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Management Guidelines for the Infant and Child with a Non-Specific Febrile Illness

Fever is one of the most common chief complaints in children who present to the pediatric emergency department for evaluation and treatment. When the history and physical reveal the cause or probable cause of the fever, the findings dictate the further evaluation and management of that child. However, there are many instances when the child has a fever that does not have an obvious source. The following guidelines present information that will help direct your efforts in a manner which will help you identify the child with a fever who is more likely to have a serious bacterial infection and thus needs more intensive evaluation and management.

Remember a few basic caveats.

  • First, no set of available guidelines (clinical and/or laboratory based) will identify 100% of children who have a serious bacterial infection.
  • Second, URIs and otitis media can both cause a fever in neonates and infants. However, many neonates and infants with a URI or otitis media do not have an associated fever. The diagnosis of URI or otitis media as a source of the fever is a diagnosis of exclusion in neonates especially, but also in infants. Be very careful and thorough in your history, physical, and assessment before attributing the fever to a URI or otitis media.
  • Third, diarrhea is a non-specific finding in many febrile etiologies. Think through your findings carefully before making the diagnosis of infectious enteritis as the cause of fever in these children.
  • Fourth, it is not the height of the fever that we are worried about, but rather what is causing the fever. A 15-month-old child with a temperature of 105, that you can not catch to give a dose of acetaminophen probably does not have a serious bacterial infection at that time. The same child listless and somnolent with a temperature of 100 is a major concern. We do use temperature cutoffs for these guidelines because they add a certain amount of specificity and sensitivity to the models.
  • Fifth, remember there are other pathologic processes besides infections that cause fever.

With these thoughts among many others, when you are caring for a neonate/infant/child with a non-specific febrile illness, the following guidelines will help.

If the neonate/infant/child is ill looking, evaluate for sepsis and consider admission regardless of the results.

Some background:

Rochester criteria were designed to help evaluate infants from 0-60 days, and include the following historical features:

  • Infant appears well
  • Infant has been previously healthy
  • 37 to 42 weeks gestation
  • No perinatal antibiotics
  • No treatment for unexplained hyperbilirubinemia
  • Has not had any antimicrobial treatment
  • No prior hospitalizations
  • No chronic or underlying illness(es)
  • Not hospitalized at birth longer than the mother
  • No evidence of skin, soft tissue, bone, joint or ear infection and the following evaluation:
    • WBC 5,000-15,000
    • Absolute band count < 1,500
    • U/A < 10 WBC/hpf (cath specimen)

Philadelphia criteria include 29-56day old infants with the same historical features as the Rochester criteria and:

  • WBC < 15,000
  • Band/neutrophil ratio < 0.2
  • U/A < 10 WBC/hpf
  • CSF < 8 WBC/hpf and gram stain
  • Stool < 5 WBC/hpf or heme
  • (Stool for WBCs is not available stat; use heme + stool as the criterion to obtain a stool culture)

Boston criteria 28-29 day old infants and same historical criteria and:

  • WBC < 20,000
  • U/A < 10 WBC/hpf
  • CSF < 10 WBC/hpf
  • CXR normal

Neonates in the 0-60 day period are very difficult to evaluate clinically for SBI. They have poor immunogenicity and ability to fight infections, but also have very unreliable clinical exams. For those reasons, the above criteria were developed to identify neonates with low-risk for SBI. All of these criteria combined help increase the sensitivity and predictive values of identifying those low-risk neonates. It is necessary to have all the above information before determining whether the patient is well or sick. Below are some recommendations based on the above studies for how best to manage neonates by age group.

Consider obtaining flu or RSV antigens in patients older than 30 days with obvious viral illness. If viral studies are positive, their likelihood of SBI is much lower, although risk of UTI is still present.

For patients 61 days and older, clinical exams are more reliable and their ability to fight infections are significantly stronger. If the patient has received at least 2 vaccinations with Prevnar, their rate of occult bacteremia is very low and blood cultures and cbc's are rarely necessary for their evaluations. UTI's and viral illness are the likely etiology for the majority of these febrile illnesses.

