Anda di halaman 1dari 15

Emergent Management of Pediatric Patients with Fever

http://emedicine.medscape.com/article/801598-overview#sh...

Emergent Management of Pediatric Patients with


Fever
Author: John W Graneto, DO, FACOEP, FACEP; Chief Editor: Russell W Steele, MD more...
Updated: Jan 30, 2014

Overview
Emergent management of pediatric patients with fever is a common challenge. Children with fever account for as
many as 20% of pediatric emergency department (ED) visits,[1] and the underlying disorders in these cases range
from mild conditions to the most serious of bacterial and viral illnesses.[2, 3]
Infants younger than 2 months have unique risks for serious bacterial infections; as such, their management is
discussed separately from that of older children.
Clinical guidelines have been studied, reported, and scrutinized in major journals for the past 2 decades, yet
definitive conclusions are sometimes still elusive and the application to each individual case in the ED is sometimes
even more frustrating for the clinician.[4] Inconsistent treatment approaches exist even in the most experienced
pediatric EDs.[5, 6]
Some of the fears and anxiety exhibited by parents are shared by ED staff as well. Myths and misperceptions about
children with temperature elevations are reported. Fever phobia is well described as existing with both caregivers as
well as medical providers.[7, 8, 9, 10]
Because pediatric fever is both a high-impact and a high-frequency chief complaint, the clinician should be
knowledgeable about febrile conditions that occur in a variety of age groups of pediatric patients. ED guidelines for
treating children with febrile illness are used in order to standardize the approach to care.
This article discusses the appropriate ED management of young febrile children, particularly those younger than 2
years. Neonates (< 28 days) and young infants (28-60 days) are discussed as subsets of this group of pediatric
febrile patients.
For more information, see the Medscape Reference articles Fever in the Infant and Toddler and Fever Without a
Focus.

Patient History
Immunizations
Determine the patient's immunization status; see the 2014 immunization schedule.[11] Simply asking whether the
child is up to date with immunizations may not elicit enough information. Ask how many doses of pneumococcal
conjugate (PCV-7) and Haemophilus influenzae type B (HIB) vaccines have been administered. It is also important to
inquire about which immunizations have been administered recently.
Some children may not be fully immunizedbecause of compliance, finances, or perceived health risks,[12] and
thus may be at risk for the infections covered by these vaccines. On the other hand, recent vaccinations might have
caused an elevation in the patient's temperature.

Temperature measurement at home


Some pediatric patients may have had a subjective determination of an elevated temperature by their caregivers
before coming to the hospital but are afebrile when they present to the ED. Parents may report a temperature
elevation in their child without having actually recorded the temperature with a thermometer.
Parental reporting of fever on the basis of subjective information (eg, touching the child's torso or extremities or
feeling his or her forehead) is a reliable indicator of a fever having been present. Studies have shown that the
parental assessment of fever in this situation is usually accurate.[13] On the other hand, one study found that the
subjective history of fever in such infants may not correlate with subsequent fever, whereas those with an elevated
rectal temperature measured at home had relatively high rates of serious bacterial infection.[14]
Home use of temporal artery thermometers have not been shown to be completely reliable indicators of febrile
children.[15]

Fever phobia
Parents may be overly concerned about possible outcomes of prolonged high temperature, or they may believe that
every fever requires antibiotic therapy.[16, 17] These usually unwarranted fears have been shown to vary by race and
ethnicity, as well as by the age of the child and parental education level.[8, 18, 19]
Temperature elevation may not be the only sign of sepsis in neonates and infants. Other potential signs and
symptoms of sepsis unique to infancy should also be assessed. History taking is an important part of clinical decision
making.
The clinician should ask the patient's parents or caretakers about the following items when they bring in a febrile or

1 dari 15

11/5/2014 12:40 AM

Emergent Management of Pediatric Patients with Fever

http://emedicine.medscape.com/article/801598-overview#sh...

ill-appearing child:
Immunization history, such as recent vaccination or a history of inadequate immunizations
History of exposure to sick contacts and treatments, such as antibiotics
Recent travel history
History of previous hospitalization, prolonged ICU stay, prematurity, or immunocompromised diseases
History of change in mental status, change in eating and/or behavioral patterns such as irritability, lethargy, or
apnea
History of neglect or abuse
Documented fever at home, the duration of any fever, and the last treatment (if any) for the fever
Environmental factors, such as being in the heat for a long time during the summer and being overdressed during
the winter, may indicate a risk for hyperthermia.
The neonate (birth to 28 days)
The history of the neonate is explored for possible symptoms of poor feeding, vomiting, poor social interaction,
changes in the quality of crying, and possible apneic episodes. Any of these findings are reasons to consider serious
bacterial infection and may warrant further investigation and laboratory evaluation.
The birth history is explored to ascertain risk factors for underlying pathology, such as prematurity, maternal
infections (eg, group B Streptococcus, sexually transmitted diseases such as genital herpes simplex), and congenital
or chronic disease states. Neonates at risk for congenital herpes are those born to mothers with a history of recent
genital infection and high-risk sexual activity; delivery-related risk factors include rupture of membranes for longer
than 6 hours and use of a scalp electrode.
Neonates who present with irritability, seizures, respiratory distress, jaundice, or a characteristic vesicular rash
should be considered at risk for neonatal herpes. Note that 10-50% will not develop skin lesions during the course of
their illness.[20]
The history is also explored for previous diagnostic studies and their results.

The older child


The following questions might be helpful:
What is the timing of the current illness?
When did the fever start?
How long has the fever been present? Are there any related symptoms?
What is the patient's medical history? The history may not be applicable in all cases, but it must be explored
to reveal potential high risk or complicating factors.
Has the child's activity significantly changed during the illness?
Is the child tolerating fluids at home? Has the child been less interested in eating?
Have the stool patterns changed in consistency or frequency?
Has there been recent antibiotic use?
Has there been exposure to illness through babysitters, day care contacts, or other caregivers? Are others at
home sick?
Have the sleep patterns changed? Has the patient been snoring more at night than usual?
Has there been any recent travel that might have exposed the child to illnesses?
It can also be helpful to ask what has been done at home to help control the fever. Was an antipyretic given at
home? If so, what dose was given?
In some cases, the clinician finds that child received an inadequate does of antipyretic medication. Over-the-counter
medications may not clearly list the correct weight-based dose for children younger than 2 years. Some product
instructions simply state "call physician" or "seek medical care." Parents should be educated that the steadily
changing weight of their child will result in a need to periodically update the correct dose of medication.[21, 22]
According to the 2003 clinical policy of the American College of Emergency Physicians (ACEP), response to
antipyretic medication does not change the likelihood of a child having a serious bacterial infection and should not be
used for clinical decision making.[23]

The Physical Exam


The physical examination of the febrile child is directed at locating a source of or reason for the temperature
elevation, with specific attention to potential serious bacterial illnesses. Alternatively, an elevated temperature is not
the only vital-sign irregularity that may indicate a potential infectious problem. Hypothermia may be a presenting
vital-sign abnormality in septic neonates.
Thermometer use varies between oral, rectal, or axillary. Ear-probe thermometers may not be as accurate as rectal
thermometers in the neonate; some study results suggest that operator error is the main reason. Axillary and rectal
temperature measurements may also vary widely in neonates.[24] A rectal-probe thermometer is probably most likely
to result in an accurate assessment of a neonate's temperature.[25, 26, 27]
Temperature elevation may not be the only sign of sepsis in neonates and infants. Other potential signs and
symptoms of sepsis unique to infancy should also be assessed.
The infant's or child's interactions with the parent or caregiver are easily observed while the history is obtained. The
following observations should be noted:

2 dari 15

What is the quality of the cry? Is it abnormal, high pitched, or weak in effort?
Does the child appear fearful of the examiner? Beyond infancy, healthy young children should fear strangers;
the child who lies on the examination table without much interaction or who is not disturbed by an
examination may be more likely to have a more serious illness

11/5/2014 12:40 AM

Emergent Management of Pediatric Patients with Fever

http://emedicine.medscape.com/article/801598-overview#sh...

