Management of Fever in Infants and Young Children

 

Am Fam Physician. 2020 Jun 15;101(12):721-729.

Author disclosure: No relevant financial affiliations.

Despite dramatic reductions in the rates of bacteremia and meningitis since the 1980s, febrile illness in children younger than 36 months continues to be a concern with potentially serious consequences. Factors that suggest serious infection include age younger than one month, poor arousability, petechial rash, delayed capillary refill, increased respiratory effort, and overall physician assessment. Urinary tract infections are the most common serious bacterial infection in children younger than three years, so evaluation for such infections should be performed in those with unexplained fever. Abnormal white blood cell counts have poor sensitivity for invasive bacterial infections; procalcitonin and C-reactive protein levels, when available, are more informative. Chest radiography is rarely recommended for children older than 28 days in the absence of localizing signs. Lumbar puncture is not recommended for children older than three months without localizing signs; it may also be considered for those from one to three months of age with abnormal laboratory test results. Protocols such as Step-by-Step, Laboratory Score, or the Rochester algorithms may be helpful in identifying low-risk patients. Rapid influenza testing and tests for coronavirus disease 2019 (COVID-19) may be of value when those diseases are circulating. When empiric treatment is appropriate, suggested antibiotics include ceftriaxone or cefotaxime for infants one to three months of age and ampicillin with gentamicin or with cefotaxime for neonates. For children three months to three years of age, azithromycin or amoxicillin is recommended if pneumonia is suspected; for urinary infections, suggested antibiotics are cefixime, amoxicillin/clavulanate, or trimethoprim/sulfamethoxazole. Choice of antibiotics should reflect local patterns of microbial resistance.

The evaluation of children younger than 36 months presenting with fever has long been challenging for physicians. Beginning in the 1980s, guidelines were developed to identify children who can be safely followed at home, but no plan has proved entirely satisfactory. Since publication of the previous article on this topic in American Family Physician,1 changes in epidemiology, microbial resistance, and available diagnostic tests have led to changes in recommendations. This review addresses the evaluation and care of previously healthy febrile children; children who are immunocompromised, were born prematurely, or who have other preexisting illness should be evaluated on a case-by-case basis.

The Authors

show all author info

JENNIFER L. HAMILTON, MD, PhD, FAAFP, is director of the Family Medicine Clerkship and an associate professor in the Department of Family, Community, and Preventive Medicine at Drexel University College of Medicine, Philadelphia, Pa....

SUSANNA G. EVANS, MD, FAAFP, is an associate professor and chair of the Department of Family, Community, and Preventive Medicine at Drexel University College of Medicine.

MUNISH BAKSHI, MD, is an assistant professor in the Department of Family, Community, and Preventive Medicine at Drexel University College of Medicine.

Address correspondence to Jennifer L. Hamilton, MD, PhD, FAAFP, 10 Shurs Ln., Ste. 301, Philadelphia, PA 19127 (email: jlh88@drexel.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Hamilton JL, John SP. Evaluation of fever in infants and young children. Am Fam Physician. 2013;87(4):254–260. Accessed February 17, 2020. https://www.aafp.org/afp/2013/0215/p254.html...

2. Centers for Disease Control and Prevention. Pneumococcal disease: surveillance and reporting: trends. Updated September 6, 2017. Accessed January 9, 2019. https://www.cdc.gov/pneumococcal/surveillance.html

3. Centers for Disease Control and Prevention. Progress toward elimination of Haemophilus influenzae type b disease among infants and children—United States, 1987–1995. MMWR Morb Mortal Wkly Rep. 1996;45(42):901–906.

4. Centers for Disease Control and Prevention. Active Bacterial Core surveillance (ABCs): ABCs Report: group B Streptococcus, 1997. Updated February 2, 2010. Accessed January 12, 2019. https://www.cdc.gov/abcs/reports-findings/survreports/gbs97.html

5. Centers for Disease Control and Prevention. Active Bacterial Core surveillance (ABCs): ABCs Report: group B Streptococcus, 2016. Updated March 4, 2018. Accessed January 12, 2019. https://www.cdc.gov/abcs/reports-findings/survreports/gbs16.html

6. Lee B, Newland JG, Jhaveri R. Reductions in neonatal listeriosis: “collateral benefit” of group B streptococcal prophylaxis? J Infect. 2016;72(3):317–323.

