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Fever (Pediatric - Younger than 3 years of age)

Children Younger Than 3 Years Presenting to the Emergency Department with Fever (October 2003)

Complete Clinical Policy on Fever - Children Younger than 3 Years  (PDF)

Scope of Application. This guideline is intended for physicians working in hospital-based emergency departments (EDs).

Inclusion Criteria. This policy applies to previously healthy term infants and children between the ages of 1 day and 36 months.

Exclusion Criteria. This policy excludes high-risk children such as those with congenital abnormalities, serious illnesses preceding the onset of a fever, those born prematurely, and those in an immunocompromised state.

Critical Questions

1. Are there useful age cutoffs for different diagnostic and treatment strategies in febrile children?

  • Level A recommendations. Infants between 1 and 28 days old with a fever should be presumed to have a serious bacterial infection.


  • Level B recommendations. None specified.


  • Level C recommendations. None specified.

2. Does a response to antipyretic medication indicate a lower likelihood of serious bacterial infection in the pediatric patient with a fever?

  • Level A recommendations. A response to antipyretic medication does not change the likelihood of a child having serious bacterial infection and should not be used for clinical decisionmaking.


  • Level B recommendations. None specified.


  • Level C recommendations. None specified.

3. What are the indications for a chest radiograph during the workup of pediatric fever?

  • Level A recommendations. None specified.


  • Level B recommendations. A chest radiograph should be obtained in febrile children aged younger than 3 months with evidence of acute respiratory illness.


  • Level C recommendations: There is insufficient evidence to determine when a chest radiograph is required in a febrile child aged older than 3 months. Consider a chest radiograph in children older than 3 months with a temperature greater than 39°C (>102.2°F) and a WBC count greater than 20,000/mm3. A chest radiograph is usually not indicated in febrile children aged older than 3 months with temperature less than 39°C (<102.2°F) without clinical evidence of acute pulmonary disease.

4. Which children are at risk for urinary tract infection?

  • Level A recommendations. Children aged younger than 1 year with fever without a source should be considered at risk for urinary tract infection.


  • Level B recommendations. Females aged between 1 and 2 years presenting with fever without source should be considered at risk for having a urinary tract infection.


  • Level C recommendations. None specified.

5. What are the best methods for obtaining urine for urinalysis and culture?

  •  Level A recommendations. None specified.


  • Level B recommendations. Urethral catheterization or suprapubic aspiration are the best methods for diagnosing urinary tract infection.


  • Level C recommendations. None specified.

6. What is the appropriate role of urinalysis, microscopy, and urine cultures?

  • Level A recommendations. None specified.


  • Level B recommendations. Obtain a urine culture in conjunction with other urine studies when urinary tract infection is suspected in a child aged younger than 2 years because a negative urine dipstick or urinalysis result in a febrile child does not always exclude urinary tract infection.


  • Level C recommendations. None specified.

7. What is the prevalence of occult bacteremia in children aged 3 to 36 months, and how frequently does it result in significant sequelae?

Conclusions

  1. The current prevalence of occult bacteremia among febrile children aged 3 to 36 months is most likely between 1.5% and 2%.

  2. Preliminary studies indicate that approximately 5% to 20% of patients aged 3 to 36 months with occult bacteremia will develop significant sequelae (eg, pneumonia, cellulitis, septic arthritis, osteomyelitis, meningitis, sepsis). Approximately 0.3% of previously well children (aged 3 to 36 months) who have a fever without source will develop significant sequelae; however, only 0.03% will develop sepsis or meningitis.

8. What is the appropriate role of empiric antibiotics among previously healthy, well-appearing children aged 3 to 36 months with fever without a source?

  • Level A recommendations. None specified.


  • Level B recommendations. Consider empiric antibiotic therapy for previously healthy, well-appearing children, aged 3 to 36 months, with fever without a source with a temperature of 39.0ºC or greater (≥102.2°F) when in association with a WBC count of 15,000/mm3 or greater if obtained.


  • Level C recommendations. In those cases when empiric antibiotics are not prescribed for children who have fever without a source, close follow-up must be ensured.

Purpose of ACEP's Clinical Policies

Clinical Findings and Strength of Recommendations