What is the skin color? Are there areas of cyanosis or jaundice? Are there any rashes present?
What is the degree of hydration? Are tears present during crying? Is there moisture on the oral mucosa/lips or
tongue? For the neonate, a gentle palpation of the anterior fontanelle may give a general indication to the
fluid status; a sunken fontanelle indicates possible hypovolemia/dehydration
What is the response to social overtures? Does the baby smile at the examiner? Does the baby smile or
appear interested in a small toy or other shiny object? Checking for a social smile is a helpful component of
the examination because it remains one of the better predictors of well babies[28]
The capillary refill time is generally thought to be the quickest assessment of early hypoperfusion. Capillary refill time
is faster to obtain than a blood-pressure measurement and is particularly helpful in a loud or busy ED. A delay in the
capillary refill time (>2 seconds) indicates hypoperfusion of the skin. Shunting of blood from the capillary beds in the
skin is an indication of increased systematic vascular resistance (SVR). An increase in SVR is generally thought to
occur early in the course of pediatric hypovolemia. Hypovolemia can result from obvious conditions, such as blood
loss and vomiting and diarrhea, or from more subtle reasons, such as tachypnea and sweating.
The presence of dyspnea, tachypnea, grunting, flaring, and retractions is noted. These findings suggest possible
serious illness and require further exploration (eg, pulse oximetry, chest radiography).[29]
Hydration status is documented to include specific signs of dehydration such as dry mucous membranes, sunken
fontanelle, absence of tears when crying, and/or a lack of urine output (by history).
Persistent irritability despite feeding or inability of parents to console the child is concerning. True irritability and
lethargy are physical signs traditionally associated with an ill child. Lethargy is defined as a decrease in the level of
consciousness, some examples of which are failure of the child to recognize parents or caregivers, absent eye
contact with the examiner, or failure to interact with the environment at an age-appropriate level.
Toxicity is defined as a clinical syndrome with the following: lethargy with (1) poor perfusion as evidenced by delayed
capillary refill or (2) cyanosis or other signs of respiratory distress. Cold hands and feet, limb pain, and pale or
mottled skin are considered "red flag" manifestations of septicemia.[30]
The presence or absence of meningeal signs is documented in older children. Clinicians should bear in mind that in
some infants and younger children (perhaps younger than 12-15 months) who develop meningitis, specific
meningeal signs, such as the Kernig or Brudzinski sign, may not be present.
A hemorrhagic rash is classically described as resulting from overwhelming systemic bacterial infection due to
meningococcemia but may be due to other (usually serious) infections. The presence of petechiae or purpura in
febrile children indicates the need for prompt evaluation and therapy.
Clinical observation scales have been developed to aid in the determination of the degree of illness.[31] Clinical
observation by house staff and seasoned clinicians has produced inconsistent results over the reliability and
consistency of clinical observation scales. Regardless of the clinical scale used, one predictor of overall wellness of a
child is the presence of a smile.[28]
A physical finding of an isolated bacterial illness, such as otitis media or pneumonia, should not preclude the clinician
from possibly pursuing a more extensive workup to exclude sepsis in the neonate.

Minimizing Patient Risk


Discharging a child from the emergency department (ED) with an unrecognized serious bacterial infection is a
potential medicolegal risk for the ED physician. The risk is minimized by performing and documenting an appropriate
history, physical examination, and, when indicated, a workup, as well as ensuring effective follow-up care.[32]
Several factors indicate an increased risk of bacteremia and/or sepsis, including age less than 2 months, an
immunocompromised state (eg, neutropenic or underlying malignancy), being unvaccinated or undervaccinated,
hypothermia (core temperature < 36.8C, or 98F), and hyperthermia (core temperature >40.5C, or 105F).[33]
Some pediatric patients may be potentially at a higher risk for bacterial illness than their age-matched counterparts.
Special consideration for these populations should include appropriate evaluation in the ED, documentation of
consultation with specialists, and chart documentation related to special needs.
Patients with inserted medical devices (eg, foreign bodes) may be at increased risk for infection related to the device.
A documented discussion with an appropriate consultant may be indicated. Examples of such devices include the
following:
Recently inserted cardiac pacemaker
Ventriculoperitoneal shunts
Central lines or other long-term intravenous access
Patients with sickle cell disease (SCD) are considered functionally asplenic. Asplenic patients are at exceptional high
risk of sepsis due to encapsulated organisms, such as Streptococcus pneumonia. Because of this, patients with SCD
are often hospitalized for observation and empiric treatment. If these patients present with fever, they are considered
at higher risk for occult bacteremia and treated accordingly. Blood cultures, CBCs, and differentials are assessed.
Parenteral antibiotics against encapsulated organisms are given early.
Patients who are absolutely or relatively immunocompromised (eg, patients with underlying malignancy, patients
undergoing chemotherapeutic regimens) must be evaluated for possible occult bacterial infection. Fever and
neutropenia should be considered, and a consultation with the oncologist may be indicated.[34]
The approach to patients with HIV infection should be aggressive enough to determine presence of serious bacterial
illness. History includes the parents or patient's knowledge of their level of CD4 cells and viral load. A sepsis workup
is usually indicated in HIV-positive patients presenting with fever. Early consultation with the primary care provider or
infectious disease specialist is indicated in the care of these patients.
Infants who were born prematurely may be at risk for infections, such as bronchiolitis or other complications (eg,
necrotizing enterocolitis). Consultation with the primary care provider or high-risk neonatologist may be indicated.

3 dari 15

11/5/2014 12:40 AM

Emergent Management of Pediatric Patients with Fever

http://emedicine.medscape.com/article/801598-overview#sh...

Patients with cystic fibrosis are especially susceptible to pneumonia and should be liberally evaluated for such.
Consultation with a pulmonologist may be indicated.
Ideally, the decision to admit or discharge these patients is established by a written protocol or guidelines previously
established in conjunction with the department of pediatrics. A documented discussion with the specialist may be
indicated.

Patients with febrile seizures


The evaluation of patients presenting with a simple febrile seizure focuses on determining the cause of the fever. In
children aged 2-24 months with simple febrile seizures, the risk for occult bacteremia is about the same as that of
patients with fever alone.
In children who remain ill appearing and/or who have signs of toxicity, the possibility of meningitis might be
considered.[35] Young children with febrile seizures, especially those younger than 12 months may not always
reliably demonstrate physical signs of meningitis.
The child with a febrile seizure should be monitored for some time in the ED, and findings on serial examinations
should be documented to differentiate children who are ill with occult disease from children who may be safely
discharged home.[36]
Lumbar puncture (LP) may be difficult to justify in the child who, after appropriate use of an antipyretic, exhibits
normal activity. LP is reserved for the younger patient, the patient already receiving antibiotics, or the patient whose
physical findings cause concern.

Workup for Neonates


Guidelines have been applied to neonatal emergency medicine. Traditionally, a febrile neonate (temperature
>100.4F [>38C]) undergoes a full sepsis workup, which includes a CBC count, urinalysis, blood culture, urine
culture, chest radiography, and diagnostic LP. The age group that is defined for this workup may vary. At minimum,
the guideline is applied to neonates younger than 28 days, and in some institutions or regions of the country, it may
be applied to infants as old as 60 days.
A full evaluation for sepsis in febrile neonates is warranted because their risk for serious bacterial infection (SBI) is
relatively high. Even among those who otherwise meet low-risk criteria, the rates of SBI are about 5%.[33, 32]
Similarly, about 10% of febrile neonates who have documented respiratory syncytial virus (RSV) infection or clinical
bronchiolitis have SBI [37] ; most of these are urinary tract infections (UTIs). This infection rate is about the same as
for those without documented RSV infection or clinical bronchiolitis; therefore, a full evaluation for sepsis should be
performed for these patients.

Cerebrospinal fluid analysis


For infants younger than 28 days, the median CSF values were as follows:
WBC count 5/L (range, 0-20)
Glucose - 46 mg/dL
Protein - 73 mg/dL
One study determined that adding polymerase chain reaction (PCR) testing for enterovirus to routine CSF testing
reduced the duration of hospitalization and antibiotic use for young infants.[38]
Another study determined normal CSF profiles among a large cohort of febrile infants with atraumatic LPs, negative
CSF bacterial cultures, and negative enteroviral PCR testing.[39]

Evaluation for herpes simplex


Evaluation of febrile neonates for herpes simplex infection should be considered when the following risk factors are
present:
Age younger than 3 weeks
Vesicles
Seizure
Toxic or ill appearance
CSF pleocytosis or red blood cells
Maternal history of herpes
Laboratory studies to screen for herpes infection may include the following:
Collecting vesicle fluid for culture and direct fluorescent antibody testing
Swabbing nasopharynx, conjunctiva, and rectum for culture
Performing LP for CSF PCR testing and culture

Workup for Children 5-8 Weeks Old


Most febrile infants aged 5-8 weeks who present to the ED warrant a full evaluation for SBI because they are difficult
to evaluate clinically and because ED physicians cannot ensure adequate follow-up.[40]
The threshold for performing an LP in these infants should be low; many of these infants will warrant CSF
examination. In select cases, at the clinician's discretion, an LP may be omitted in well-appearing infants who have
blood and urine studies obtained and when the following apply:

4 dari 15

Reliable follow-up is possible in 12-24 hours

11/5/2014 12:40 AM

Emergent Management of Pediatric Patients with Fever

http://emedicine.medscape.com/article/801598-overview#sh...