7. Veesenmeyer AF, Edmonson MB. Trends in US hospital stays for listeriosis in infants. Hosp Pediatr. 2016;6(4):196–203.

8. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Pediatric Fever, Mace SE, Gemme SR, Valente JH, et al. Clinical policy for well-appearing infants and children younger than 2 years of age presenting to the emergency department with fever [published correction appears in Ann Emerg Med. 2017;70(5): 758]. Ann Emerg Med. 2016;67(5):625–639.e13.

9. Watt K, Waddle E, Jhaveri R. Changing epidemiology of serious bacterial infections in febrile infants without localizing signs. PLoS One. 2010;5(8):e12448.

10. Hassoun A, Stankovic C, Rogers A, et al. Listeria and enterococcal infections in neonates 28 days of age and younger: is empiric parenteral ampicillin still indicated? Pediatr Emerg Care. 2014;30(4):240–243.

11. Cioffredi LA, Jhaveri R. Evaluation and management of febrile children: a review. JAMA Pediatr. 2016;170(8):794–800.

12. Baraff LJ, Bass JW, Fleisher GR, et al.; Agency for Health Care Policy and Research. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source [published correction appears in Ann Emerg Med. 1993;22(9):1490]. Ann Emerg Med. 1993;22(7):1198–1210.

13. Stoll ML, Rubin LG. Incidence of occult bacteremia among highly febrile young children in the era of the pneumococcal conjugate vaccine: a study from a Children’s Hospital Emergency Department and Urgent Care Center. Arch Pediatr Adolesc Med. 2004;158(7):671–675.

14. Greenhow TL, Hung YY, Herz AM. Changing epidemiology of bacteremia in infants aged 1 week to 3 months. Pediatrics. 2012;129(3):e590–e596.

15. Powell EC, Mahajan PV, Roosevelt G, et al.; Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). Epidemiology of bacteremia in febrile infants aged 60 days and younger. Ann Emerg Med. 2018;71(2):211–216.

16. Bonadio W, Huang F, Nateson S, et al. Meta-analysis to determine risk for serious bacterial infection in febrile outpatient neonates with RSV infection. Pediatr Emerg Care. 2016;32(5):286–289.

17. Gomez B, Mintegi S, Bressan S, et al.; European Group for Validation of the Step-by-Step Approach. Validation of the “step-by-step” approach in the management of young febrile infants. Pediatrics. 2016;138(2):e20154381.

18. Cruz AT, Mahajan P, Bonsu BK, et al.; Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network. Accuracy of complete blood cell counts to identify febrile infants 60 days or younger with invasive bacterial infections [published correction appears in JAMA Pediatr. 2018;172(3):302]. JAMA Pediatr. 2017;171(11):e172927.

19. Subcommittee on Urinary Tract Infection. Reaffirmation of AAP clinical practice guideline: the diagnosis and management of the initial urinary tract infection in febrile infants and young children 2–24 months of age. Pediatrics. 2016;138(6):e20163026.

20. Greenhow TL, Hung YY, Pantell RH. Management and outcomes of previously healthy, full-term, febrile infants ages 7 to 90 days. Pediatrics. 2016;138(6):e20160270.

21. Aronson PL, Thurm C, Alpern ER, et al.; Febrile Young Infant Research Collaborative. Variation in care of the febrile young infant <90 days in US pediatric emergency departments [published correction appears in Pediatrics. 2015;135(4):775]. Pediatrics. 2014;134(4):667–677.

22. Biondi E, Evans R, Mischler M, et al. Epidemiology of bacteremia in febrile infants in the United States [published correction appears in Pediatrics. 2014;133(4):754]. Pediatrics. 2013;132(6):990–996.

23. Vos-Kerkhof E, Gomez B, Milcent K, et al. Clinical prediction models for young febrile infants at the emergency department: an international validation study. Arch Dis Child. 2018;103(11):1033–1041.

