AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Pediatric patients presenting in the ED with fever are sometimes the more challenging patients emergency physicians face. Patients with fever can be present in a wide variety of clinical presentations ranging from mild clinical conditions to the most serious of bacterial illnesses. Fever is both a high-impact and a high-frequency chief complaint. The clinician should be knowledgeable about febrile conditions that occur in pediatric patients. Although clinical guidelines have been reported and scrutinized in major journals in the past few years, definitive conclusions are sometimes elusive.¹

Fever phobia is well described as existing with both caregivers as well as medical providers.²

Inconsistent treatment approaches exist even in the most experienced pediatric EDs.³

For related information, see Medscape's Pediatrics Resource Center.

Pathophysiology

A child's core temperature may normally vary by as much as 1-1.5°F throughout the day. This variation occurs with or without pathology being present. An elevated temperature above the normal range is defined as a fever. The standard definition of fever is a rectal temperature of 100.4°F (38.0°C) or higher.

In the face of pathology, pyrogens release prostaglandin E1 and D2. Pyrogens are low-molecular-weight proteins produced by leukocytes.

Prostaglandins mediate the set point for heat regulation in the human body. Their effects act on the hypothalamus and affect the body's response to heat by altering vascular constriction and other heat production and/or release mechanisms.

Frequency

United States

In the general emergency department setting, the chief complaint of fever accounts for approximately 20-25% of the presenting concerns of pediatric patients, with another 10-15% of children having a fever as an associated sign on presentation.

International

International studies both in Europe and Asia show rates of fever similar to US rates in acute care settings.

Mortality/Morbidity

The incidence of serious bacterial illness (SBI) occurs in approximately 1% of children presenting to an acute care setting with fever.

• Serious bacterial infection includes infections causing meningitis, bacteremia or sepsis, enteritis, pneumonia, pericarditis, osteomyelitis, septic arthritis, or cellulitis.^{4, 5}
• Febrile patients may present with other more common bacterial illnesses, such as otitis media, pharyngitis, sinusitis, urinary tract infections, enteritis, and appendicitis, or with viral illnesses, such as upper respiratory infections, bronchiolitis, enteroviral exanthems, gastroenteritis, and flulike illnesses.

Race

No race-based differences are appreciable in the occurrence of fever.

Sex

No sex-based differences are appreciable in the occurrence of fever.

Age

Fevers may occur in any age group. Neonates (<28 d) and young infants (28-60 d) have been traditionally discussed as subsets of pediatric febrile patients. Their presentation and evaluation and management will be the focus of this discussion. Children younger than 24 months of age were traditionally another subset of febrile patients.

• When presenting with fever, neonates and infants are considered at risk for sepsis until proven otherwise. The neonate has been traditionally described as being at greater risk than older children for 2 reasons. First, their bacterial pathogens may be different from those in older children. Their immune systems may be less capable than those of older children to opsonize and compartmentalize infection.
• Note: Not all septic neonates present with fever. Septic neonates may present to the ED with a lower than normal temperature.
• Careful attention to the rectal temperature is suggested in all neonates and young infants presenting in the ED.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The evaluation of any child in the emergency department should include documentation of the presence or absence of temperature changes.

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. A rectal-probe thermometer is probably most likely to result in an accurate assessment of a neonate's temperature.

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.

• For the neonate, the history is explored for possible evidence 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 laboratory evaluation.
• The birth history is explored to ascertain risk factors for underlying pathology, such as prematurity, maternal infections, and congenital or chronic disease states. Neonates at risk for congenital herpes are those born to mothers with recent genital infection, high-risk sexual activity, and rupture of membranes >6 hours, and 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.
• The history is also explored for previous diagnostic studies and their results.
• For 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 has been done at home to help control the fever?
  • Has the correct dose of antipyretic been given at home?
  • What is the patients' medical history? The past 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 there been less interest in eating?
  • What is the patient's immunization status? Which recent immunizations have been administered? Some children may not be fully immunized secondary to compliance, finances, or perceived health risks.⁶
  • • See also Complications of routine administration of childhood vaccinations below.
  • • In particular, what recent vaccinations might have caused an elevation in the patient's temperature? How many doses of pneumococcal conjugate (PCV-7) vaccine have been administered? How many doses of Haemophilus influenzae type B (HIB) vaccine have been administered?
  • Have the stool patterns changed in consistency or frequency?
  • Has there been recent antibiotic use?
  • Has there been exposure to illness through babysitters, daycare 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?
• 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.⁷
• Inquire about the use of antipyretics at home. At times, the clinician finds that the dose of medication used at home is not sufficient. Over-the-counter medications do not always list the correct weight-based dose for children younger than 2 years. Some boxes simply state "call physician" or "seek medical care." Parents should be educated that the ever-changing weight of their child will result in a need to periodically calculate or update the correct dose of medication.^{8, 9}

Physical

The physical examination of the febrile child is directed at locating a source of the temperature elevation, with specific attention to potential serious bacterial illnesses. Hypothermia may be a presenting vital-sign abnormality in septic neonates.

