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Fever Without Source in Infants and Young Children

Two-thirds of children visit their physician with an acute febrile illness before the age of three. The most common causes of fever in children are respiratory, urinary tract, gastrointestinal, and central nervous system infections. Bacteremia may occur with any of these infections. Fever without a source that is related to a viral illness is often difficult to differentiate.

Clinical Evaluation of the Febrile Child

The child's health status, course of the current illness, birth and past medical history, and immunization status.

Infants can be considered at low risk for serious bacterial infection if they had been healthy with no previous hospitalizations, were delivered at term and discharged home with their mother without complications.

Physical Examination

Assessment of cardiopulmonary status includes a determination of vital signs. Children who are toxic require immediate cardiovascular stabilization and a complete sepsis evaluation.

Fever is usually defined as a rectal temperature of at least 38.0EC (100.4EF). Axillary and tympanic measurements are unreliable. Serious infections can also occur in afebrile or hypothermic infants. Fever may also be related to vaccine reactions.

Over bundling of small infants can cause temperature elevations. When this is suspected, the temperature should be rechecked with the child unbundled.

If no focal bacterial infection (eg, skin, soft tissue infection, otitis media) is apparent, the child is at low risk.

Children with clinical signs of a serious illness or sepsis (lethargy, signs of poor perfusion, marked hypoventilation or hyperventilation, or cyanosis) are considered to be toxic.

The quality of cry, reaction to parents, color, state of hydration, response to social overtures, affect, respiratory status and effort, and peripheral perfusion.

Treatment

Toxic-appearing Infants and Children

All toxic-appearing febrile infants and children less than 36 months of age should be hospitalized for evaluation and treatment of meningitis.

Occult bacteremia can lead to osteomyelitis, septic arthritis, meningitis, urinary tract infections, pneumonia, enteritis, and meningitis.

Febrile Infants Less than 28 Days of Age

Fever in infants less than 28 days of age always mandates a sepsis evaluation and hospitalization for parenteral antibiotic therapy until culture results.

Febrile Infants 28 to 90 Days of Age

Infants who do not meet low-risk criteria should be hospitalized for a sepsis evaluation and empiric antimicrobial therapy, until culture results.

Febrile infants less than three months of age who meet low-risk criteria, can be observed after a urine culture.

Empiric parenteral antimicrobial therapy may be used in the outpatient management of low-risk infants. Ceftriaxone ( Rocephin), a third-generation parenteral cephalosporin with a half-life of 5-6 hours, is often used; 50 mg/kg once daily. Empiric antimicrobial therapy is initiated after blood and urine cultures and a lumbar puncture.

Children who have met low-risk criteria with reliable parents can be treated as outpatients if close follow-up within 18-24 hours can be ensured. Caregivers are instructed to check the child every 4 hours for activity, rectal temperature.

If the clinical condition worsens, the child is admitted for parenteral antimicrobial therapy and a sepsis evaluation.

Febrile Children 3 Months to 36 Months of Age

Occult bacteremia in febrile children 3 to 36 months of age without a source of infection has an incidence of 3-11%, with a mean probability of 4.3%.

Febrile children who are managed as outpatients should be assessed every four hours and the physician should be informed of any changes, including skin rash, mottling or cyanosis, poor feeding or vomiting, inconsolability.