Clinicians are confident that parents or caretakers can comply with appropriate observation and follow-up
No antibiotics have been started
A recent study defined median CSF profiles among uninfected infants in this age range.[39]
WBC count - 3/mm3 (range, 0-11)
Glucose - 48 mg/dL
Protein - 54 mg/dL
Urine studies are important in this age group, as UTIs are a common source of SBI.[41, 42, 43] Additional studies such
as stool cultures are performed selectively. Chest radiographs do not need to be obtained routinely in those without
signs of respiratory disease.[44, 45]

Workup for Children 2-24 Months Old


In children who have been immunized against pneumococcal disease, the routine use of CBC and blood culture are
no longer recommended.[46, 47, 48] If a CBC is obtained, interpretation of the total WBC remains controversial.
Distinguishing between a high total WBC count versus a very high WBC count may leave the physicians with even
more questions about the relevance of this laboratory result.[46, 49, 50]
The rates of bacteremia and invasive pneumococcal disease have dramatically declined since the licensing of the
7-valent pneumococcal vaccine (PCV7) vaccine in 2000.[12, 51, 52, 53, 54, 55, 56] This vaccine protects against the 7
pneumococcal serotypes that cause 85% of invasive pneumococcal disease in children, including nearly all of the
serotypes that are highly penicillin resistant.
Prior to routine use of the pneumococcal vaccine, occult bacteremia occurred with an incidence of 3-5% in children
younger than 24 months with fever. Studies in the 1980s-1990s showed the rate of occult bacteremia was as high as
5%. In the 21st century, studies show a decline in the rates to as low as 0.5-1%.[57] This change is most likely due to
the increasing rates of pneumococcal vaccinations.[58]
Before widespread PCV7 use, approximately 60-70% of all cases of occult bacteremia were caused by
Streptococcus pneumoniae. S pneumoniae is the most prevalent and certainly the most significant cause of
morbidity and mortality related to occult bacteremia.
In 2010, the US Food and Drug Administration (FDA) licensed a 13-valent pneumococcal vaccine (PCV13), which
includes protection against additional strains of pneumococcus, including serotype 19A. This PCV13 vaccination will
supplant the PCV7 vaccination, presumptively causing a further decline in invasive pneumococcal disease. [59, 60]
The routine use of pneumococcal vaccine has essentially made rates of occult bacteremia a classic historical
discussion.[56]
Before routine use of the HIB vaccine, HIB accounted for 20% of occult illness, but this cause also decreased in
frequency after the vaccination became routine in the 1990s.[61, 62]
An increase in the total band count or erythrocyte sedimentation rate (ESR) is not more predictive of occult
pneumococcal bacteremia than an elevated WBC count alone. Before the routine use of the pneumococcal vaccine,
a WBC count above 15,000/mm3 had been reported to be 70% sensitive for predicting occult bacteremia from
pneumococcus. [63]
Children in this age group who present with a higher temperature (>102.9F [>39.4C]) may be at risk for occult
bacteremia, especially if they are underimmunized or immunosuppressed. By definition, occult means that the
patient exhibits no other signs or symptoms suggesting the etiology of the temperature elevation.
Other less common etiologic agents are Neisseria meningitides and (especially in patients with sickle cell disease)
Salmonella species. [51] Herpes and community-acquired methicillin-resistant Streptococcus aureus (MRSA) are now
emerging as more common pathogens in neonates.[64, 65, 66, 67, 68, 69, 70, 71]
Children younger than 24 months presenting with the clinical syndrome of bronchiolitis are at a lower risk of
bacteremia and UTIs. Therefore, routine urine and blood culturing in previously healthy children presenting with fever
and bronchiolitis is usually not indicated; extreme fever or ill appearance may be indications to obtain a blood culture.
Testing of the nasal secretions for a viral etiology such as respiratory syncytial viral (RSV) or influenza A/B may be
helpful. [72]
Rates of UTI may be lower in patients with bronchiolitis than those without any fever source.[73]
Viral infections are the most common cause of fever in young children aged 2-24 months. Well-appearing children
with unremarkable histories and physical examinations may be discharged home without laboratory testing or
presumptive use of antibiotics. An LP should be considered for those who are irritable, lethargic, inconsolable, or
toxic appearing.
During summer months, children with fever and no other signs may have an enterovirus infection. Some studies
report the incidence as high as 50% in febrile children in the ED. Enteroviral infection is a clinical diagnosis for the
emergency physician. No specific laboratory testing is indicated.
Diarrhea most commonly has a viral etiology in this age group. The presence of diarrhea with blood or mucus or
recent use of antibiotics may be indications for ordering stool cultures to assess for a bacterial etiology.
The routine acquisition of CBC and/or blood cultures to screen for occult bacteremia in immunocompetent children is
strongly discouraged for the following reasons:

5 dari 15

The peripheral white blood cell count has a low positive predictive value for bacteremia
Bacteremia rates are less than 1% in the postpneumococcal vaccine era[51, 12, 56]
Bacteremia spontaneous resolution rates (without antibiotics) are greater than 90%; therefore, few children
with pneumococcal bacteremia develop complications[74, 75]
High false-positive blood culture rates from contamination leads to unnecessary testing and/or

11/5/2014 12:40 AM

Emergent Management of Pediatric Patients with Fever

http://emedicine.medscape.com/article/801598-overview#sh...

hospitalizations
Indiscriminate testing is costly and invasive
Similarly, the presumptive use of broad-spectrum antibiotics is strongly discouraged because of low bacteremia and
complication rates, high costs, adverse drug reactions, and increasing rates of antibiotic resistance due to
indiscriminate antibiotic use, as well as because the outcomes for febrile young children not treated presumptively
with parenteral antibiotics are uniformly good.
For clinically ill-appearing children, a sepsis workup to include a blood culture should be obtained. Use of serum
markers for sepsis, including a lactate level and procalcitonin, have been described as being helpful in stratifying the
sickest children.[76, 77, 78, 79] This is especially true in children ill enough to warrant an LP as described above, those
exhibiting signs of shock, or those with a petechial rash.

Workup for Children Older Than 24 Months


The febrile child older than 24 months (who has been previously fully immunized) is primarily evaluated by obtaining
a history and performing a physical examination.
Specific workup and/or treatment is based on the clinical findings and suspicion of disease.[80, 81, 82]

Urinalysis and Urine Culture


UTI is a common cause of SBI in infants and young children.[83, 41, 42, 43] Clinicians should have a lower threshold for
ordering UA and urine cultures than for screening for bacteremia, especially for those with risk factors.
For boys, risk factors for UTI include age younger than 6 months and being uncircumcised.[84] For girls, risk factors
for UTI include the following:
Age younger than 12 months
White race
Temperature above 39C
Illness for 2 days or more
Absence of any other source for fever
In particular, clinicians should have a lower threshold for UTI screening for white girls; in 2 separate studies, UTI
rates were as high as 17% in this group.[84, 85]
Urethral catheterization is the method of choice to obtain urine to avoid contamination with skin flora. Urine collected
in a bag placed on the perineum is often contaminated and should not be evaluated for bacterial culture.[86, 87]
Suprapubic aspiration of the bladder for urine should be discouraged. Urethral catheterization is less invasive and
less painful and is associated with a higher yield of urine.
An enhanced UA, with a hemocytometer cell count and Gram stain of unspun urine, is more sensitive than a
standard UA. [88] Since negative urine dipstick or UA results in febrile young children do not always exclude UTI,
urine cultures should be performed regardless of UA results.[23] In bacteremic children with UTI, blood cultures and
urine cultures are likely to have identical organisms with identical antimicrobial sensitivities.[89]

Stool Studies
Diarrhea in children is commonly caused by viral organisms and is usually not considered a major source of fever.
However, diarrhea with blood or mucus is an indication for further testing for fecal leukocytes, which suggests
invasive bacterial etiologies.
If fecal leukocytes (>5 per high-powered field) are present, a bacterial etiology is suggested and cultures are
indicated. This finding may indicate infection with species of Salmonella, Campylobacter, Shigella, Yersinia, or toxic
strains of Escherichia coli. The final diagnosis can be made only by obtaining stool cultures.
During winter months, children presenting with low-grade fever, vomiting, and diarrhea should be considered
possibly infected with rotavirus. Children in day care centers are at increased risk for rotavirus infection. Rotavirus
vaccine may change the incidence of this clinical etiology as well.

