be monitored for some time in the ED, and findings on
serial examinations should be documented to differentiate children who are ill with occult
disease from children who may be safely discharged home.[36]

Lumbar puncture (LP) may be difficult to justify in the child who, after appropriate use of an
antipyretic, exhibits normal activity. LP is reserved for the younger patient, the patient already
receiving antibiotics, or the patient whose physical findings cause concern.

Workup for Neonates

Guidelines have been applied to neonatal emergency medicine. Traditionally, a febrile neonate
(temperature >100.4F [>38C]) undergoes a full sepsis workup, which includes a CBC count,
urinalysis, blood culture, urine culture, chest radiography, and diagnostic LP. The age group that
is defined for this workup may vary. At minimum, the guideline is applied to neonates younger
than 28 days, and in some institutions or regions of the country, it may be applied to infants as
old as 60 days.

A full evaluation for sepsis in febrile neonates is warranted because their risk for serious
bacterial infection (SBI) is relatively high. Even among those who otherwise meet low-risk
criteria, the rates of SBI are about 5%.[33, 32]

Similarly, about 10% of febrile neonates who have documented respiratory syncytial virus (RSV)
infection or clinical bronchiolitis have SBI[37] ; most of these are urinary tract infections (UTIs).
This infection rate is about the same as for those without documented RSV infection or clinical
bronchiolitis; therefore, a full evaluation for sepsis should be performed for these patients.

Cerebrospinal fluid analysis

For infants younger than 28 days, the median CSF values were as follows:

WBC count 5/L (range, 0-20)

Glucose - 46 mg/dL

Protein - 73 mg/dL
One study determined that adding polymerase chain reaction (PCR) testing for enterovirus to
routine CSF testing reduced the duration of hospitalization and antibiotic use for young infants.
[38]

Another study determined normal CSF profiles among a large cohort of febrile infants with
atraumatic LPs, negative CSF bacterial cultures, and negative enteroviral PCR testing.[39]

Evaluation for herpes simplex

Evaluation of febrile neonates for herpes simplex infection should be considered when the
following risk factors are present:

Age younger than 3 weeks

Vesicles

Seizure

Toxic or ill appearance

CSF pleocytosis or red blood cells

Maternal history of herpes

Laboratory studies to screen for herpes infection may include the following:

Collecting vesicle fluid for culture and direct fluorescent antibody testing
Swabbing nasopharynx, conjunctiva, and rectum for culture

Performing LP for CSF PCR testing and culture

Workup for Children 5-8 Weeks Old

Most febrile infants aged 5-8 weeks who present to the ED warrant a full evaluation for SBI
because they are difficult to evaluate clinically and because ED physicians cannot ensure
adequate follow-up.[40]

The threshold for performing an LP in these infants should be low; many of these infants will
warrant CSF examination. In select cases, at the clinician's discretion, an LP may be omitted in
well-appearing infants who have blood and urine studies obtained and when the following apply:

Reliable follow-up is possible in 12-24 hours

Clinicians are confident that parents or caretakers can comply with appropriate
observation and follow-up
No antibiotics have been started

A recent study defined median CSF profiles among uninfected infants in this age range.[39]
 WBC count - 3/mm3 (range, 0-11)
Glucose - 48 mg/dL

Protein - 54 mg/dL

Urine studies are important in this age group, as UTIs are a common source of SBI.[41, 42, 43]
Additional studies such as stool cultures are performed selectively. Chest radiographs do not
need to be obtained routinely in those without signs of respiratory disease.[44, 45]

Workup for Children 2-24 Months Old

In children who have been immunized against pneumococcal disease, the routine use of CBC
and blood culture are no longer recommended.[46, 47, 48] If a CBC is obtained, interpretation of the
total WBC remains controversial. Distinguishing between a high total WBC count versus a very
high WBC count may leave the physicians with even more questions about the relevance of this
laboratory result.[46, 49, 50]

The rates of bacteremia and invasive pneumococcal disease have dramatically declined since the
licensing of the 7-valent pneumococcal vaccine (PCV7) vaccine in 2000.[12, 51, 52, 53, 54, 55, 56] This
vaccine protects against the 7 pneumococcal serotypes that cause 85% of invasive pneumococcal
disease in children, including nearly all of the serotypes that are highly penicillin resistant.

