An Approach to Fever
in Infants & Children
Pediatric Fever Evaluation and Management
Clinical Practice
Why Is The Topic Important?
• 20-35% of urban pediatric ED visits:
– “Fever Phobia”
• 65% of children visit their pediatrician with
complaint of fever before their 2nd birthday
• Diagnoses range from minor to life-threatening
• Multiple conflicting recommendations,
guidelines, and algorithms
To Work Up or Not to Work Up?
Specific Questions:
– Blood tests
– Lumbar Puncture
– Urinalysis / Urine Culture
– CXR
– Antibiotic use
– Observation
– Hospital admission
Significant Fever: Defined
Temperature of 38.0 ̊ rectally at rest:
– 0-2 months
risks increase at 38.0 ̊
(the occurrence of Serious Bacterial Infection
(SBI) increases from < 1% to 5% at 38.0° C)
– 3-36 months
risks increase at 39.0 ̊
Fever Without Source:
“Fever without source is an acute
febrile illness in which the etiology of
the fever is not apparent after a careful
history and physical exam.”
Pediatric Fever
Evaluation and
Management
Clinical Practice
Reduce
unnecessary
testing
Shorten
time to
initiation of
antibiotics
Goal: to evaluate and
manage fever in
infants and young
children based on
best available clinical
evidence
Lessen
length of ED
stay
Reduce
unnecessary
antibiotics
Sample Case #1
21 day old uncircumcised male presents with:
– Fever of 38.3°
– Has a runny nose
– Cough
– Alert and well appearing child
– No wheezing or retractions
– Previously healthy
What is Your
Work Up?
Neonates (0-28 days)
• CBC with manual diff, blood culture
• Cath urinalysis, C&S
• Lumbar puncture
• Antibiotic therapy
• Consider CXR if white count > 20,000, tachypnea,
or respiratory symptoms
• Admit
Prevalence of Serious Bacterial Infection (SBI)
Infants 0-2 Months Old
• Febrile neonates: SBI = 13%
• Febrile infants 1 to 2 months of age: SBI = 10%
• Febrile infants younger than 3 months of age
Urinary Tract Infections account for 1/3 all
bacterial diseases
Management of Fever In Infants and Children
Jeffrey R. Avner MD, M. Douglas Baker MD
Emergency Medicine Clinics of North America
Volume 20 • Number 1 • February 2002
SBI in Infants 1-2 Months Old
With Temperature > 38.0 ̊
• Meningitis:
– Bacterial (1.2%)
• Bacteremia (2.1%):
– Group B Streptococci 30%
– Other Bacteria:
•
•
•
•
•
S. Pneumoniae
E. Coli
N. Meningitidis
Salmonella
H. Flu
• Urinary Tract Infection ( 4% )
The Efficacy Of Routine Outpatient
Management Without Antibiotics Of Fever
In Selected Infants.
Pediatrics 103:660–665,1999 : Baker MD,
Bell LM, Avner JR
Sample Case #2
6 week (42 day) old male presents with:
–
–
–
–
–
–
Temperature of 38.3°
Runny nose
Sneezing
Taking fluids well
Has no retractions
Parents are reliable
What is Your
Work Up?
Young infants (29-60 days)
• Cath urinalysis, C&S
• LP
• CBC with manual diff, blood culture
• If all labs normal, then outpatient management with
antimicrobial therapy Rocephin 50 mg/kg IV/IM (one time dose)
• If UA, CBC, or LP abnormal, then start antibiotics
and admit
Sample Case #3
10 week (70 day) old male presents with:
– Temperature of 38.5°
– Alert and well appearing child
– No cough, wheezing or retractions
– Previously healthy
What is Your
Work Up?
Young infants (61-90 days)
• Cath urinalysis, C&S
• CBC with manual diff, blood culture
• LP if toxic appearing or significant risk
factors
• If CBC abnormal, may consider LP. Otherwise, give
Rocephin 50mg/kg IM/IV for outpatient management
Sample Case #4
4 month old male presents with:
– Fever of 39.1°
– Some nasal congestion
– Cough for 2 days
– Feeding poorly
– Difficult to arouse
What is Your
Work Up?
