by Jabeen Fayyaz
A 2-month-old female child was brought in with a history of cough and fever for 2 days. As per mother, the fever was high grade, documented as 38.5ºC with an inability to drink for the last 4 hours. There was history of an episode of cyanosis at home with coughing an hour ago. On examination, the child was looking dull and lethargic. Her vital signs were: Temp 39ºC, HR 170/ min, RR 65/ min, SPO2 89% in room air, BP 75/50mm of Hg, and Capillary refill time 4 sec. Chest on auscultation has bilateral crepitation. The child was taken immediately in the resuscitation area and was put on high flow oxygen. Reflo was 4.5 mmol/ L. The blood work up and CX-ray ordered showed right middle zone consolidation. IV antibiotic, Cefotaxime was administered. The child was kept on IV fluids and cardiac monitoring. The child was admitted to the high dependency unit.
Fever is one of the most common reasons for the Pediatric Emergency Department (PED) visits. It accounts for almost 10% to 25% of PED visits annually. Febrile illness in children is caused mostly by viral infections, but a significant proportion, especially in children who are less than 3 months old, are caused by serious bacterial infection (SBI). As an ED physician, the goal is to identify this population at risk and to promptly manage them.
SBI has been reported to affect 6-10 % of infants who are younger than 3 months and 5-7% of children who are between 3-36 months of age. Therefore, you should always be very careful when evaluating a child with fever under 3 years old. The infant’s immune system is relatively immature during the first 2 to 3 months of life. This puts them in a very high risk group.
SBI can even be found in the presence of viral infection concomitantly, 5% of patients with confirmed viral sources having urinary tract infections or other SBIs. Infants and children presenting with a fever and signs of a viral illness should have investigations to confirm the viral etiology, but should also be assessed for other sources of bacterial infections. Details of this approach can be found in Policy Clinical Guideline.Children with an apparent focus or are sick looking are easy to manage. However, it is very challenging and many gray zones in managing the well-appearing infants and children with febrile illness without any source in the chaotic ED environment. Febrile illness in children results in significant parental anxiety. Management decisions about febrile children are further complicated by the fact that parents and physicians weigh the risks and costs differently.
In a study (Byington 2004), common sources of bacterial infection in children less than 90 days were found UTI, bacteremia, soft tissue infection, meningitis, and pneumonia.
Fever is defined as temperature ≥38°C measured rectally or tympanic/axillary temperature of approximately 37.5°C. If parents state that fever is documented at home by a thermometer, it should be considered as fever recorded in the ED and should be evaluated in the same manner. Another important consideration mainly in neonates is hypothermia. Neonates may respond to SBI with hypothermia rather than hyperthermia, so they need to be evaluated carefully for any other sign of toxicity.
Normal temperature ranges in children measured by different method
|Measurement method||Normal temperature range|
|Rectal||36.6°C to 38°C (97.9°F to 100.4°F)|
|Ear||35.8°C to 38°C (96.4°F to 100.4°F)|
|Oral||35.5°C to 37.5°C (95.9°F to 99.5°F)|
|Axillary||34.7°C to 37.3°C (94.5°F to 99.1°F)|
Temperature in children can be measured at the axilla, rectally, orally or via the ear (tympanic). Younger children (<5 years old) cannot manage the glass thermometers because it can break easily. Therefore, this method is not recommended for this age group. To check the temperature in newborns and young children, axillary measurement is an acceptable method. However, children under 2 years of age may need confirmation with a rectal temperature. Rectal temperature is considered the gold standard. Bundling a young child may increase the skin temperature but not the core temperature. It should also be considered in neonates and children less than 2 years of age where other methods are not reliable. Studies have shown a good correlation between the tympanic temperature and rectal temperature, especially in children more than 2 years of age. On the contrary, axillary temperatures have a lower correlation. If there is any doubt about a child’s temperature, rectal temperature measurement should be considered for confirmation. Rectal temperature should be avoided in neutropenic and immunocompromised children.