Prior to routine use of the pneumococcal vaccine, occult bacteremia occurred with an incidence
of 3-5% in children younger than 24 months with fever. Studies in the 1980s-1990s showed the
rate of occult bacteremia was as high as 5%. In the 21st century, studies show a decline in the
rates to as low as 0.5-1%.[57] This change is most likely due to the increasing rates of
pneumococcal vaccinations.[58]

Before widespread PCV7 use, approximately 60-70% of all cases of occult bacteremia were
caused by Streptococcus pneumoniae. S pneumoniae is the most prevalent and certainly the most
significant cause of morbidity and mortality related to occult bacteremia.

In 2010, the US Food and Drug Administration (FDA) licensed a 13-valent pneumococcal
vaccine (PCV13), which includes protection against additional strains of pneumococcus,
including serotype 19A. This PCV13 vaccination will supplant the PCV7 vaccination,
presumptively causing a further decline in invasive pneumococcal disease.[59, 60] The routine use
of pneumococcal vaccine has essentially made rates of occult bacteremia a classic historical
discussion.[56]

Before routine use of the HIB vaccine, HIB accounted for 20% of occult illness, but this cause
also decreased in frequency after the vaccination became routine in the 1990s.[61, 62]

An increase in the total band count or erythrocyte sedimentation rate (ESR) is not more
predictive of occult pneumococcal bacteremia than an elevated WBC count alone. Before the
routine use of the pneumococcal vaccine, a WBC count above 15,000/mm3 had been reported to
be 70% sensitive for predicting occult bacteremia from pneumococcus.[63]
Children in this age group who present with a higher temperature (>102.9F [>39.4C]) may be
at risk for occult bacteremia, especially if they are underimmunized or immunosuppressed. By
definition, occult means that the patient exhibits no other signs or symptoms suggesting the
etiology of the temperature elevation.

Other less common etiologic agents are Neisseria meningitides and (especially in patients with
sickle cell disease) Salmonella species.[51] Herpes and community-acquired methicillin-resistant
Streptococcus aureus (MRSA) are now emerging as more common pathogens in neonates.[64, 65, 66,
67, 68, 69, 70, 71]

Children younger than 24 months presenting with the clinical syndrome of bronchiolitis are at a
lower risk of bacteremia and UTIs. Therefore, routine urine and blood culturing in previously
healthy children presenting with fever and bronchiolitis is usually not indicated; extreme fever or
ill appearance may be indications to obtain a blood culture. Testing of the nasal secretions for a
viral etiology such as respiratory syncytial viral (RSV) or influenza A/B may be helpful.[72]

Rates of UTI may be lower in patients with bronchiolitis than those without any fever source.[73]

Viral infections are the most common cause of fever in young children aged 2-24 months. Well-
appearing children with unremarkable histories and physical examinations may be discharged
home without laboratory testing or presumptive use of antibiotics. An LP should be considered
for those who are irritable, lethargic, inconsolable, or toxic appearing.

During summer months, children with fever and no other signs may have an enterovirus
infection. Some studies report the incidence as high as 50% in febrile children in the ED.
Enteroviral infection is a clinical diagnosis for the emergency physician. No specific laboratory
testing is indicated.

Diarrhea most commonly has a viral etiology in this age group. The presence of diarrhea with
blood or mucus or recent use of antibiotics may be indications for ordering stool cultures to
assess for a bacterial etiology.

The routine acquisition of CBC and/or blood cultures to screen for occult bacteremia in
immunocompetent children is strongly discouraged for the following reasons:

The peripheral white blood cell count has a low positive predictive value for bacteremia
Bacteremia rates are less than 1% in the postpneumococcal vaccine era[51, 12, 56]

Bacteremia spontaneous resolution rates (without antibiotics) are greater than 90%;
therefore, few children with pneumococcal bacteremia develop complications[74, 75]
High false-positive blood culture rates from contamination leads to unnecessary testing
and/or hospitalizations
Indiscriminate testing is costly and invasive
Similarly, the presumptive use of broad-spectrum antibiotics is strongly discouraged because of
low bacteremia and complication rates, high costs, adverse drug reactions, and increasing rates of
antibiotic resistance due to indiscriminate antibiotic use, as well as because the outcomes for
febrile young children not treated presumptively with parenteral antibiotics are uniformly good.

For clinically ill-appearing children, a sepsis workup to include a blood culture should be
obtained. Use of serum markers for sepsis, including a lactate level and procalcitonin, have been
described as being helpful in stratifying the sickest children.[76, 77, 78, 79] This is especially true in
children ill enough to warrant an LP as described above, those exhibiting signs of shock, or those
with a petechial rash.