Chest Radiographs
Chest radiographs are most useful for patients with high fever accompanied by focal pulmonary examination
findings. Chest radiographs should not be routinely performed for fever alone, in the absence of lower respiratory
tract findings or hypoxemia.
A study from Spain found that 13% of young children with fever above 39.0C and a peripheral white blood cell
(WBC) count of greater than 20 109/L had occult pneumonia.[90] However, just 20% of the radiographs were
interpreted by radiologists, and the authors estimate that just one third to one half of the children had received the
pneumococcal vaccine.
Given the very low positive predictive value of the WBC count, its routine acquisition in the setting of high fever
should be discouraged. On the other hand, if the WBC is obtained and is markedly elevated, consideration should be
given to obtaining a chest radiograph, in the absence of an alternative source of fever.
In febrile neonates and young infants, a chest radiograph may only be a routine part of a sepsis workup in the
presence of respiratory signs in neonates (eg, rales, grunting, flaring, retractions, hypoxia) or lower respiratory tract
findings (eg, cough, tachypnea) in infants. An increased respiratory rate is the earliest indicator of respiratory distress
and should be considered in the overall decision to obtain a chest radiograph.
In febrile children aged 3-24 months, pneumonia may be present even in the absence of definite auscultatory signs.

6 dari 15

11/5/2014 12:40 AM

Emergent Management of Pediatric Patients with Fever

http://emedicine.medscape.com/article/801598-overview#sh...

An abnormal respiratory rate or pulse oximetry should alert the emergency physician to the need for a chest
radiograph. Chest radiography is indicated if the child shows signs of respiratory distress, such as tachypnea;
grunting, flaring, or retractions; or hypoxia, as determined with pulse oximetry. A history of prolonged fever or cough
may also be predictors of occult respiratory tract infection.[91]
In children older than 2 years, chest radiography is not routinely ordered unless a specific indication is present, such
as prolonged cough, tachypnea, or hypoxia.[92]

Lumbar Puncture
Diagnostic LP is suggested for ill-appearing febrile infants and children associated with any of the following:
Age younger than 8 weeks
Complex febrile seizure (< 12 mo)
Full anterior fontanelle
Persistent vomiting
Persistent irritability, lethargy, inconsolability
Petechial rash
In young children, the classic signs of meningismus, such as the Kernig or Brudzinski signs, may be absent, even in
the presence of CNS infection. See Pediatric Bacterial Meningitis.

Prehospital Care
Prehospital care provided by emergency medical service (EMS) personnel may vary from region to region based on
regional differences in education, training, and transport times. Children with fever alone may require no specific
intervention in the EMS setting, except for those other conditions that exist in the presence of fever.
Assessment of and attention to airway, breathing, and circulation is recommended first for all ill children. Securing
intravenous (IV) access is part of the prehospital care, especially in toxic-appearing children. Children who have had
prolonged or very high fever may become dehydrated, and assessment of the hydration status is indicated. Some
children may be prone to febrile seizures. Seizure precautions should be followed in those with a history of febrile
seizures.

Emergency Department Care


Airway, breathing, circulation
Clinicians first need to address airway, breathing, and circulation if this has not already been done. Manage the
airway (supplemental oxygen or intubation as needed) and secure intravenous access if it was not established
during prehospital care. Monitor the patient's heart rate, blood pressure, and pulse oximetry readings. Administer
intravenous fluids, such as normal sodium chloride solution with boluses (weight based), as needed for hypotension.
Pressors should be given as needed for hypotension that does not respond to fluid.

Vital signs
Vital signs recorded in triage should routinely include a temperature in young children. This should be recorded for all
neonates and infants presenting with fever or other potentially infectious complaints (eg, not eating well, not
breathing well, color changes, behavior changes). A rectal temperature is the most accurate for infants.[93]
Nursing triage includes an accurate assessment of the patient's weight to ascertain the correct dose of an antipyretic
or other medications. An antipyretic should be given as early as possible during the ED visit.

Fever reduction
Reduction of fever is used to help comfort the child as well as provide for the optimal examination conditions and
should be addressed in triage protocols. Acetaminophen and ibuprofen have both been used for fever control.[22]
These drugs are sometimes alternated to achieve an overlapping period of fever control.[94, 95, 96] Some studies
suggest that acetaminophen may reduce fever more quickly, while ibuprofen may have a longer-lasting effect on
fever reduction.[21, 97]
In a study of children aged 6 months to 6 years whose fever could be managed at home (37.5-41C) Hay et al, found
that the use of acetaminophen and ibuprofen improved time without fever during the first 4 hours and was superior to
acetaminophen alone, but not ibuprofen alone.[95]
The combination also decreased fever 23 minutes faster than acetaminophen alone, but no faster than ibuprofen
alone. Time without fever during the first 24 hours was improved with the combination compared with either
acetaminophen or ibuprofen. Dosage was calculated as acetaminophen 15 mg/kg/dose and ibuprofen 10
mg/kg/dose.[95]
The ED staff should be educated that a positive response to antipyretics (evidenced by a drop in the measured
temperature) does not predict the absence of a potentially serious bacterial disease.[97]
Criteria for discharge from the ED do not necessarily include reduction of the child's fever to a certain level before
discharge. No evidence indicates that fever reduction is necessary for the child to be discharged from the ED.
The infant with only a history of subjectively estimated fever whose rectal temperature is normal on repeated
measurements and who has an entirely normal clinical evaluation may be assessed as not requiring laboratory
studies. All such infants discharged home still warrant close follow-up and continued short-term monitoring of rectal
temperature.[1]

Presumptive antibiotic treatment

7 dari 15

11/5/2014 12:40 AM

Emergent Management of Pediatric Patients with Fever

http://emedicine.medscape.com/article/801598-overview#sh...

Neonates with fever who undergo a routine workup to rule out sepsis should then receive 2 antibiotics as treatment
for their potential septicemia: an aminopenicillin (eg, ampicillin) and a cephalosporin (eg, cefotaxime).[98] Local
surveillance for ampicillin resistance is critical.[99, 100] Neonates may also receive antiviral treatment with acyclovir if
they are at risk for neonatal herpes infection.
Administer antibiotics as indicated:
Age 0-28 days: Presumptive therapy with ampicillin and either gentamicin or a third-generation cephalosporin
is indicated, while awaiting culture results
Age 29-56 days: Children ill enough to warrant hospitalization may be treated in the same way as younger
neonates; most who meet low-risk criteria and are well enough to be discharged home do not require
presumptive antibiotics; some clinicians may choose to administer ceftriaxone prior to ED discharge
Age 2-24 months: No presumptive antibiotic therapy is indicated for well-appearing children who do not have
a defined bacterial source and who will be managed as outpatients
Corticosteroid therapy is not routinely indicated in the treatment of young infants with bacterial meningitis.
Controversy continues over whether early bacterial meningitis or other severe systemic bacterial illness in these
patients may not be apparent. Therefore, all such patients discharged from the ED require meticulous examination
and thorough documentation.
Any discharge protocol in which patients may be observed on an outpatient basis should be developed
collaboratively by the department of emergency medicine and the department of pediatrics.

Decision to admit
The decision to admit older neonates and young infants for presumptive sepsis should be based on several factors,
including their ability to be reevaluated by a primary care provider the next day, toxic appearance, need for
monitoring, need for hydration or other supportive measures, or poor social situation.
Admission is warranted for febrile infants 28-56 days old; however, these patients may be discharged home if they
meet all of the following low-risk criteria[101, 102, 103, 104, 105, 106, 107] :
Well-appearing infant
No skeletal, soft tissue, skin, or ear infections
Full-term birth
No hyperbilirubinemia
No chronic or underlying illness
No previous hospitalizations
Not hospitalized longer than the mother after delivery
Did not receive antibiotics within the past 48 hours before presentation
No dehydration, lethargy, irritability, or wheezing
No focal source of infection on physical examination (except otitis media)
Cerebrospinal fluid (CSF) white blood cell (WBC) count < 8 per high-power field (hpf)
WBC 500-15,000/mm3 and band:poly ratio < 0.2
Urinalysis showing < 10 WBC/hpf
Chest radiograph without infiltrate (if obtained)
If diarrhea is present, fecal leukocytes < 5/hpf and urine WBCs < 10/hpf

Follow-up Care
Follow-up necessitates reliable parents with a telephone at home, with transportation readily available to them, and
with follow-up care arranged with the primary physician the next day. If next-day follow-up with the primary physician
cannot be arranged, the patient should return to the ED. Diagnosis-specific information sheets can enhance parental
understanding of ED discharge instructions.[108]
Older children with a low-grade fever, no risk factors, no localized signs of infection, a good appearance, and no
irritability may require only symptomatic treatment and close follow-up care. These patients do not routinely need
laboratory evaluation, radiography, or empiric antibiotics.
For patients discharged from the ED, close follow-up with the primary care physicians should be arranged, and an
ED protocol for notification of positive cultures is needed. Primary care physicians or ED physicians should notify
caretakers if an outpatient has a positive blood culture. Such children, if they remain febrile, may require collection of
CSF, a repeat blood culture, and hospitalization.
Primary care physicians or ED physicians should notify caretakers if a child has a positive urine culture. Older
children with pyelonephritis may continue outpatient treatment if they appear well and can tolerate oral antibiotics.
Clinicians should have a low threshold for hospitalizing those who are younger than 6 months with pyelonephritis.
The child should return either to the ED or to the primary care physician's office if his or her clinical presentation
worsens after discharge.