There are three age groups to consider:

  1. Birth to 28 days with temp = 100.4 F (38C):
    *The fourth tube of CSF can be used for viral studies as indicated. Strongly consider sending an HSV PCR in this age group and starting the patient on empiric acyclovir pending those results.
    1. Full sepsis evaluation: CBC with differential, blood culture, urinalysis, urine culture, CSF for gram stain, culture and cell count*
    2. Chest radiograph for lower respiratory tract symptoms (including tachypnea or decreased O2 sats)
    3. Stool culture if diarrhea
    4. Admit for IV antibiotics while awaiting cultures
  2. 29-60 days old with temp = 100.4 F (38C), meeting Rochester criteria: Consider full evaluation as above. Possible options for management:
    1. Negative evaluation but social or follow up concerns. Admit and the admitting team will decide on antibiotics.
    2. Negative evaluation and no social concerns, two options:
      1. home without antibiotics if phone available and reliable for a next day recheck
      2. ceftriaxone 50mg/kg with recheck within 24 hours. If still not ill and cultures negative, repeat ceftriaxone. Recheck the next day if still not ill and cultures negative, no additional follow up necessary. If any culture becomes positive, admit. Again, family needs phone and transportation availability, and reliability for follow up visits
    3. If evaluation positive, admit, discuss choice of antibiotics with floor team.
  3. 61-days to two years of age with temperature 102.2 F (39C) and well- or mildly ill-appearing
    1. females 2 - 24 months, and males 2 - 6 months old
      1. urinalysis and urine culture only
      2. chest x-ray if indicated
      3. stool culture if indicated, i.e., known contact, gross blood in the stool or hemoccult positive.
      4. treat if evaluation positive as an outpatient or inpatient as indicated
    2. male 6 - 24 months old
      1. urinalysis and urine culture if prior history of UTI or renal disease
      2. chest x-ray if indicated
      3. stool culture if indicated
      4. treat if evaluation is positive as outpatient or inpatient

Children over two years of age are managed based on their appearance (assessment triangle), VS, CC, nurse's evaluation, and your H&P

These are guidelines, not protocols

Balcher RG, Harper MB. Predictive model for serious bacterial infections among infants younger than 3 months of age. Pediatrics 108(2) Aug 2001

Baker MD. Evaluation and management of infants with fever. Pediatric Clinics of North America 46(6) Dec 1999

Baskin MN, O'Rourke EJ, Fleischer GR. Outpatient treatment of febrile infants28-89 days of age with intramuscular administration of ceftriaxone. J Pediatrics 120(1):22-7 Jan 1992

Dagan RD, Powell KR, Hall CB. Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis. J Pediatrics 107:855-60 1985

Philadelphia: Baker MD et al. N Engl J Med 1993;329:1437-1441

Bonsu BK, Harper MB. Utility of Peripheral Blood White Blood Cell Count for Identifying Sick Young Infants Who Need Lumbar Puncture. Ann of Emerg Med 2003; 41(2):206-214.

Lin DS et al. Urinary Tract Infections in Febrile Infants Younger than Eight Weeks of Age, Pediatrics 2000; 105(2)

Bonsu BK, Harper MB. Identifying Febrile Young Infants with Bacteremia: Is the Peripheral White Blood Cell Count an Accurate Screen. Ann Emerg Med 2003; 42(2): 216-225.

Titus MO, Wright SW Prevalence of Serious Bacterial Infections in Febrile Infants With Respiratory Syncytial Virus..Pediatrics 2003; 112: 282-284.

Byington et al., Serious Bacterial Infections in Febrile Infants 1 to 90 days old with and without viral infections. Pediatrics 2004; 113(6) 1662-1666.

Baraff LJ, Bass JW, Fleisher GR, et al. Pediatrics 1993;92:1-12

Hsiao AL, Chen L, Baker MD; Incidence and Predictors of Serious Bacterial Infection Among 57-180-Day Old Infants. Pediatrics 2006; 117:1695-1701.

Gorelick et al. Validation of Decision Rule Identifying Febrile Young Girls at High Risk for Urinary Tract Infections, Peds Emer Care 2003; 19(3): 162:164.

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