Workup for Children Older Than 24 Months

The febrile child older than 24 months (who has been previously fully immunized) is primarily
evaluated by obtaining a history and performing a physical examination.

Specific workup and/or treatment is based on the clinical findings and suspicion of disease.[80, 81,
82]

Urinalysis and Urine Culture

UTI is a common cause of SBI in infants and young children.[83, 41, 42, 43] Clinicians should have a
lower threshold for ordering UA and urine cultures than for screening for bacteremia, especially
for those with risk factors.

For boys, risk factors for UTI include age younger than 6 months and being uncircumcised.[84]
For girls, risk factors for UTI include the following:

Age younger than 12 months

White race

Temperature above 39C

Illness for 2 days or more

Absence of any other source for fever

In particular, clinicians should have a lower threshold for UTI screening for white girls; in 2
separate studies, UTI rates were as high as 17% in this group.[84, 85]

Urethral catheterization is the method of choice to obtain urine to avoid contamination with skin
flora. Urine collected in a bag placed on the perineum is often contaminated and should not be
evaluated for bacterial culture.[86, 87] Suprapubic aspiration of the bladder for urine should be
discouraged. Urethral catheterization is less invasive and less painful and is associated with a
higher yield of urine.
An enhanced UA, with a hemocytometer cell count and Gram stain of unspun urine, is more
sensitive than a standard UA.[88] Since negative urine dipstick or UA results in febrile young
children do not always exclude UTI, urine cultures should be performed regardless of UA results.
[23]
In bacteremic children with UTI, blood cultures and urine cultures are likely to have identical
organisms with identical antimicrobial sensitivities.[89]

Stool Studies
Diarrhea in children is commonly caused by viral organisms and is usually not considered a
major source of fever. However, diarrhea with blood or mucus is an indication for further testing
for fecal leukocytes, which suggests invasive bacterial etiologies.

If fecal leukocytes (>5 per high-powered field) are present, a bacterial etiology is suggested and
cultures are indicated. This finding may indicate infection with species of Salmonella,
Campylobacter, Shigella, Yersinia, or toxic strains of Escherichia coli. The final diagnosis can be
made only by obtaining stool cultures.

During winter months, children presenting with low-grade fever, vomiting, and diarrhea should
be considered possibly infected with rotavirus. Children in day care centers are at increased risk
for rotavirus infection. Rotavirus vaccine may change the incidence of this clinical etiology as
well.

Chest Radiographs

Chest radiographs are most useful for patients with high fever accompanied by focal pulmonary
examination findings. Chest radiographs should not be routinely performed for fever alone, in
the absence of lower respiratory tract findings or hypoxemia.

A study from Spain found that 13% of young children with fever above 39.0C and a peripheral
white blood cell (WBC) count of greater than 20 109/L had occult pneumonia.[90] However, just
20% of the radiographs were interpreted by radiologists, and the authors estimate that just one
third to one half of the children had received the pneumococcal vaccine.

Given the very low positive predictive value of the WBC count, its routine acquisition in the
setting of high fever should be discouraged. On the other hand, if the WBC is obtained and is
markedly elevated, consideration should be given to obtaining a chest radiograph, in the absence
of an alternative source of fever.

In febrile neonates and young infants, a chest radiograph may only be a routine part of a sepsis
workup in the presence of respiratory signs in neonates (eg, rales, grunting, flaring, retractions,
hypoxia) or lower respiratory tract findings (eg, cough, tachypnea) in infants. An increased
respiratory rate is the earliest indicator of respiratory distress and should be considered in the
overall decision to obtain a chest radiograph.

In febrile children aged 3-24 months, pneumonia may be present even in the absence of definite
auscultatory signs. An abnormal respiratory rate or pulse oximetry should alert the emergency
physician to the need for a chest radiograph. Chest radiography is indicated if the child shows
signs of respiratory distress, such as tachypnea; grunting, flaring, or retractions; or hypoxia, as
determined with pulse oximetry. A history of prolonged fever or cough may also be predictors of
occult respiratory tract infection.[91]

In children older than 2 years, chest radiography is not routinely ordered unless a specific
indication is present, such as prolonged cough, tachypnea, or hypoxia.[92]

Lumbar Puncture

Diagnostic LP is suggested for ill-appearing febrile infants and children associated with any of
the following:

Age younger than 8 weeks

Complex febrile seizure (< 12 mo)

Full anterior fontanelle

Persistent vomiting

Persistent irritability, lethargy, inconsolability

Petechial rash

In young children, the classic signs of meningismus, such as the Kernig or Brudzinski signs, may
be absent, even in the presence of CNS infection. See Pediatric Bacterial Meningitis.