Infants (3-5 months)
• Cath urinalysis, C&S
• CBC with manual diff, blood culture
• LP
• Start antibiotics and admit
Sample Case #5
13 month old female presents with:
– Fever of 40.1° for 2 days
– Some nasal congestion
– One episode of non-bloody diarrhea
– She received first 2 immunizations to date
– On exam, she is alert and well hydrated
What is Your
Work Up?
Children (6-36 months)
• Cath urinalysis, C&S
• CBC, Blood Culture
• Empiric antibiotic treatment with Rocephin
50mg/kg IV/IM
• Disposition per clinical judgment
Fever Pitfalls
• Bundling:
– Bundling can lead to a rise in skin temperature and eventually rectal
temperature.
(Study 1: Cheng, 1993, Study 2: Grover, 1994)
• Route of Measurement:
– Tympanic/axillary don’t correlate well with rectal temps
(Craig, 2000; Craig, 2002; Jean-Mary, 2002)
• Antipyretics:
– No correlation between disease etiology/severity and response to antipyretics
(Baker, 1987; numerous others)
• Tactile temperatures:
– Sensitivity 83%
– Specificity 76% (Hooker, 1996; Graneto, 1996)
• Afebrile on presentation:
– 6 of 63 infants 0-3 months with bacteremia/meningitis afebrile in clinic after being
febrile at home (pantell, 2004)
– * No comment on whether or not antipyretics were given
Home Care Instructions
• Educate parent about appropriate wt-based med dose
with return demonstration
• When discharged from ED follow up with primary care
provider within 24 hrs
• When discharged from inpatient follow up with primary
care provider in 1-2 days
• Reasons to call provider or return to ED
• Provide Fever Instruction sheet with fever dosing chart
for ED discharges
• Provide Krames sheets: Fever in infants & young
children and Kidcare: Fever
Putting it into YOUR practice
• The following 10
questions will review
the clinical practice
• Check the rationale for
correct answers on the
subsequent slide
1. In infants younger than 3
months of age, the most
commonly occurring
bacterial infection is:
A.
B.
C.
D.
Group B Streptococcal
infection
Meningitis
Neonatal sepsis
Urinary tract infection
Answer to question1.
In infants younger than 3 months of age, the most commonly occurring
bacterial infection is urinary tract infection (D)
The Avner & Baker article (slide 9) included 2 related studies:
A 1994-1996 study by Baker &
Bell, published in 1999, looked at
36 neonates admitted with rectal
temperatures of 38° or higher
and diagnosed with serious
bacterial infection.
Another study by Baker, Bell, &
Avner completed during the
same time period, using the
same criteria, and also published
in 1999 involved 43 infants
between the ages of 29 and 60
days with serious bacterial
infection.
Group B Streptococcal infection
2
3
Meningitis
4
5
Neonatal sepsis
6
na
Urinary tract infection
17
17
2. Which statement about temperature measurement in infants less
than 3 months of age is accurate?
A. Bundling (swaddling) causes elevation in skin temperature,
but not in rectal temperature
B. Fever that lowers quickly after antipyretic medication
indicates a less severe infection than a fever that is less
responsive to medication
C. Temperature of 38.0°C (100.4°F) is defined as fever
D. Tympanic measurement is closely correlated with rectal
measurement
Answer to question 2.
The accurate statement about temperature measurement in infants less
than 3 months of age is:
Temperature of 38.0°C (100.4°F) is defined as fever (C)
From slide 23:
•
In a study by Cheng & Partridge published in 1993, 2 of 12 newborns older than 1 day
reached rectal temperatures of 38.0°C after being bundled for 2 ½ hrs.
A study by Grover & others (1994) of 36 infants aged 11-95 days showed an insignificant
0.06° C increase in rectal temp within1 hr of bundling.