Inpatient Care
All febrile neonates aged 0-28 days old should be hospitalized for presumed sepsis and treated with antibiotics until
cultures of CSF, blood, and urine are all negative for growth after 48 hours.[109, 102, 110] Two parenteral antibiotics are
administered during these inpatient admissions: an aminopenicillin, such as ampicillin, and either a cephalosporin,
such as cefotaxime, or an aminoglycoside such as gentamicin.
If admitted, febrile patients outside of the neonatal period are prophylactically treated with an antibiotic (eg, a thirdgeneration cephalosporin, such as ceftriaxone), until cultures are shown to be negative.[111]
Iatrogenic risks are involved with routine hospitalizations of all febrile neonates and young infants.[101] Protocols

8 dari 15

11/5/2014 12:40 AM

Emergent Management of Pediatric Patients with Fever

http://emedicine.medscape.com/article/801598-overview#sh...

developed in advance, in cooperation with the ED staff as well as the pediatric staff, streamline the approach at each
institution.
If the initial facility is not designed for pediatric inpatient care, transfer to a pediatric facility as needed after his or her
condition is stabilized in the ED and after initial workup and treatments are completed.

Policy for Positive Culture Results


To ensure the quality of care, an ED policy should be established for positive culture results requiring a call back to
the care provider or to the patient.
For a positive cerebrospinal fluid culture, a patient who was sent home should return to the hospital for intravenous
antibiotics until identification of the organism is confirmed. Many EDs routinely admit all patients receiving lumbar
puncture in the ED.
For a positive blood culture, the patient should be reevaluated by a physician. An afebrile patient who is doing well
may be treated on an outpatient basis after infection with penicillinase-resistant Streptococcus pneumoniae is
considered. A repeat blood culture is indicated in most cases.
For a positive urine culture, the patient may be treated on an outpatient basis, with follow-up care and repeated
cultures to prove effective treatment.[112]

9 dari 15

Contributor Information and Disclosures


Author
John W Graneto, DO, FACOEP, FACEP Associate Professor of Emergency Medicine, Chicago College of
Osteopathic Medicine at Midwestern University; EM Residency Core Faculty, Department of Emergency
Medicine, Swedish Covenant Hospital
John W Graneto, DO, FACOEP, FACEP is a member of the following medical societies: American Academy of
Pediatrics, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians,
American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.
Chief Editor
Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center;
Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American

11/5/2014 12:40 AM

Emergent Management of Pediatric Patients with Fever

http://emedicine.medscape.com/article/801598-overview#sh...

Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases
Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric
Research, and Southern Medical Association
Disclosure: Nothing to disclose.
Additional Contributors
Kirsten A Bechtel, MD Associate Professor, Department of Pediatrics, Yale University School of Medicine;
Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital
Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.
Mary Beth Crawford, MD Clinical Assistant Professor, Departments of Surgery and Emergency Medicine,
Medical College of Ohio, St Vincent Mercy Medical Center
Mary Beth Crawford, MD is a member of the following medical societies: American Academy of Emergency
Medicine
Disclosure: Nothing to disclose.
Stuart A Friedman, DO Director of Emergency Medicine Residency, Associate Director, Department of
Emergency Medicine, Frankford Hospitals
Stuart A Friedman, DO is a member of the following medical societies: American Osteopathic Association
Disclosure: Nothing to disclose.
Michael H Goodyear, DO, FACEP Consulting Staff, Associate Program Director, Department of Emergency
Medicine, Frankford Hospital
Michael H Goodyear, DO, FACEP is a member of the following medical societies: American Academy of
Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency
Physicians, American Osteopathic Association, and Wilderness Medical Society
Disclosure: Nothing to disclose.
William G Gossman, MD Associate Clinical Professor of Emergency Medicine, Creighton University School of
Medicine; Consulting Staff, Department of Emergency Medicine, Creighton University Medical Center
William G Gossman, MD is a member of the following medical societies: American Academy of Emergency
Medicine
Disclosure: Nothing to disclose.
Fred Henretig, MD Director, Section of Clinical Toxicology, Professor, Medical Director, Delaware Valley Regional
Poison Control Center, Departments of Emergency Medicine and Pediatrics, University of Pennsylvania School of
Medicine, Children's Hospital
Disclosure: Nothing to disclose.
Richard J Scarfone, MD Associate Professor, Department of Pediatrics, University of Pennsylvania School of
Medicine; Attending Physician, Division of Emergency Medicine and Medical Director of Emergency
Preparedness, The Children's Hospital of Philadelphia
Richard J Scarfone, MD is a member of the following medical societies: Alpha Omega Alpha and American
Academy of Pediatrics
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of
Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Wayne Wolfram, MD, MPH Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical
Center
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency
Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Stella C Wong, DO Assistant Professor, Department of Emergency Medicine, Emory University School of
Medicine
Stella C Wong, DO is a member of the following medical societies: American Academy of Clinical Toxicology,
American Academy of Emergency Medicine, American College of Emergency Physicians, American College of
Medical Toxicology, American College of Osteopathic Emergency Physicians, American Osteopathic Association,
and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

References

10 dari 15

1. Alpern ER, Henretig FM. Fever. Fleisher GR, Ludwg S, Henretig FM, eds. Textbook of Pediatric Emergency
Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:295-306.

11/5/2014 12:40 AM

Emergent Management of Pediatric Patients with Fever

11 dari 15

http://emedicine.medscape.com/article/801598-overview#sh...

