Practice Guidelines

Fever in Well-Appearing Children Younger Than Two Years: A Clinical Policy from the ACEP


Am Fam Physician. 2017 Apr 15;95(8):524-525.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Lumbar puncture can be delayed in well-appearing infants 29 to 90 days of age with fever and suspected virus provided they are followed closely or hospitalized.

• Chest radiography should not be performed in well-appearing children two months to two years of age with fever of at least 100.4°F and wheezing or a high chance of bronchiolitis.

• Urinalysis and urine cultures to diagnose urinary tract infection should be considered in well-appearing children two months to two years of age who have a fever of at least 100.4°F, especially if they are at higher risk.

From the AFP Editors

In one year, 15% of visits to the emergency department by persons younger than 15 years are children with fever, usually attributed to a benign, self-limited viral infection. Some fevers, however, can be a sign of serious infection, especially in infants younger than three months. Although treating those who appear ill is clear cut, it can be difficult to distinguish between a benign condition and a serious bacterial infection in those who appear well. The American College of Emergency Physicians (ACEP) has released a clinical policy addressing issues in children younger than two years who visit the emergency department with fever, but who appear well.



Laboratory studies, including a lumbar puncture to evaluate for meningitis, are commonly performed in the emergency department when an infant presents with fever. Routinely performing a lumbar puncture, which is invasive and has associated risks, is controversial. On the other hand, initiating antibiotic treatment without performing a lumbar puncture can lead to incomplete treatment or late identification of meningitis. Being able to predict which infants presenting with fever would benefit from a lumbar puncture could help lessen parent anxiety, as well as decrease costs, the use of invasive testing, exposure to antibiotics, and admissions to the hospital.

Lumbar puncture

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Associate Deputy Editor.

A collection of Practice Guidelines published in AFP is available at



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Mar 15, 2018

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