24. Kim S, Moon HM, Lee JK, et al. Changes in trends and impact of testing for influenza in infants with fever <90 days of age. Pediatr Int. 2017;59(12):1240–1245.

25. Bressan S, Gomez B, Mintegi S, et al. Diagnostic performance of the lab-score in predicting severe and invasive bacterial infections in well-appearing young febrile infants. Pediatr Infect Dis J. 2012;31(12):1239–1244.

26. Galetto-Lacour A, Zamora SA, Andreola B, et al. Validation of a laboratory risk index score for the identification of severe bacterial infection in children with fever without source. Arch Dis Child. 2010;95(12):968–973.

27. Balamuth F, Alpern ER, Grundmeier RW, et al. Comparison of two sepsis recognition methods in a pediatric emergency department. Acad Emerg Med. 2015;22(11):1298–1306.

28. Geijer H, Udumyan R, Lohse G, et al. Temperature measurements with a temporal scanner: systematic review and meta-analysis. BMJ Open. 2016;6(3):e009509.

29. Hernandez JM, Upadhye S. Do peripheral thermometers accurately correlate to core body temperature? Ann Emerg Med. 2016;68(5):562–563.

30. Zhen C, Xia Z, Ya Jun Z, et al. Accuracy of infrared tympanic thermometry used in the diagnosis of fever in children: a systematic review and meta-analysis. Clin Pediatr (Phila). 2015;54(2):114–126.

31. Verbakel JY, MacFaul R, Aertgeerts B, et al. Sepsis and meningitis in hospitalized children: performance of clinical signs and their prediction rules in a case-control study. Pediatr Emerg Care. 2014;30(6):373–380.

32. Van den Bruel A, Haj-Hassan T, Thompson M, et al.; European Research Network on Recognising Serious Infection investigators. Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: a systematic review. Lancet. 2010;375(9717):834–845.

33. Fleming S, Gill P, Jones C, et al. Validity and reliability of measurement of capillary refill time in children: a systematic review. Arch Dis Child. 2015;100(3):239–249.

34. Balamuth F, Alpern ER, Abbadessa MK, et al. Improving recognition of pediatric severe sepsis in the emergency department: contributions of a vital sign–based electronic alert and bedside clinician identification. Ann Emerg Med. 2017;70(6):759–768.e2.

35. Plunkett A, Tong J. Sepsis in children [published correction appears in BMJ. 2015;350:h3704]. BMJ. 2015;350:h3017.

36. Finnell SM, Carroll AE, Downs SM; Subcommittee on Urinary Tract Infection. Technical report—diagnosis and management of an initial UTI in febrile infants and young children. Pediatrics. 2011;128(3):e749–e770.

37. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595–610.

38. Hay AD, Sterne JA, Hood K, et al. Improving the diagnosis and treatment of urinary tract infection in young children in primary care: results from the DUTY prospective diagnostic cohort study. Ann Fam Med. 2016;14(4):325–336. Accessed March 5, 2020. https://www.annfammed.org/content/14/4/325.long

39. Ebell MH, Butler CC, Hay AD. Diagnosis of urinary tract infections in children. Am Fam Physician. 2018;97(4):273–274. Accessed March 5, 2020. https://www.aafp.org/afp/2018/0215/p273

40. Dagan R, Powell KR, Hall CB, et al. Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis. J Pediatr. 1985;107(6):855–860.

41. Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics of fever in selected infants. N Engl J Med. 1993;329(20):1437–1441.

42. Gomez B, Bressan S, Mintegi S, et al. Diagnostic value of procalcitonin in well-appearing young febrile infants. Pediatrics. 2012;130(5):815–822.

43. Mintegi S, Bressan S, Gomez B, et al. Accuracy of a sequential approach to identify young febrile infants at low risk for invasive bacterial infection. Emerg Med J. 2014;31(e1):e19–e24.

44. Waddle E, Jhaveri R. Outcomes of febrile children without localising signs after pneumococcal conjugate vaccine. Arch Dis Child. 2009;94(2):144–147.