2. Selent MU, Molinari NM, Baxter A, Nguyen AV, Siegelson H, Brown CM, et al. Mass screening for fever in
children: a comparison of 3 infrared thermal detection systems. Pediatr Emerg Care. Mar
2013;29(3):305-13. [Medline].
3. Muth M, Statler J, Gentile DL, Hagle ME. Frequency of Fever in Pediatric Patients Presenting to the
Emergency Department with Non-illness-related Conditions. J Emerg Nurs. Feb 1 2013;[Medline].
4. Schweich PJ, Smith KM, Dowd MD, et al. Pediatric emergency medicine practice patterns: a comparison of
pediatric and general emergency physicians. Pediatr Emerg Care. Apr 1998;14(2):89-94. [Medline].
5. Seow VK, Lin AC, Lin IY, Chen CC, Chen KC, Wang TL, et al. Comparing different patterns for managing
febrile children in the ED between emergency and pediatric physicians: impact on patient outcome. Am J
Emerg Med. Nov 2007;25(9):1004-8. [Medline].
6. Goldman RD, Scolnik D, Chauvin-Kimoff L, Farion KJ, Ali S, Lynch T, et al. Practice variations in the
treatment of febrile infants among pediatric emergency physicians. Pediatrics. Aug 2009;124(2):439-45.
[Medline].
7. Walsh A, Edwards H. Management of childhood fever by parents: literature review. J Adv Nurs. Apr
2006;54(2):217-27. [Medline].
8. Rupe A, Ahlers-Schmidt CR, Wittler R. A comparison of perceptions of fever and fever phobia by ethnicity.
Clin Pediatr (Phila). Mar 2010;49(2):172-6. [Medline].
9. Poirier MP, Davis PH, Gonzalez-del Rey JA, Monroe KW. Pediatric emergency department nurses'
perspectives on fever in children. Pediatr Emerg Care. Feb 2000;16(1):9-12. [Medline].
10. Greensmith L. Nurses' knowledge of and attitudes towards fever and fever management in one Irish
children's hospital. J Child Health Care. Mar 1 2013;[Medline].
11. American Academy of Pediatrics. Recommended Immunization Schedule for Persons Age 0-6 Years--United States 2014. Available at http://aapredbook.aappublications.org/resources/IZSchedule0-6yrs.pdf.
Accessed January, 2014.
12. 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. Jul 2004;158(7):671-5. [Medline].
13. Graneto JW, Soglin DF. Maternal screening of childhood fever by palpation. Pediatr Emerg Care. Jun
1996;12(3):183-4. [Medline].
14. Bonadio WA, Hegenbarth M, Zachariason M. Correlating reported fever in young infants with subsequent
temperature patterns and rate of serious bacterial infections. Pediatr Infect Dis J. Mar 1990;9(3):158-60.
[Medline].
15. Hoffman RJ, Etwaru K, Dreisinger N, Khokhar A, Husk G. Comparison of temporal artery thermometry and
rectal thermometry in febrile pediatric emergency department patients. Pediatr Emerg Care. Mar
2013;29(3):301-4. [Medline].
16. Crocetti M, Moghbeli N, Serwint J. Fever phobia revisited: have parental misconceptions about fever
changed in 20 years?. Pediatrics. Jun 2001;107(6):1241-6. [Medline].
17. Purssell E. Parental fever phobia and its evolutionary correlates. J Clin Nurs. Jan 2009;18(2):210-8.
[Medline].
18. Crocetti M, Sabath B, Cranmer L, Gubser S, Dooley D. Knowledge and management of fever among Latino
parents. Clin Pediatr (Phila). Mar 2009;48(2):183-9. [Medline].
19. Tessler H, Gorodischer R, Press J, Bilenko N. Unrealistic concerns about fever in children: the influence of
cultural-ethnic and sociodemographic factors. Isr Med Assoc J. May 2008;10(5):346-9. [Medline].
20. Colletti JE, Homme JL, Woodridge DP. Unsuspected neonatal killers in emergency medicine. Emerg Med
Clin North Am. Nov 2004;22(4):929-60. [Medline].
21. Noyola DE, Fernandez M, Kaplan SL. Reevaluation of antipyretics in children with enteric fever. Pediatr
Infect Dis J. Aug 1998;17(8):691-5. [Medline].
22. Carson SM. Alternating acetaminophen and ibuprofen in the febrile child: examination of the evidence
regarding efficacy and safety. Pediatr Nurs. Sep-Oct 2003;29(5):379-82. [Medline].
23. Clinical policy for children younger than three years presenting to the emergency department with fever.
Ann Emerg Med. Oct 2003;42(4):530-45. [Medline].
24. Hissink Muller PC, van Berkel LH, de Beaufort AJ. Axillary and rectal temperature measurements poorly
agree in newborn infants. Neonatology. 2008;94(1):31-4. [Medline].
25. Rhoads FA, Grandner J. Assessment of an aural infrared sensor for body temperature measurement in
children. Clin Pediatr (Phila). Feb 1990;29(2):112-5. [Medline].
26. Fortuna EL, Carney MM, Macy M, Stanley RM, Younger JG, Bradin SA. Accuracy of non-contact infrared
thermometry versus rectal thermometry in young children evaluated in the Emergency Department for
Fever. J Emerg Nurs. Mar 2010;36(2):101-4. [Medline].
27. Jean-Mary MB, Dicanzio J, Shaw J, Bernstein HH. Limited accuracy and reliability of infrared axillary and
aural thermometers in a pediatric outpatient population. J Pediatr. Nov 2002;141(5):671-6. [Medline].
28. McCarthy PL, Lembo RM, Fink HD, et al. Observation, history, and physical examination in diagnosis of
serious illnesses in febrile children less than or equal to 24 months. J Pediatr. Jan 1987;110(1):26-30.

11/5/2014 12:40 AM

Emergent Management of Pediatric Patients with Fever

12 dari 15

http://emedicine.medscape.com/article/801598-overview#sh...

[Medline].
29. Richardson M, Lakhanpaul M. Assessment and initial management of feverish illness in children younger
than 5 years: summary of NICE guidance. BMJ. Jun 2 2007;334(7604):1163-4. [Medline]. [Full Text].
30. Knight C, Glennie L. Early recognition of meningitis and septicaemia. J Fam Health Care. 2010;20(1):6-8.
[Medline].
31. Baker MD, Avner JR, Bell LM. Failure of infant observation scales in detecting serious illness in febrile, 4- to
8-week-old infants. Pediatrics. Jun 1990;85(6):1040-3. [Medline].
32. Nijman RG, Vergouwe Y, Thompson M, van Veen M, van Meurs AH, van der Lei J, et al. Clinical prediction
model to aid emergency doctors managing febrile children at risk of serious bacterial infections: diagnostic
study. BMJ. Apr 2 2013;346:f1706. [Medline]. [Full Text].
33. Perry AM, Caviness AC, Allen JY. Characteristics and diagnoses of neonates who revisit a pediatric
emergency center. Pediatr Emerg Care. Jan 2013;29(1):58-62. [Medline].
34. Ammann RA, Hirt A, Lthy AR, Aebi C. Predicting bacteremia in children with fever and chemotherapyinduced neutropenia. Pediatr Infect Dis J. Jan 2004;23(1):61-7. [Medline].
35. Shah SS, Alpern ER, Zwerling L, Reid JR, McGowan KL, Bell LM. Low risk of bacteremia in children with
febrile seizures. Arch Pediatr Adolesc Med. May 2002;156(5):469-72. [Medline].
36. Boyle DA, Sturm JJ. Clinical factors associated with invasive testing and imaging in patients with complex
febrile seizures. Pediatr Emerg Care. Apr 2013;29(4):430-4. [Medline].
37. Levine DA, Platt SL, Dayan PS, et al. Risk of serious bacterial infection in young febrile infants with
respiratory syncytial virus infections. Pediatrics. Jun 2004;113(6):1728-34. [Medline].
38. King RL, Lorch SA, Cohen DM, Hodinka RL, Cohn KA, Shah SS. Routine cerebrospinal fluid enterovirus
polymerase chain reaction testing reduces hospitalization and antibiotic use for infants 90 days of age or
younger. Pediatrics. Sep 2007;120(3):489-96. [Medline].
39. Byington CL, Kendrick J, Sheng X. Normative cerebrospinal fluid profiles in febrile infants. J Pediatr. Jan
2011;158(1):130-4. [Medline]. [Full Text].
40. Garra G, Cunningham SJ, Crain EF. Reappraisal of criteria used to predict serious bacterial illness in febrile
infants less than 8 weeks of age. Acad Emerg Med. Oct 2005;12(10):921-5. [Medline].
41. Newman TB, Bernzweig JA, Takayama JI, Finch SA, Wasserman RC, Pantell RH. Urine testing and urinary
tract infections in febrile infants seen in office settings: the Pediatric Research in Office Settings' Febrile
Infant Study. Arch Pediatr Adolesc Med. Jan 2002;156(1):44-54. [Medline].
42. Pantell RH, Newman TB, Bernzweig J, Bergman DA, Takayama JI, Segal M, et al. Management and
outcomes of care of fever in early infancy. JAMA. Mar 10 2004;291(10):1203-12. [Medline].
43. Zorc JJ, Levine DA, Platt SL, Dayan PS, Macias CG, Krief W, et al. Clinical and demographic factors
associated with urinary tract infection in young febrile infants. Pediatrics. Sep 2005;116(3):644-8. [Medline].
44. Crain EF, Bulas D, Bijur PE, Goldman HS. Is a chest radiograph necessary in the evaluation of every febrile
infant less than 8 weeks of age?. Pediatrics. Oct 1991;88(4):821-4. [Medline].
45. Bramson RT, Meyer TL, Silbiger ML, Blickman JG, Halpern E. The futility of the chest radiograph in the
febrile infant without respiratory symptoms. Pediatrics. Oct 1993;92(4):524-6. [Medline].
46. Rudinsky SL, Carstairs KL, Reardon JM, Simon LV, Riffenburgh RH, Tanen DA. Serious bacterial infections
in febrile infants in the post-pneumococcal conjugate vaccine era. Acad Emerg Med. Jul 2009;16(7):585-90.
[Medline].
47. Mintegi S, Benito J, Sanchez J, Azkunaga B, Iturralde I, Garcia S. Predictors of occult bacteremia in young
febrile children in the era of heptavalent pneumococcal conjugated vaccine. Eur J Emerg Med. Aug
2009;16(4):199-205. [Medline].
48. Wilkinson M, Bulloch B, Smith M. Prevalence of occult bacteremia in children aged 3 to 36 months
presenting to the emergency department with fever in the postpneumococcal conjugate vaccine era. Acad
Emerg Med. Mar 2009;16(3):220-5. [Medline].
49. Brauner M, Goldman M, Kozer E. Extreme leucocytosis and the risk of serious bacterial infections in febrile
children. Arch Dis Child. Mar 2010;95(3):209-12. [Medline].
50. Huppler AR, Eickhoff JC, Wald ER. Performance of low-risk criteria in the evaluation of young infants with
fever: review of the literature. Pediatrics. Feb 2010;125(2):228-33. [Medline].
51. Herz AM, Greenhow TL, Alcantara J, Hansen J, Baxter RP, Black SB, et al. Changing epidemiology of
outpatient bacteremia in 3- to 36-month-old children after the introduction of the heptavalent-conjugated
pneumococcal vaccine. Pediatr Infect Dis J. Apr 2006;25(4):293-300. [Medline].
52. Whitney CG, Farley MM, Hadler J, Harrison LH, Bennett NM, Lynfield R, et al. Decline in invasive
pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine. N Engl J Med.
May 1 2003;348(18):1737-46. [Medline].
53. Kaplan SL, Mason EO Jr, Wald ER, Schutze GE, Bradley JS, Tan TQ, et al. Decrease of invasive
pneumococcal infections in children among 8 children's hospitals in the United States after the introduction
of the 7-valent pneumococcal conjugate vaccine. Pediatrics. Mar 2004;113(3 Pt 1):443-9. [Medline].
54. Hsu K, Pelton S, Karumuri S, Heisey-Grove D, Klein J. Population-based surveillance for childhood invasive
pneumococcal disease in the era of conjugate vaccine. Pediatr Infect Dis J. Jan 2005;24(1):17-23.

