Regardless of age, all toxic-appearing infants and children with fever require a full septic work-up, urgent treatment with broad-spectrum antibiotics, and admission.
Initial management of fever in infants less than 30 days old includes a complete examination of cerebrospinal fluid, blood, and urine for a serious bacterial infection, prompt empiric antibiotic administration, and hospitalization.
Management of well-appearing febrile infants aged 1–3 months is determined by analyzing risk factors for serious bacterial infection.
Well-appearing, low-risk, febrile infants and children who do not have a source of infection must have reliable follow-up when discharged from the emergency department.
Fever in children is defined as a rectal temperature ≥38.0°C (100.4°F) and accounts for approximately 20% of all pediatric visits to the emergency department (ED). Fever is part of a larger, comprehensive host response to infection. Leukocytes and other phagocytic cells release pyrogens, which trigger an increase in prostaglandin synthesis, resulting in an elevation of the thermoregulatory set point. Fever occurs when the hypothalamus responds to this new set point by initiating physiologic changes involving endocrine, metabolic, autonomic, and behavioral processes. Specific physiologic changes associated with fever such as increased oxygen consumption, protein breakdown, and gluconeogenesis can quickly deplete the already limited reserves of infants and children.
Fever can be the first and only physiologic sign of illness. It can herald a serious bacterial infection (SBI) such as meningitis, bacteremia, osteomyelitis, septic arthritis, urinary tract infection (UTI), or pneumonia. These and other SBIs can rapidly lead to sepsis, an overwhelming and devastating systemic syndrome caused by infection. A child or infant with a SBI may appear “toxic” (very ill-appearing with unstable vital signs). Alternatively, well-appearing febrile children can also have an SBI such as occult bacteremia. Occult bacteremia is the presence of pathogenic bacteria in the blood of well-appearing, febrile children without any identifiable focus of infection, also described as “fever without a source.” Approximately 20% of all children presenting with fever will have no identifiable cause. Neonates (<30 days old) have immature immune systems that place them at high risk for SBI with fever.
Elicit the duration, pattern, and maximum recorded temperature from caregivers. Young infants do not usually have localizing symptoms and often present with nonspecific complaints such as excessive crying, poor feeding, irritability, or lethargy. Parents of older children may report more specific complaints such as cough, rhinorrhea, sore throat, vomiting, diarrhea, dysuria, joint pain, body aches, or headache. Questions regarding oral intake and urine output will help the clinician assess the degree of associated dehydration, if present.
The presence of a seizure in a febrile infant may suggest a benign simple febrile seizure or could be an indicator of meningitis. A simple febrile seizure is defined as a single generalized tonic-clonic seizure that lasts <15 minutes in children aged 6 months to 6 years with no resulting focal neurologic deficits. These seizures occur in the setting of fever in previously healthy children with no history of epilepsy or signs of central nervous system (CNS) infection. Three percent to 5% of all children will have a simple febrile seizure. A source should be investigated for a patient presenting with a simple febrile seizure, but an extensive work-up is usually not indicated. A febrile seizure is considered complex if it has focal features, lasts longer than 15 minutes, or occurs more than once in 24 hours. A more extensive work-up including laboratory studies, imaging, and lumbar puncture should be strongly considered in those presenting with complex febrile seizures.
Vital signs and general appearance should always be evaluated before proceeding with the remainder of the physical exam. Heart rate can be elevated approximately 10 bpm for every 1°C of elevation in temperature. However, tachycardia out of proportion to fever can indicate sepsis. Children and infants with sepsis differ from adults as they often do not demonstrate hypotension until very late in the course due to a compensatory increase in cardiac output. Thus a normal blood pressure is not necessarily reassuring. Tachycardia and poor peripheral perfusion occur before hypotension and can be early signs of impending circulatory collapse.
Evaluating the general appearance of an infant or child with fever is also crucial. Infants or children who are lethargic or demonstrate paradoxical irritability (eg, inconsolable when held by parents) may have a CNS infection. A head-to-toe physical exam should be performed. Special attention should be paid to the anterior fontanelle in infants; a bulging tense fontanelle may indicate meningitis, whereas a sunken fontanelle may indicate severe dehydration. In older children, assessment of neck pain, stiffness, and range of motion may also be useful in helping establish a diagnosis of CNS infection. Evaluate the lung fields for crackles, asymmetry, and work of breathing. Forced expiration and percussion may assist in the detection of areas of consolidation. Carefully examine the skin to identify any rashes, petechiae, or purpura. Meningococcemia should be assumed in a febrile, ill-appearing child with a petechial or purpuric rash until proven otherwise. Additionally, jaundice in a neonate may indicate the presence of sepsis but is not a specific finding. The extremities should be examined closely for erythema, swelling, warmth, focal tenderness, and decreased range of motion, as this may indicate osteomyelitis, pyomyositis, or septic arthritis. These infections are more common in children than in adults. A reassuring clinical examination in infants <3 months does not necessarily rule out an SBI and should not be used in isolation to guide management in this age group.
Laboratory tests to consider include a complete blood count, urinalysis, urine culture, blood culture, and cerebrospinal fluid (CSF) studies. The appropriate tests to order, if any, depend on the history and physical examination, clinical appearance, age, and risk factors for SBI.
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