• Observation of the infant or child's interactions with the parent or caregiver is easily done while the history is obtained.
• • 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 there 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? Social smile remains one of the best predictors of well babies.¹⁰
  • Lethargy is defined as a decrease in the level of consciousness, some examples of which may include the following:
    • Failure of the child to recognize parents or caregivers
    • Absent eye contact with the examiner
    • Failure to interact with the environment at an age-appropriate level
    Toxicity is defined as a clinical syndrome with the following:
  • • Lethargy (see the bullet point above), with,
    • Poor perfusion as evidenced by delayed capillary refill, or,
    • Cyanosis or other signs of respiratory distress
• Physical examination findings suggestive of serious illness (eg, serious bacterial infection) include the following:
• • Presence of dyspnea, tachypnea, grunting, flaring, and retractions should be noted. These findings are abnormal and require further exploration (eg, pulse oximetry, chest radiography).
  • Hydration status should be documented. Specific signs of dehydration might include 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.
  • The presence or absence of meningeal signs should be documented in older children.
  • Caution: 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.¹¹
• • Clinical observation by house staff and seasoned clinicians has produced inconsistent results over the reliability and consistency of clinical observational scales.
  • Regardless of the clinical scale used, one predictor of overall wellness of a child is the presence of a smile.
• 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.
• Note: The capillary refill time is generally thought to be the quickest early assessment of hypoperfusion. Faster to obtain than a blood-pressure measurement, the capillary refill time is particularly helpful in a loud or busy ED. Triage nurses should be trained in the rapid assessment of hypoperfusion.
• 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 face 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.

Causes

Causes of elevated temperature include the following:¹²

• Infectious etiologies (SBI is the concern in the evaluation of the child with fever)
• • Meningitis, or encephalitis
  • Upper respiratory tract infection (URI)
  • Bacterial or viral pneumonia
  • Otitis media
  • Local skin infections, such as cellulitis
  • Oral infections, including pharyngitis due to Streptococcus pyogenes (group A Streptococcus species) and viral herpetic gingivostomatitis
  • Urinary tract infection (UTI)
  • Generalized viral illness
• Parents may be overly concerned about possible outcomes of prolonged high temperature, or they may believe that every fever requires antibiotic therapy.¹³
• The emergency physician may spend time educating parents on these subjects. In fact, not all temperature elevations are caused by bacterial infections. Temperature elevations may occur without infectious etiology.
• • Noninfectious causes of fever include environmental factors, such as the following:
  • • High external temperature (especially in the warmer weather months)
    • Over bundling of children in colder weather months
    • Malignancy
    • Rheumatoid diseases
    • Recent immunization administration
• Complications of routine administration of childhood vaccinations carry the risk of temperature elevation as a common adverse effect.
• • Administration of the diphtheria, tetanus, and pertussis (DTP) vaccine may cause fever within a few hours after administration and may persist up to 48 hours.
  • Administration of live-virus vaccinations, such as the measles, mumps, and rubella (MMR) vaccine, may result in temperature elevations up to 7-10 days after its administration.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Guidelines have been applied to neonatal emergency medicine. Traditionally, a febrile neonate (temperature 100.4°F [>38.0°C]) undergoes a full sepsis workup, eg, CBC, 1 blood culture, urinalysis, and urine culture (obtained by using a catheter), and diagnostic lumbar puncture (LP) for CSF analysis.^{14, 15}
• • 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 other infants as old as 60 days.
  • Older children (2-24 mo) who present with a higher temperature (>102.9°F [39.4°C]), and who are under immunized, may be at risk for occult bacteremia. By definition, occult means no other signs or symptoms suggesting the etiology of the temperature elevation. Higher temperatures are associated with increased rates of occult bacteremia. These situations are most common in unimmunized or immunosuppressed children.
  • 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%. This change is most likely due to the increasing rates of pneumococcal vaccinations.¹⁶
  • Before pneumococcal vaccinations, 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. The routine use of pneumococcal vaccine has essentially made this a classic historical discussion.¹⁷
  • Before routine use of the HIB vaccine, HIB accounted for 20% of occult illness, but this cause has also decreased in frequency after the vaccination became routine in the 1990s.
  • Other less common etiologic agents are Neisseria meningitides and (especially in patients with sickle cell disease) Salmonella species.¹⁸
  • Herpes and community-acquired MRSA are now emerging as more common pathogens in neonate.^{19, 20}
  • Before the routine use of the pneumococcal vaccine, a WBC count >15,000/mm³ had been reported to be 70% sensitive for predicting occult bacteremia from pneumomoccus.¹⁴
  • An increase in the total band count or erythrocyte sedimentation rate (ESR) is not more predictive of occult pneumococcal bacteremia than the elevated WBC count alone.
• Diarrhea in children is commonly caused by viral organisms and usually not considered a major source of fever. 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, and 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 daycare centers are at increased risk for rotavirus infection. Rotavirus vaccine may change the incidence of this clinical etiology as well.
• 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.
• Boys younger than 6 months with fever have an increased rate of UTIs. Several groups report an incidence of approximately 7%. For this reason, urinalysis and urine culture (obtained by catheterization) are recommended in male infants without another source of fever.²¹
• Girls younger than 12 months have about an 8% incidence in UTIs. Urinalysis and urine culture (obtained by catheterization) should be performed in febrile girls younger than 12 months if no other focus of fever is discovered. Fecal and skin contamination make the urine bag inadequate for obtaining specimens for culture. Bladder catheterization is required for culture.²²
• 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. Rates of UTI may be lower in those with bronchiolitis than those without any fever source.²³
• 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.^{24, 25, 26}