Bundling may be a factor and warrants investigation.
•
Baker & others (1987) investigated the association between severity of disease and
response to acetaminophen in 1,559 children between the ages of 8 wks and 6 yrs with
temperatures greater than 38.4°C. No correlation was found, and children with some
serious bacterial infections actually demonstrated the greatest response.
•
Jean-Mary & others (2002) compared infrared axillary and aural thermometer readings with
digital rectal thermometer readings in 198 children aged 3-36 mos. Axillary and aural
measurements were comparable, but significantly different than rectal measurements.
•
A systematic review of 44 studies with 5,935 children aged birth-18 yrs published in 2002 by
Craig & others also revealed insufficient agreement between aural and rectal
measurements. In 2000, Craig published a systematic review of 20 studies with 3,201
children aged birth-18 yrs demonstrating wide variation between axillary and rectal
measurements using either mercury or electronic thermometers.
3. The following asymptomatic
infants come to the emergency
department with fever of
unknown source. Who will
definitely have a lumbar
puncture?
A. 1 month old
B. 5 month old
C. 7 month old
D. All of them
4. For a young infant with fever
of unknown source, the
nurse should notify the
physician for which abnormal
lab finding?
A. ANC of 2,000
B. ANC of 9,000
C. WBC of 4,000
D. WBC of 11,000
3. The 1 month old (A) will definitely
have a lumbar puncture?
•
•
Following the Fever Clinical Practice, infants
under 2 mos of age with fever > 38.0°C will
have an LP
Neonates 0-28 days of age (slide 7)
Infants 29-60 days of age (slide 12)
In those between 3 and 36 mos with fever >
39° C, physicians should consider a full septic
work up if the child appears toxic or shows signs
of meningitis or encephalitis
Infants 3-5 mos of age (slide 18)
Children 6-36 mos of age (slide 21)
4. For a young infant with fever of
unknown source, the nurse
should notify the physician for
WBC of 4,000 (C)
Low risk criteria (slide 12):
•
•
WBC > 5,000, < 15,000
ANC > 1,000, < 10,000
5. A 3 week old infant presents
with fever and cough. He
has no signs of respiratory
distress and has been
healthy since birth. Based on
the Pediatric Fever Clinical
Practice, the nurse
anticipates which of the
following orders?
A.
B.
C.
D.
Blood culture
Chest x-ray
Lumber puncture
All of the above
6. A fully immunized 6 month
old uncircumcised male
infant presents with cough,
decreased feeding,
temperature of 39.0°C
(102.2°F) and a diagnosis
of clinical bronchiolitis.
Based on the Pediatric Fever
Clinical Practice, the nurse
anticipates which of the
following orders?
A. Blood culture
B. Cath UA and culture
C. Lumbar puncture
D. RSV viral study
5. Following the Fever Clinical
Practice, the 3 week old infant with
fever will have a full septic work-up.
Infants with respiratory signs may
also warrant a CXR.
All of the above (D)
•
Fever > 38.0°C in Neonates 0-28
days of age (slide 7)
6. The 6 month old uncircumcised
male infant will have a cath UA and
culture (B)
•
Fever > 39.0°C in Children 6-36
mos of age (slide 21)
These children will have a full septic
work-up only if they appear toxic or
show signs of meningitis or
encephalitis. Those with clear
clinical diagnosis of bronchiolitis do
not need RSV viral studies.
7. A 2 year old presents with a
fever of 39.1°C, is difficult
to arouse, and eating poorly.
Based on the Pediatric Fever
Clinical Practice, the nurse
anticipates which of the
following orders?
A. Blood culture
B. Cath UA and culture
C. Lumbar puncture
D. All of the above
8. A 3 month old is discharged
from the ED after work up for
fever of unknown source.
The nurse’s parent teaching
should include the
importance of a follow up
appointment with the baby’s
primary care provider at:
A. 24 hours
B. 2-3 days
C. 1 week
D. Next well baby check at 4
months of age
7. Following the Fever Clinical
Practice, the 2 year old will have all
of the above (D).