Prehospital Care

Prehospital care provided by emergency medical service (EMS) personnel may vary from region
to region based on regional differences in education, training, and transport times. Children with
fever alone may require no specific intervention in the EMS setting, except for those other
conditions that exist in the presence of fever.

Assessment of and attention to airway, breathing, and circulation is recommended first for all ill
children. Securing intravenous (IV) access is part of the prehospital care, especially in toxic-
appearing children. Children who have had prolonged or very high fever may become
dehydrated, and assessment of the hydration status is indicated. Some children may be prone to
febrile seizures. Seizure precautions should be followed in those with a history of febrile
seizures.

Emergency Department Care

Airway, breathing, circulation

Clinicians first need to address airway, breathing, and circulation if this has not already been
done. Manage the airway (supplemental oxygen or intubation as needed) and secure intravenous
access if it was not established during prehospital care. Monitor the patient's heart rate, blood
pressure, and pulse oximetry readings. Administer intravenous fluids, such as normal sodium
chloride solution with boluses (weight based), as needed for hypotension. Pressors should be
given as needed for hypotension that does not respond to fluid.

Vital signs

Vital signs recorded in triage should routinely include a temperature in young children. This
should be recorded for all neonates and infants presenting with fever or other potentially
infectious complaints (eg, not eating well, not breathing well, color changes, behavior changes).
A rectal temperature is the most accurate for infants.[93]

Nursing triage includes an accurate assessment of the patient's weight to ascertain the correct
dose of an antipyretic or other medications. An antipyretic should be given as early as possible
during the ED visit.

Fever reduction

Reduction of fever is used to help comfort the child as well as provide for the optimal
examination conditions and should be addressed in triage protocols. Acetaminophen and
ibuprofen have both been used for fever control.[22] These drugs are sometimes alternated to
achieve an overlapping period of fever control.[94, 95, 96] Some studies suggest that acetaminophen
may reduce fever more quickly, while ibuprofen may have a longer-lasting effect on fever
reduction.[21, 97]

In a study of children aged 6 months to 6 years whose fever could be managed at home (37.5-
41C) Hay et al, found that the use of acetaminophen and ibuprofen improved time without fever
during the first 4 hours and was superior to acetaminophen alone, but not ibuprofen alone.[95]

The combination also decreased fever 23 minutes faster than acetaminophen alone, but no faster
than ibuprofen alone. Time without fever during the first 24 hours was improved with the
combination compared with either acetaminophen or ibuprofen. Dosage was calculated as
acetaminophen 15 mg/kg/dose and ibuprofen 10 mg/kg/dose.[95]

The ED staff should be educated that a positive response to antipyretics (evidenced by a drop in
the measured temperature) does not predict the absence of a potentially serious bacterial disease.
[97]

Criteria for discharge from the ED do not necessarily include reduction of the child's fever to a
certain level before discharge. No evidence indicates that fever reduction is necessary for the
child to be discharged from the ED.

The infant with only a history of subjectively estimated fever whose rectal temperature is normal
on repeated measurements and who has an entirely normal clinical evaluation may be assessed as
not requiring laboratory studies. All such infants discharged home still warrant close follow-up
and continued short-term monitoring of rectal temperature.[1]
Presumptive antibiotic treatment

Neonates with fever who undergo a routine workup to rule out sepsis should then receive 2
antibiotics as treatment for their potential septicemia: an aminopenicillin (eg, ampicillin) and a
cephalosporin (eg, cefotaxime).[98] Local surveillance for ampicillin resistance is critical.[99, 100]
Neonates may also receive antiviral treatment with acyclovir if they are at risk for neonatal
herpes infection.

Administer antibiotics as indicated:

Age 0-28 days: Presumptive therapy with ampicillin and either gentamicin or
a third-generation cephalosporin is indicated, while awaiting culture results
Age 29-56 days: Children ill enough to warrant hospitalization may be treated
in the same way as younger neonates; most who meet low-risk criteria and
are well enough to be discharged home do not require presumptive
antibiotics; some clinicians may choose to administer ceftriaxone prior to ED
discharge

Age 2-24 months: No presumptive antibiotic therapy is indicated for well-

appearing children who do not have a defined bacterial source and who will
be managed as outpatients

Corticosteroid therapy is not routinely indicated in the treatment of young infants with bacterial
meningitis.