Imaging Studies

• Chest radiography
• • In febrile neonates and young infants, a chest radiograph may not be part of a routine sepsis workup in the absence of respiratory complaints (neonates) or lower respiratory tract findings/tachypnea (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. 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.
  • In children older than 2 years, chest radiography is not routinely ordered unless a specific indication is present.
  • Tachypnea on physical examination remains the most sensitive indicator of lower respiratory tract infection.
  • Infants who present with fever and signs of respiratory syncytial viral (RSV) bronchiolitis may be diagnostically challenging. Studies have shown they are at lower risk for serious bacterial illness. Testing of the nasal secretions for a viral etiology may be helpful.

Procedures

• In young children, the classic signs of meningismus, such as Kernig or Brudzinski signs, may be absent, even in the presence of CNS infection. 
• Diagnostic LP is suggested for ill-appearing patients with associated persistent vomiting, irritability, lethargy, full anterior fontanelle, complex febrile seizure (<12 mo), or petechial rash.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

Prehospital care provided by emergency medical technicians (EMTs) and paramedics may vary from region to region on the basis of 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.
• Those 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 and seizure precautions should be followed in those with a history of febrile seizures.

Emergency Department Care

Vital signs recorded in triage should routinely include a temperature in young children. This should be recorded on 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.

The 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. Reduction of fever is used to help comfort the child as well as provide for the optimal examination conditions. Triage protocols are developed to facilitate this.
• • The ED staff should be educated that a positive response to antipyretics (evidenced by a drop in the measured temperature) is not predictive of the absence of a potentially serious bacterial disease.^{27, 28}
  • 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.²⁹
• Neonates with fever who undergo the previously described 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). Neonates may also receive antiviral treatment with acyclovir if they are at risk for neonatal herpes infection.
• 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.

Consultations

Contact with the patient's primary care provider or designee helps ensure a continuum of care and enables effective follow-up care.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Drug Category: Antipyretics

These agents provide patient comfort during the ED visit and are used liberally in febrile children. A child whose temperature has been reduced is more comfortable and more likely to have an optimal examination.