•
Fever > 39.0°C in Children 6-36
mos of age (slide 21)
This child warrants full septic workup due to fever, altered level of
consciousness, and poor eating.
8. Home care instructions should
include the importance of a follow
up appointment with the baby’s
primary care provider at 24 hours
9. Fever of unknown
origin is most
dangerous in the
following age groups:
A. 0-3 years
B. 5-7 years
C. 10-12 years
D. 15-17 years
10. Successful implementation of the Banner
Health Fever Clinical Practice will be
demonstrated by:
A. Extended time between child’s hospital
arrival and initiation of antibiotic therapy
B. Increased use of antibiotic therapy in
treatment of young children with fever
C. Longer length of ED stay resulting in
fewer hospital admissions
D. Reduction in number of diagnostic tests
utilized in children younger than 3 years of
age
9. Fever of unknown origin is
most dangerous in children
aged 0-3 years (A)
•Evaluation & management of fever
of unknown source in infants and
young children is challenging
•History & physical exam may
provide few clues to guide therapy
•Findings may be nonspecific
•Social interaction skill is limited
•Clinical scoring systems
identifying those at low risk of SBI
have varying degrees of reliability
in the very young
(Avner & Baker, 2002)
10. Successful implementation of the Banner
Health Fever Clinical Practice will be demonstrated
by reduction in number of diagnostic tests utilized in
children younger than 3 years of age (D)
Consistent use of this practice, based on best clinical evidence,
will result in:
• reduction in unnecessary testing
• reduction in length of ED stay
• reduction in unnecessary antibiotics
• reduction in time to initiation of necessary antibiotics
References
Avner, J. R., & Baker, M. D. (2002). Management of fever in infants and children. Emergency
Medicine Clinics of North America, 20(1), 49-67.
Baker, M.D., Bell, L.M., Avner, J.R. (1999). The efficacy of routine outpatient management
without antibiotics of fever in selected infants. Pediatrics, 103(3), 627-631.
Baker, M.D., Fosarelli, P.D., Carpenter, R.O. (1987). Childhood fever: Correlation of diagnosis
with temperature response to acetaminophen. Pediatrics, 80(3), 315-318.
Cheng, T. L., & Partridge, J. C. (1993). Effect of bundling and high environmental
temperature on neonatal body temperature. Pediatrics, 92(2), 238-240.
Craig, J.V., Lancaster, G.A., Taylor, S., Williamson, P. R., & Smyth, R. (2002). Infrared ear
thermometry compared with rectal thermometry in children: A systematic review. Lancet,
360(9333), 603-609.
Craig, J.V., Lancaster, G.A., Smyth, R. L., & Williamson, P.R. (2000). Temperature measured
at the axilla compared with rectum in children and young people: Systematic review. BMJ,
320(7243), 1174-1178.
Graneto, J.W., Soglin D.F. (1996). Maternal screening of childhood fever by palpation.
Pediatric Emergency Care, 12(3), 183-184.
Grover, G., Berkowitz, C. D., Lewis, R. J., Thompson, M., & Berry, L. (1994). The effects of
bundling on infant temperature. Pediatrics, 94(5), 669-673.
Hooker, E.A., Smith, S.W., Miles, T., & King, L. (1996). Subjective assessment of fever by
parents: Comparison with measurement by noncontact tympanic thermometer and
calibrated rectal glass mercury thermometer. Annals of Emergency Medicine, 28(3), 313317.
Jean-Mary, M.B., Dicanzio, J., Shaw J., Bernstein, H. H. (2002). Limited accuracy and
reliability of infrared axillary and aural thermometers in a pediatric outpatient
population. Journal of Pediatrics, 141(5), 671-676.
Pantell, R.H., Newman, T.B., Bernzweig J., Bergman, D. A,. Takayama, J. Segal, J. I., … &
Wasserman, R. C. (2004). Management and outcomes of care of fever in early
infancy. JAMA, 291(10),1203-1212.