FEBRILE INFANT CHECKLIST
INVESTIGATION OF FEVER
WITHOUT SOURCE
Fever
·
Under
age 3 yr. >38º C
·
3
mo. – 3 yr. seldom investigated <39º C
·
3
mo. to 3 yr. >39º C
·
Always
rectal temperature under age 3 yr.
Bacteremia
·
Bacteria
in blood with no signs or symptoms of sepsis
·
Can
lead to serious bacterial infection (SBI) such as meningitis, sepsis,
osteomyelitis, pyelonephritis, pneumonia or septicemia.
Source
·
Origin
of infection not found in 25% of febrile infants and children.
Temperature
·
High
fever carries no inherent risk by itself.
·
Risk
of SBI increases with increasing temperature.
White blood cell count (WBC)
·
Liklihood
ratios for SBI:
3.9
for <5,000
2.0
for >5,000 - 20,000
3.5
for >20,000
·
55%
of SBI in 5,000 - 20,000 range
Chest X-ray (CXR) to be considered if:
1.
Respiratory
rate > 50
2.
Cough,
wheeze, retraction, rales
3.
WBC
> 20,000
·
Any
1 of the above yields 33% positive CXR.
·
None
of the above yields < 1% positive CXR.
Lumbar Puncture
·
Indicated
on clinical grounds or if full septic workup indicated.
·
Absence
of WBC’s does not exclude meningitis.
Urinalysis and Culture
·
Bagged
specimen only useful if negative.
Otherwise use clean catch, catheter or suprapubic specimen.
·
10%
of infants with fever have UTI
·
Increased
liklihood UTI in girls < 2yr and in uncircumcised males.
·
Significant
factors include:
Temp > 39º C
Fever > 2 days
Caucasian
< 1 year of age
No apparent source of fever otherwise
·
2
or more risk factors 95% sensitive and 30% specific for UTI.
·
These
are all guidelines based mainly on opinion rather that firm data. None are endorsed by any particular group.
·
Investigation
depends on age of child.
1.
0
– 28 days – neonates
·
Chance
of SBI is 12% - relatively high risk.
·
If
temp >38º C, do full septic workup and hospitalize. Consider empiric parenteral antibiotics.
2.
29
days – 3 months – younger infants
·
Chance
of SBI of 6-9% - somewhat less risk
·
Rochester
criteria include healthy appearance, full term, no previous antibiotics, no
focus on examination, WBC 5,000-15,000, urine < 10 WBC/hpf, fecal leucocytes
< 5/hpf if diarrhoea.
·
If
any criteria are not met, admit and do septic workup. Consider empirical parenteral antibiotics.
·
If
all criteria met consider followup at home (perhaps after negative LP) after
single IM dose of Ceftriaxone 50 mg/kg.
3.
3
months – 3 years – older infants and young children.
·
Chance
of SBI 1.5 – 2%. 0.3% will have serious
infective sequellae and 0.03% will have meningitis.
·
If
non-toxic and temperature <39º C, no investigation or antibiotic.
·
If
temperature > 39º C, do urinalysis and culture on all females < 24 mo,
all uncircumcised males under 12 mo., and all circumcised males < 6 mo.
·
If
age < 6 months or have not had 3 doses each of Hib and PCV7 vaccine, do
urine and culture, CBC, blood culture.
CXR if WBC >20,000.
Antibiotic if WBC > 15000.
·
If
age > 6 months and have had 3 doses each of Hib and PCV7 vaccine, do urine
and culture only – no routine blood work.
Algorithm for investigation of fever
1.
Baraff
LJ. Practice Guideline for the
Management of Infants and Children 0 to 36 Months of Age with Fever Without
Source. Ann Emerg Med. July 1993;22:108-115
2.
Baraff
LJ. Management of fever without source in infants and children. Ann Emerg Med.
December 2000;36:602-614.
3.
Hoberman
A. Wald, Ellen R. Reynolds Ellen A. Penchansky L. Charron M. Update
on the management of the febrile infant. Pediatric Infectious Disease Journal.
15(4):304-309, April 1996.
4.
Marvin
B. Harper. Update on the management of the febrile infant Clinical Pediatric
Emergency Medicine Volume 5 • Number 1 • March 2004
5.
ACEP
Clinical Policies Committee Clinical Policies Subcommittee on Pediatric Fever
Clinical Policy for Children Younger Than Three Years Presenting to the
Emergency Department With Fever. Annals of Emergency Medicine Volume 42 •
Number 4 • October 2003
6.
Nigrovic
Lise E. , Malley Richard. Evaluation of the febrile child 3 to 36
months old in the era of pneumococcal conjugate vaccine: focus on occult
bacteremia. Clinical Pediatric Emergency Medicine Volume 5 • Number 1 •
March 2004