Drug Category: Antimicrobial agents

Antibiotics are used to treat occult bacterial infection. Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting. Whenever feasible, select antibiotics based upon blood culture sensitivity. Consider initiating acyclovir for suspected HSV or VSV infections.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Febrile neonates (<28 d) may be admitted for presumed sepsis until cultures of CSF, blood, and urine are all negative for growth after 48 hours.
• • Two parenteral antibiotics are administered during these inpatient admissions: an aminopenicillin, such as ampicillin, and a cephalosporin, such as cefotaxime.
  • Some suggest that a subgroup of older neonates or young infants might not need such a complete sepsis workup. This change is not the current standard of care for all hospitals, and regional variation may exist.
  • 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, their toxic appearance, need for monitoring, need for hydration or other supportive measures, or poor social situation.
• 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.³⁰
• Iatrogenic risks are involved with routine hospitalizations of all febrile neonates and young infants.³¹
• Protocols developed in advance, in cooperation with the ED staff as well as the pediatric staff, streamline the approach at each institution.

Further Outpatient Care

• The neonate or young infant who has just undergone a complete sepsis workup may be admitted for parenteral antibiotics, as described above. Some EDs have established discharge criteria for this age group based on several factors.
• Criteria are sometimes applied to patients older than 30 days, as follows:
• • Well-appearing infant
  • No skeletal, soft tissue, skin, or ear infections
  • Full-term birth
  • No previous illness
  • No previous hospitalizations
  • Not hospitalized longer than the mother after delivery
  • No previous antibiotics
  • No hyperbilirubinemia
  • No chronic or underlying illness
  • WBC count 500-15,000/mm³
  • Bands <1500/mm³
  • If diarrhea is present, fecal leukocytes <5 per high-powered field and urine WBCs <10 per high-powered field
• 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.
• 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.
• In the absence of a clinically significant history and suggestive physical or positive laboratory and/or radiographic findings, empiric antibiotic treatment may not be indicated.
• For infants younger than 60 days of age, standard guidelines exist for use of antibiotics among outpatients. Infants younger than 60 days should not receive empiric antibiotic therapy without a complete sepsis evaluation including lumbar puncture.
• 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.
• An ED policy established for positive culture results requiring a call back to the care provider or to the patient should be in place to ensure the quality of care.
• Care for specific positive findings after the patient is discharged:
• • Positive CSF culture: A patient who was sent home should return to the hospital for intravenous antibiotics until identification is confirmed. Many EDs routinely admit all patients receiving LP in the ED.
  • Positive blood culture: The patient should be reevaluated by a physician. The afebrile patient who is doing well may be treated on an outpatient basis after infection with penicillinase-resistant S pneumoniae is considered. A repeat blood culture is indicated in most cases.
  • Positive urine culture: The patient may be treated on an outpatient basis with follow-up care and repeated cultures to prove effective treatment.³²
• Home health agencies can assist in the care of patients outside of the hospital.

Complications

• Dehydration is common in children with untreated fevers. Specific attention on the hydration should be addressed in febrile children.
• Occult bacteremia in the unimmunized child may progress to secondary sites of infection such as meningitis or osteomyelitis. Localized infections may lead to hematogenous seeding and sepsis.
• Morbidity and mortality are related to untreated sepsis syndromes and meningitis.

Prognosis

• The prognosis for routine febrile children treated as described is generally good but ultimately depends on the etiology of the fever.

Patient Education

• Parents should be reminded about fever control so that children with high fevers are promptly given antipyretics to increase their comfort and to allow for optimal fluid intake.
• Acetaminophen and ibuprofen have both been used for fever control.⁹
• • These drugs are sometimes alternated to achieve an overlapping period of fever control. However, no data support the safety of this practice of alternating medications.^{29, 28}
  • Some studies have shown that acetaminophen works faster by initially lowering elevations in temperature.²⁷
  • Some studies have shown that ibuprofen takes longer to initially result in fever reduction but that its effect may last longer than that of acetaminophen.⁸

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• The ED physician who discharges a child with the continued risk for unrecognized serious bacterial infection may incur potential medicolegal risk.
• The risk is minimized by performing an appropriate ED workup and ensuring effective follow-up care. Adherence to established guidelines (locally developed but based on published evidence) is valuable for minimizing risk.

Special Concerns

• 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:
  • • 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 S 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.
    • 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.
  • The approach to patients with HIV should be aggressive enough to determine presence of serious bacterial illness. History includes the 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.
  • 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, possible meningitis might be considered.³³
  • Young children with febrile seizures, especially those younger than 12 months may not always reliably demonstrate physical signs of meningitis.
  • • LP may be difficult to justify in the child who, after appropriate use of an antipyretic, is exhibiting normal activity.
    • 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.
    • LP is reserved for the younger patient, the patient already receiving antibiotics, or the patient whose physical findings cause concern.
  • 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

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Sep 4, 2008