11/5/2014 12:40 AM

Emergent Management of Pediatric Patients with Fever

13 dari 15

http://emedicine.medscape.com/article/801598-overview#sh...

[Medline].
55. Black SB, Shinefield HR, Hansen J, Elvin L, Laufer D, Malinoski F. Postlicensure evaluation of the
effectiveness of seven valent pneumococcal conjugate vaccine. Pediatr Infect Dis J. Dec
2001;20(12):1105-7. [Medline].
56. Carstairs KL, Tanen DA, Johnson AS, Kailes SB, Riffenburgh RH. Pneumococcal bacteremia in febrile
infants presenting to the emergency department before and after the introduction of the heptavalent
pneumococcal vaccine. Ann Emerg Med. Jun 2007;49(6):772-7. [Medline].
57. Black S, France EK, Isaacman D, Bracken L, Lewis E, Hansen J, et al. Surveillance for invasive
pneumococcal disease during 2000-2005 in a population of children who received 7-valent pneumococcal
conjugate vaccine. Pediatr Infect Dis J. Sep 2007;26(9):771-7. [Medline].
58. Teele DW, Pelton SI, Grant MJ, et al. Bacteremia in febrile children under 2 years of age: results of cultures
of blood of 600 consecutive febrile children seen in a "walk- in" clinic. J Pediatr. Aug 1975;87(2):227-30.
[Medline].
59. Hsu KK, Shea KM, Stevenson AE, Pelton SI. Changing serotypes causing childhood invasive
pneumococcal disease: Massachusetts, 2001-2007. Pediatr Infect Dis J. Apr 2010;29(4):289-93. [Medline].
60. Singleton RJ, Hennessy TW, Bulkow LR, Hammitt LL, Zulz T, Hurlburt DA, et al. Invasive pneumococcal
disease caused by nonvaccine serotypes among alaska native children with high levels of 7-valent
pneumococcal conjugate vaccine coverage. JAMA. Apr 25 2007;297(16):1784-92. [Medline].
61. World Health Organization. Haemophilus influenzae type B (HiB). Available at http://www.who.int
/mediacentre/factsheets/fs294/en/index.html. Accessed May 14, 2008.
62. Center for Disease Control and Prevention (CDC). Decline in Haemophilus influenzae Type b meningitis-Seattle-King County, Washington, 1984-1989. MMWR Weekly. Available at http://www.cdc.gov
/mmwr/preview/mmwrhtml/00001865.htm. Accessed May 14, 2008.
63. Bonsu BK, Chb M, Harper MB. Identifying febrile young infants with bacteremia: is the peripheral white
blood cell count an accurate screen?. Ann Emerg Med. Aug 2003;42(2):216-25. [Medline].
64. Brown ZA, Wald A, Morrow RA, Selke S, Zeh J, Corey L. Effect of serologic status and cesarean delivery on
transmission rates of herpes simplex virus from mother to infant. JAMA. Jan 8 2003;289(2):203-9. [Medline].
65. Yee-Guardino S, Kumar D, Abughali N, Tuohy M, Hall GS, Kumar ML. Recognition and treatment of
neonatal community-associated MRSA pneumonia and bacteremia. Pediatr Pulmonol. Feb
2008;43(2):203-5. [Medline].
66. Hakim H, Mylotte JM, Faden H. Morbidity and mortality of Staphylococcal bacteremia in children. Am J
Infect Control. Mar 2007;35(2):102-5. [Medline].
67. Chuang YY, Huang YC, Lee CY, Lin TY, Lien R, Chou YH. Methicillin-resistant Staphylococcus aureus
bacteraemia in neonatal intensive care units: an analysis of 90 episodes. Acta Paediatr. Jun
2004;93(6):786-90. [Medline].
68. Khairulddin N, Bishop L, Lamagni TL, Sharland M, Duckworth G. Emergence of methicillin resistant
Staphylococcus aureus (MRSA) bacteraemia among children in England and Wales, 1990-2001. Arch Dis
Child. Apr 2004;89(4):378-9. [Medline]. [Full Text].
69. Healy CM, Hulten KG, Palazzi DL, Campbell JR, Baker CJ. Emergence of new strains of methicillinresistant Staphylococcus aureus in a neonatal intensive care unit. Clin Infect Dis. Nov 15
2004;39(10):1460-6. [Medline].
70. Isaacs D, Fraser S, Hogg G, Li HY. Staphylococus aureus infections in Australasian neonatal nurseries.
Arch Dis Child Fetal Neonatal Ed. 2004;89:F331-5.
71. Healy CM, Palazzi DL, Edwards MS, Campbell JR, Baker CJ. Features of invasive staphylococcal disease
in neonates. Pediatrics. Oct 2004;114(4):953-61. [Medline].
72. Krief WI, Levine DA, Platt SL, Macias CG, Dayan PS, Zorc JJ, et al. Influenza virus infection and the risk of
serious bacterial infections in young febrile infants. Pediatrics. Jul 2009;124(1):30-9. [Medline].
73. Kuppermann N, Bank DE, Walton EA, Senac MO Jr, McCaslin I. Risks for bacteremia and urinary tract
infections in young febrile children with bronchiolitis. Arch Pediatr Adolesc Med. Dec 1997;151(12):1207-14.
[Medline].
74. Alpern ER, Alessandrini EA, Bell LM, Shaw KN, McGowan KL. Occult bacteremia from a pediatric
emergency department: current prevalence, time to detection, and outcome. Pediatrics. Sep
2000;106(3):505-11. [Medline].
75. Bandyopadhyay S, et al. Risk of serious bacterial infection in children with fever without a source in the
post-Haemophilus influenza era when antibiotics are reserved for culture-proven bacteremia. Arch Pediatr
Adolesc Med. 2002;156:512-519.
76. Gomez B, Bressan S, Mintegi S, Da Dalt L, Blazquez D, Olaciregui I, et al. Diagnostic value of procalcitonin
in well-appearing young febrile infants. Pediatrics. Nov 2012;130(5):815-22. [Medline].
77. Kasem AJ, Bulloch B, Henry M, Shah K, Dalton H. Procalcitonin as a marker of bacteremia in children with
fever and a central venous catheter presenting to the emergency department. Pediatr Emerg Care. Oct
2012;28(10):1017-21. [Medline].
78. Scott HF, Donoghue AJ, Gaieski DF, Marchese RF, Mistry RD. The utility of early lactate testing in
undifferentiated pediatric systemic inflammatory response syndrome. Acad Emerg Med. Nov
2012;19(11):1276-80. [Medline].

11/5/2014 12:40 AM

Emergent Management of Pediatric Patients with Fever

14 dari 15

http://emedicine.medscape.com/article/801598-overview#sh...