45. Henry BM, Roy J, Ramakrishnan PK, et al. Procalcitonin as a serum bio-marker for differentiation of bacterial meningitis from viral meningitis in children: evidence from a meta-analysis. Clin Pediatr (Phila). 2016;55(8):749–764.

46. Mintegi S, Benito J, Astobiza E, et al. Well appearing young infants with fever without known source in the emergency department: are lumbar punctures always necessary? Eur J Emerg Med. 2010;17(3):167–169.

47. Scarfone R, Murray A, Gala P, et al. Lumbar puncture for all febrile infants 29–56 days old: a retrospective cohort reassessment study. J Pediatr. 2017;187:200–205.e1.

48. Chancey RJ, Jhaveri R. Fever without localizing signs in children: a review in the post-Hib and postpneumococcal era. Minerva Pediatr. 2009;61(5):489–501.

49. Mintegi S, Gomez B, Martinez-Virumbrales L, et al. Outpatient management of selected young febrile infants without antibiotics. Arch Dis Child. 2017;102(3):244–249.

50. Leazer R, Erickson N, Paulson J, et al. Epidemiology of cerebrospinal fluid cultures and time to detection in term infants. Pediatrics. 2017;139(5):e20163268.

51. Expert Panel on Pediatric Imaging, Westra SJ, Karmazyn BK, Alazraki AL, et al. ACR appropriateness criteria fever without source or unknown origin—child. J Am Coll Radiol. 2016;13(8):922–930.

52. Quinonez RA, Garber MD, Schroeder AR, et al. Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value. J Hosp Med. 2013;8(9):479–485.

53. Mintegi S, Garcia-Garcia JJ, Benito J, et al. Rapid influenza test in young febrile infants for the identification of low-risk patients. Pediatr Infect Dis J. 2009;28(11):1026–1028.

54. Centers for Disease Control and Prevention. Rapid influenza diagnostic tests. Updated October 25, 2016. Accessed January 13, 2019. https://www.cdc.gov/flu/professionals/diagnosis/clinician_guidance_ridt.htm

55. Levine DA, Platt SL, Dayan PS, et al.; Multicenter RSV-SBI Study Group of the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics. 2004;113(6):1728–1734.

56. Lacour AG, Zamora SA, Gervaix A. A score identifying serious bacterial infections in children with fever without source. Pediatr Infect Dis J. 2008;27(7):654–656.

57. Markic J, Kovacevic T, Krzelj V, et al. Lab-score is a valuable predictor of serious bacterial infection in infants admitted to hospital. Wien Klin Wochenschr. 2015;127(23–24):942–947.

58. Steinberg J. Young febrile infants: step-by-step evaluation [published correction appears in Am Fam Physician. 2018;97(3):159]. Am Fam Physician. 2018;97(1):45–46. Accessed March 6, 2020. https://www.aafp.org/afp/2018/0101/p45

59. Aronson PL, Shabanova V, Shapiro ED, et al.; Febrile Young Infant Research Collaborative. A prediction model to identify febrile infants ≤ 60 days at low risk of invasive bacterial infection. Pediatrics. 2019;144(1):e20183604.

60. Ouchenir L, Renaud C, Khan S, et al. The epidemiology, management, and outcomes of bacterial meningitis in infants. Pediatrics. 2017;140(1):e20170476.

61. Pneumococcal infections. In: Kimberlin DW, Brady MT, Jackson MA, et al., eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. American Academy of Pediatrics; 2018:639–650.

62. Bradley JS, Byington CL, Shah SS, et al.; Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25–e76.

63. Table of antibacterial drug dosages. In: Kimberlin DW, Brady MT, Jackson MA, et al., eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. American Academy of Pediatrics; 2018:903–1028.

64. Sur DK, Bukont EL. Evaluating fever of unidentifiable source in young children. Am Fam Physician. 2007;75(12):1805–1811. Accessed February 17, 2020. https://www.aafp.org/afp/2007/0615/p1805

65. Luszczak M. Evaluation and management of infants and young children with fever. Am Fam Physician. 2001;64(7):1219–1227. Accessed February 17, 2020. https://www.aafp.org/afp/2001/1001/p1219

 

 

Copyright © 2020 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Nov 1, 2020

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article