Recommended methods to measure temperature by age
|Birth -2 years||First Choice||Rectal (for exact temperature)|
|Second Choice||Axillary (to check for fever)|
|Between 2 and 5 years||First Choice||Rectal|
|Older than 5 years||First Choice||Oral|
History and Physical Examination Hints
The detailed history and physical examination are the most vital in the assessment of the febrile child. It is critical to pay attention to the history provided by parents for documented fever at home as studies have shown it is moderately accurate; further evaluation should always be carried out because a subjective fever at home may be the only indicator of a possibly serious bacterial infection in a child who is afebrile in the ED.
Focused history on fever characteristics should be asked, as it may provide useful clues. There is an increase in the rate of pneumococcal bacteremia with a rise in temperature, especially in young children. Studies suggest that the incidence of SBI is higher in patients who have higher temperatures. The duration of the fever at the time of ED presentation does not help to predict occult bacteremia. The response to antipyretic medications does not predict bacterial or viral infection. Other important data to be considered include associated signs and symptoms, underlying medical conditions, exposure to ill contacts, and immunization status.
In the exam, evaluate the quality of the cry? High pitched, or weak in effort? Does the child appear fearful of the doctor, nurse? It is normal to see healthy young children’s fear of strangers. Therefore, if you expose to a child who lies on the exam bed and not interacting things around him or not showing his/her fear, then you need to think about more serious illness on those. Examination of skin is very important. So, skin color, cyanosis or jaundice, rashes should be evaluated. Although the skin may give a clue about the degree of hydration, tears during crying, moisture on the oral mucosa/lips and tongue should be checked. For the neonate, “gentle” palpation of the anterior fontanelle indicates current the fluid status. If the fontanelle is sunken, this shows hypovolemia/dehydration.
An assessment of the child’s overall appearance is critical. Although there is an imperfect correlation between physical examination findings and serious bacterial illness, ill-appearing children are more likely than well-appearing children to have serious bacterial infection, and most well-appearing children do not have serious bacterial infection.
Toxic appearence includes lethargy with poor perfusion (delayed capillary refill, cold hands and feet, pale or mottled skin) or cyanosis or respiratory distress findings. Grunting is considered one of the most important signs to identify a sick child and may indicate an impending respiratory failure.
Assessment of Clinical Condition in Children on Physical Examination
|Alertness/ Activity||Strong cry or not crying / smiles / stay awake/ normal response to social cues||Drowsy / decreased activity / poor smile/response to social cues/ irritable||Wakes only with prolonged stimulation/ unable to arouse/ weak cry / high pitched cry/ continuous cry/ bulging fontanelle /grunting|
|Breathing||Normal work of breathing||Nasal flaring||Chest indrawing /RR more than age specific rates/grunting|
|Color / Circulation||Normal lips, skin, tongue color||Pale per caregiver||Pale / mottled / blue / ashen|
|Fluid/ Urine output||Normal skin and eyes/ moist mucus membranes||Poor feeding in infants / dry mucus membranes / reduced urine output||Reduced skin turgor / bilious vomiting|
|Others||New lump >2 cm||Appears very unwell to health care professional|
The physical examination may reveal focal infection, and if so the need for additional testing decreases. For example, the children who have clinically obvious viral illness such as croup, chicken pox have lower rates of bacteremia than the children who have no obvious infection source. Except for neonates and young infants, if a child has a nontoxic appearance, a more selective approach can be undertaken. When a child has an identifiable cause, the treatment and disposition should generally be tailored to this specific infection.
Investigations and management of fever without focus.FIGURES ????
Emergency Treatment Options
Airway, breathing, circulation (ABC) is the priority for all patients. Supplemental oxygen or advance airway measure can be necessary. Open intravenous access to draw blood samples, fluid infusion, and medications. Monitor the patients’ vitals. Early treatment of fever is important. This gives the patient comfort as well as optimal physical examination condition for the physician.
Acetaminophen and ibuprofen both can be used. They can overlap during the treatment period to control fever. Some studies favor acetaminophen because of its fast effect. Other studies found that combination of acetaminophen and ibuprofen is very effective regime. Recommended doses are acetaminophen 15 mg/kg and ibuprofen 10 mg/kg.