79. Myers AL, Hall M, Williams DJ, Auger K, Tieder JS, Statile A, et al. Prevalence of Bacteremia in
Hospitalized Pediatric Patients with Community-Acquired Pneumonia. Pediatr Infect Dis J. Mar 20
2013;[Medline].
80. Baraff LJ, Bass JW, Fleisher GR, Klein JO, McCracken GH Jr, Powell KR, et al. Practice guideline for the
management of infants and children 0 to 36 months of age with fever without source. Agency for Health
Care Policy and Research. Ann Emerg Med. Jul 1993;22(7):1198-210. [Medline].
81. Downs SM, McNutt RA, Margolis PA. Management of infants at risk for occult bacteremia: a decision
analysis. J Pediatr. Jan 1991;118(1):11-20. [Medline].
82. [Best Evidence] Trautner BW, Caviness AC, Gerlacher GR, Demmler G, Macias CG. Prospective evaluation
of the risk of serious bacterial infection in children who present to the emergency department with
hyperpyrexia (temperature of 106 degrees F or higher). Pediatrics. Jul 2006;118(1):34-40. [Medline]. [Full
Text].
83. Waddle E, Jhaveri R. Outcomes of febrile children without localising signs after pneumococcal conjugate
vaccine. Arch Dis Child. Feb 2009;94(2):144-7. [Medline].
84. Shaw KN, Gorelick M, McGowan KL, Yakscoe NM, Schwartz JS. Prevalence of urinary tract infection in
febrile young children in the emergency department. Pediatrics. Aug 1998;102(2):e16. [Medline].
85. Hoberman A, Chao HP, Keller DM, Hickey R, Davis HW, Ellis D. Prevalence of urinary tract infection in
febrile infants. J Pediatr. Jul 1993;123(1):17-23. [Medline].
86. Downs SM. Technical report: urinary tract infections in febrile infants and young children. The Urinary Tract
Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement. Pediatrics. Apr
1999;103(4):e54. [Medline].
87. Gorelick MH, Hoberman A, Kearney D, Wald E, Shaw KN. Validation of a decision rule identifying febrile
young girls at high risk for urinary tract infection. Pediatr Emerg Care. Jun 2003;19(3):162-4. [Medline].
88. Herr SM, Wald ER, Pitetti RD, Choi SS. Enhanced urinalysis improves identification of febrile infants ages
60 days and younger at low risk for serious bacterial illness. Pediatrics. Oct 2001;108(4):866-71. [Medline].
89. Pitetti RD, Choi S. Utility of blood cultures in febrile children with UTI. Am J Emerg Med. Jul
2002;20(4):271-4. [Medline].
90. Mintegi S, Benito J, Pijoan JI, Maraon R, Pealba A, Gonzalez A, et al. Occult pneumonia in infants with
high fever without source: a prospective multicenter study. Pediatr Emerg Care. Jul 2010;26(7):470-4.
[Medline].
91. Murphy CG, van de Pol AC, Harper MB, Bachur RG. Clinical predictors of occult pneumonia in the febrile
child. Acad Emerg Med. Mar 2007;14(3):243-9. [Medline].
92. Rutman MS, Bachur R, Harper MB. Radiographic pneumonia in young, highly febrile children with
leukocytosis before and after universal conjugate pneumococcal vaccination. Pediatr Emerg Care. Jan
2009;25(1):1-7. [Medline].
93. Spruijt B, Vergouwe Y, Nijman RG, Thompson M, Oostenbrink R. Vital signs should be maintained as
continuous variables when predicting bacterial infections in febrile children. J Clin Epidemiol. Apr
2013;66(4):453-7. [Medline].
94. Sarrell EM, Wielunsky E, Cohen HA. Antipyretic treatment in young children with fever: acetaminophen,
ibuprofen, or both alternating in a randomized, double-blind study. Arch Pediatr Adolesc Med. Feb
2006;160(2):197-202. [Medline].
95. Hay AD, Redmond NM, Costelloe C, Montgomery AA, Fletcher M, Hollinghurst S, et al. Paracetamol and
ibuprofen for the treatment of fever in children: the PITCH randomised controlled trial. Health Technol
Assess. May 2009;13(27):iii-iv, ix-x, 1-163. [Medline].
96. Kramer LC, Richards PA, Thompson AM, Harper DP, Fairchok MP. Alternating antipyretics: antipyretic
efficacy of acetaminophen versus acetaminophen alternated with ibuprofen in children. Clin Pediatr (Phila).
Nov 2008;47(9):907-11. [Medline].
97. Torrey SB, Henretig F, Fleisher G, Goldstein RM, Ardire A, Ludwig S, et al. Temperature response to
antipyretic therapy in children: relationship to occult bacteremia. Am J Emerg Med. May 1985;3(3):190-2.
[Medline].
98. Brown JC, Burns JL, Cummings P. Ampicillin use in infant fever: a systematic review. Arch Pediatr Adolesc
Med. Jan 2002;156(1):27-32. [Medline].
99. Byington CL, Rittichier KK, Bassett KE, Castillo H, Glasgow TS, Daly J, et al. Serious bacterial infections in
febrile infants younger than 90 days of age: the importance of ampicillin-resistant pathogens. Pediatrics.
May 2003;111(5 Pt 1):964-8. [Medline].
100. Sadow KB, Derr R, Teach SJ. Bacterial infections in infants 60 days and younger: epidemiology, resistance,
and implications for treatment. Arch Pediatr Adolesc Med. Jun 1999;153(6):611-4. [Medline].
101. Baker MD, Bell LM, Avner JR. The efficacy of noninvasive in hospital and outpatient management of febrile
infants: a four year experience. Ann Emerg Med. 1991;20:445.
102. Ishimine P. Fever without source in children 0 to 36 months of age. Pediatr Clin North Am. Apr
2006;53(2):167-94. [Medline].
103. Dagan R, Sofer S, Phillip M, Shachak E. Ambulatory care of febrile infants younger than 2 months of age
classified as being at low risk for having serious bacterial infections. J Pediatr. Mar 1988;112(3):355-60.
[Medline].

11/5/2014 12:40 AM

Emergent Management of Pediatric Patients with Fever

http://emedicine.medscape.com/article/801598-overview#sh...

104. Baskin MN, O'Rourke EJ, Fleisher GR. Outpatient treatment of febrile infants 28 to 89 days of age with
intramuscular administration of ceftriaxone. J Pediatr. Jan 1992;120(1):22-7. [Medline].
105. Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics of fever in selected infants. N
Engl J Med. Nov 11 1993;329(20):1437-41. [Medline].
106. Wasserman GM, White CB. Evaluation of the necessity for hospitalization of the febrile infant less than
three months of age. Pediatr Infect Dis J. Mar 1990;9(3):163-9. [Medline].
107. Barkin RM, Zukin DD. Marx JA, Hockberger RS, Wall RM. Rosen's Emergency Medicine: Concepts and
Clinical Practice. 5th ed. 2002:2233-45.
108. Waisman Y, Siegal N, Siegal G, Amir L, Cohen H, Mimouni M. Role of diagnosis-specific information sheets
in parents' understanding of emergency department discharge instructions. Eur J Emerg Med. Aug
2005;12(4):159-62. [Medline].
109. Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for fever of
uncertain source in children 2 to 36 months of age [National Guideline Clearinghouse Web site]. Cincinnati,
OH: Cincinnati Children's Hospital Medical Center.
110. Kadish HA, Loveridge B, Tobey J, Bolte RG, Corneli HM. Applying outpatient protocols in febrile infants 1-28
days of age: can the threshold be lowered?. Clin Pediatr (Phila). Feb 2000;39(2):81-8. [Medline].
111. Yamamoto LG, Worthley RG, Melish ME, Seto DS. A revised decision analysis of strategies in the
management of febrile children at risk for occult bacteremia. Am J Emerg Med. Mar 1998;16(2):193-207.
[Medline].
112. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile
infants and young children. American Academy of Pediatrics. Committee on Quality Improvement.
Subcommittee on Urinary Tract Infection. Pediatrics. Apr 1999;103(4 Pt 1):843-52. [Medline].
113. Banks T, Paul SP, Wall M. Managing fever in children with a single antipyretic. Nurs Times. Feb 19-25
2013;109(7):24-5. [Medline].
114. Pereira GL, Tavares NU, Mengue SS, Pizzol Tda S. Therapeutic procedures and use of alternating
antipyretic drugs for Fever management in children. J Pediatr (Rio J). Jan-Feb 2013;89(1):25-32. [Medline].
115. 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. Sep 2011;128(3):595-610. [Medline].
116. Schneider C, Blumberg S, Crain EF. A survey of the management of febrile infants in pediatric emergency
departments. Pediatr Emerg Care. Oct 2012;28(10):1022-6. [Medline].
Medscape Reference 2011 WebMD, LLC

15 dari 15

11/5/2014 12:40 AM

Anda mungkin juga menyukai