Controversy continues over whether early bacterial meningitis or other severe systemic bacterial
illness in these patients may not be apparent. Therefore, all such patients discharged from the ED
require meticulous examination and thorough documentation.

Any discharge protocol in which patients may be observed on an outpatient basis should be
developed collaboratively by the department of emergency medicine and the department of
pediatrics.

Decision to admit

The decision to admit older neonates and young infants for presumptive sepsis should be based
on several factors, including their ability to be reevaluated by a primary care provider the next
day, toxic appearance, need for monitoring, need for hydration or other supportive measures, or
poor social situation.

Admission is warranted for febrile infants 28-56 days old; however, these patients may be
discharged home if they meet all of the following low-risk criteria[101, 102, 103, 104, 105, 106, 107] :

Well-appearing infant
No skeletal, soft tissue, skin, or ear infections

Full-term birth
 No hyperbilirubinemia

No chronic or underlying illness

No previous hospitalizations

Not hospitalized longer than the mother after delivery

Did not receive antibiotics within the past 48 hours before presentation

No dehydration, lethargy, irritability, or wheezing

No focal source of infection on physical examination (except otitis media)

Cerebrospinal fluid (CSF) white blood cell (WBC) count < 8 per high-power
field (hpf)

WBC 500-15,000/mm3 and band:poly ratio < 0.2

Urinalysis showing < 10 WBC/hpf

Chest radiograph without infiltrate (if obtained)

If diarrhea is present, fecal leukocytes < 5/hpf and urine WBCs < 10/hpf

Follow-up Care

Follow-up necessitates reliable parents with a telephone at home, with transportation readily
available to them, and with follow-up care arranged with the primary physician the next day. If
next-day follow-up with the primary physician cannot be arranged, the patient should return to
the ED. Diagnosis-specific information sheets can enhance parental understanding of ED
discharge instructions.[108]

Older children with a low-grade fever, no risk factors, no localized signs of infection, a good
appearance, and no irritability may require only symptomatic treatment and close follow-up care.
These patients do not routinely need laboratory evaluation, radiography, or empiric antibiotics.

For patients discharged from the ED, close follow-up with the primary care physicians should be
arranged, and an ED protocol for notification of positive cultures is needed. Primary care
physicians or ED physicians should notify caretakers if an outpatient has a positive blood
culture. Such children, if they remain febrile, may require collection of CSF, a repeat blood
culture, and hospitalization.

Primary care physicians or ED physicians should notify caretakers if a child has a positive urine
culture. Older children with pyelonephritis may continue outpatient treatment if they appear well
and can tolerate oral antibiotics. Clinicians should have a low threshold for hospitalizing those
who are younger than 6 months with pyelonephritis.

The child should return either to the ED or to the primary care physician's office if his or her
clinical presentation worsens after discharge.
Inpatient Care

All febrile neonates aged 0-28 days old should be hospitalized for presumed sepsis and treated
with antibiotics until cultures of CSF, blood, and urine are all negative for growth after 48 hours.
[109, 102, 110]
Two parenteral antibiotics are administered during these inpatient admissions: an
aminopenicillin, such as ampicillin, and either a cephalosporin, such as cefotaxime, or an
aminoglycoside such as gentamicin.

If admitted, febrile patients outside of the neonatal period are prophylactically treated with an
antibiotic (eg, a third-generation cephalosporin, such as ceftriaxone), until cultures are shown to
be negative.[111]

Iatrogenic risks are involved with routine hospitalizations of all febrile neonates and young
infants.[101] Protocols developed in advance, in cooperation with the ED staff as well as the
pediatric staff, streamline the approach at each institution.

If the initial facility is not designed for pediatric inpatient care, transfer to a pediatric facility as
needed after his or her condition is stabilized in the ED and after initial workup and treatments
are completed.

Policy for Positive Culture Results

To ensure the quality of care, an ED policy should be established for positive culture results
requiring a call back to the care provider or to the patient.

For a positive cerebrospinal fluid culture, a patient who was sent home should return to the
hospital for intravenous antibiotics until identification of the organism is confirmed. Many EDs
routinely admit all patients receiving lumbar puncture in the ED.

For a positive blood culture, the patient should be reevaluated by a physician. An afebrile patient
who is doing well may be treated on an outpatient basis after infection with penicillinase-
resistant Streptococcus pneumoniae is considered. A repeat blood culture is indicated in most
cases.

For a positive urine culture, the patient may be treated on an outpatient basis, with follow-up care
and repeated cultures to prove effective treatment.[112]

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