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Fever - Infants and Children Younger than 2 Years (Jan 2016)

Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the Emergency Department With Fever (2016)

Scope of Application

This guideline is intended for physicians working in Emergency Departments.

Inclusion Criteria

This guideline applies to previously healthy term infants and children, appropriately immunized for age, with ages as described in each critical question.

Exclusion Criteria

This guideline excludes neonates, prematurely born infants, and pediatric patients considered to be at high risk such as those with significant congenital abnormalities, with serious illnesses preceding the onset of fever, and in an immunocompromised state.

Critical Questions

  • For well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (≥38.0°C [100.4°F]), are there clinical predictors that identify patients at risk for urinary tract infection?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    Infants and children at increased risk for urinary tract infection include females younger than 12 months, uncircumcised males, nonblack race, fever duration greater than 24 hours, higher fever (≥39°C), negative test result for respiratory pathogens, and no obvious source of infection. Although the presence of a viral infection decreases the risk, no clinical feature has been shown to effectively exclude urinary tract infection. Physicians should consider urinalysis and urine culture testing to identify urinary tract infection in well-appearing infants and children aged 2 months to 2 years with a fever ≥38°C (100.4°F), especially among those at higher risk for urinary tract infection.

    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    Infants and children at increased risk for urinary tract infection include females younger than 12 months, uncircumcised males, nonblack race, fever duration greater than 24 hours, higher fever (≥39°C), negative test result for respiratory pathogens, and no obvious source of infection. Although the presence of a viral infection decreases the risk, no clinical feature has been shown to effectively exclude urinary tract infection. Physicians should consider urinalysis and urine culture testing to identify urinary tract infection in well-appearing infants and children aged 2 months to 2 years with a fever ≥38°C (100.4°F), especially among those at higher risk for urinary tract infection.

  • For well-appearing febrile infants and children aged 2 months to 2 years undergoing urine testing, which laboratory testing method(s) should be used to diagnose a urinary tract infection?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    Physicians can use a positive test result for any one of the following to make a preliminary diagnosis of urinary tract infection in febrile patients aged 2 months to 2 years: urine leukocyte esterase, nitrites, leukocyte count, or Gram’s stain.
    Level C Recommendations
    (1) Physicians should obtain a urine culture when starting antibiotics for the preliminary diagnosis of urinary tract infection in febrile patients aged 2 months to 2 years. (2) In febrile infants and children aged 2 months to 2 years with a negative dipstick urinalysis result in whom urinary tract infection is still suspected, obtain a urine culture.
    Level A Recommendations
    None specified.
    Level B Recommendations
    Physicians can use a positive test result for any one of the following to make a preliminary diagnosis of urinary tract infection in febrile patients aged 2 months to 2 years: urine leukocyte esterase, nitrites, leukocyte count, or Gram’s stain.
    Level C Recommendations
    (1) Physicians should obtain a urine culture when starting antibiotics for the preliminary diagnosis of urinary tract infection in febrile patients aged 2 months to 2 years. (2) In febrile infants and children aged 2 months to 2 years with a negative dipstick urinalysis result in whom urinary tract infection is still suspected, obtain a urine culture.
  • For well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (≥38.0°C [100.4°F]), are there clinical predictors that identify patients at risk for pneumonia for whom a chest radiograph should be obtained?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    In well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (≥38°C [100.4°F]) and no obvious source of infection, physicians should consider obtaining a chest radiograph for those with cough, hypoxia, rales, high fever (≥39°C), fever duration greater than 48 hours, or tachycardia and tachypnea out of proportion to fever.

    Level C Recommendations

    In well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (≥38°C [100.4°F]) and wheezing or a high likelihood of bronchiolitis, physicians should not order a chest radiograph.

    Level A Recommendations

    None specified.

    Level B Recommendations

    In well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (≥38°C [100.4°F]) and no obvious source of infection, physicians should consider obtaining a chest radiograph for those with cough, hypoxia, rales, high fever (≥39°C), fever duration greater than 48 hours, or tachycardia and tachypnea out of proportion to fever.

    Level C Recommendations

    In well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (≥38°C [100.4°F]) and wheezing or a high likelihood of bronchiolitis, physicians should not order a chest radiograph.

  • For well-appearing immunocompetent full-term infants aged 1 month to 3 months (29 days to 90 days) presenting with fever (≥38.0ºC [100.4°F]), are there predictors that identify patients at risk for meningitis from whom cerebrospinal fluid should be obtained?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    (1) Although there are no predictors that adequately identify full-term well-appearing febrile infants aged 29 to 90 days from whom cerebrospinal fluid should be obtained, the performance of a lumbar puncture may still be considered. (2) In the full-term well-appearing febrile infant aged 29 to 90 days diagnosed with a viral illness, deferment of lumbar puncture is a reasonable option, given the lower risk for meningitis. When lumbar puncture is deferred in the full-term well-appearing febrile infant aged 29 to 90 days, antibiotics should be withheld unless another bacterial source is identified. Admission, close follow-up with the primary care provider, or a return visit for a recheck in the Emergency Department is needed. (Consensus recommendation)
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    (1) Although there are no predictors that adequately identify full-term well-appearing febrile infants aged 29 to 90 days from whom cerebrospinal fluid should be obtained, the performance of a lumbar puncture may still be considered. (2) In the full-term well-appearing febrile infant aged 29 to 90 days diagnosed with a viral illness, deferment of lumbar puncture is a reasonable option, given the lower risk for meningitis. When lumbar puncture is deferred in the full-term well-appearing febrile infant aged 29 to 90 days, antibiotics should be withheld unless another bacterial source is identified. Admission, close follow-up with the primary care provider, or a return visit for a recheck in the Emergency Department is needed. (Consensus recommendation)

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Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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