Empiric antibiotic regimes should also be considered
- Age 0-28 days: ampicillin + gentamicin or a third-generation cephalosporin
- Age 29-56 days: Ill appearing children can receive same regimen above. The children who can discharge home do not need empiric antibiotics.
Ceftriaxone is a preferred agent by some clinicians before ED discharge.
- Age 2-24 months: Empiric antibiotic therapy is not indicated for well-appearing children if there is no defined bacterial source and will be managed as outpatients.
Finding venous access, waiting the lab results and availability of the antibiotics are couple obstacles to apply timely antibiotics to children with fever.
Toxic appearance, need for monitoring, need for fluid treatment, poor social condition, follow up chance for the next day with the primary physician are factors affecting admission decisions. However, admission is warranted for febrile infants 28-56 days old regardless of the above factors.
If the patient meets all of the following low-risk criteria, they may be discharged home.
- Full-term birth
- Not hospitalized longer than the mother
- No toxic appearing
- Not received antibiotic within 48 h
- No dehydration
- No lethargy
- No irritability
- No wheezing
- No infections in the ear, skin, soft tissue, skeletal
- No focal infection source
- No hyperbilirubinemia
- No underlying or chronic illness
- No previous admissions
- CSF – WBC < 8/hpf
- WBC – 500-15000/mm3, PMNL < 0.2
- Urine WBC <10/hpf
- No infiltration on chest x-ray
- Fecal leukocytes < 5/hpf
Red Flags to be explained to parents at the time of discharge. The parents should be instructed to follow-up after 24-48 hours as per clinical condition in the primary health care system. A detailed account of danger signs should be explained to parents and if possible given a handout. It should be emphasized to them that if they notice or observe any of the following, they should come back to the ED immediately as it indicates worsening of the child’s condition:
- Have breathing difficulty
- The lips, tongue or nails appear blue
- Crying continuously and inconsolable
- Refuse to eat or drink or appear too sick to eat or drink
- Vomiting whatever eating
- Has headache
- Has stiffness
- Develop skin rash
- Has severe abdominal pain
- Anything that worried parents from his baseline
Links To More Information
- CDEM Curriculum – Pediatric Fever- https://cdemcurriculum.com/pediatric-fever/
- REBEL EM – The Challenge of Fever in Kids – http://rebelem.com/the-challenge-of-fever-in-kids/
- LITFL – NICE fever guidelines for kids – https://lifeinthefastlane.com/nice-fever-guidelines-for-kids/
- EM cases – Episode 48 – Pediatric Fever Without A Source – https://emergencymedicinecases.com/episode-48-pediatric-fever-without-source/
- DFTB – A NEW APPROACH TO FEBRILE INFANTS – https://dontforgetthebubbles.com/step-by-step-a-new-approach-to-febrile-infants/
- DFTB – FINDING THE FEVER – https://dontforgetthebubbles.com/finding-fever/
References and Further Reading
- Chamberlain JM, Patel KM, Pollack MM. Association of emergency department care factors with admission and discharge decisions for pediatric patients. J Pediatr 2006;149(5):644–9.
- Mahajan P, Knazik S, Chen X. Evaluation of febrile infants <60 days of age: review of NHAMCS data. PAS: Pediatric Academic Societies Annual Meeting, May6, 2008. Toronto.
- McCaig LF, Nawar EW. National Hospital Ambulatory Medical Care Survey: 2004 emergency department summary. Adv Data 2006;(372):1–29.
- Baraff LJ, Bass JW, Fleisher GR, 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 1993;22(7):1198–210.
- Lee GM, Fleisher GR, Harper MB. Management of febrile children in the age of the conjugate pneumococcal vaccine: a cost-effectiveness analysis. Pediatrics 2001;108:835–44.
- Bachur RG, Harper MB. Predictive model for serious bacterial infections among infants younger than 3 months of age. Pediatrics 2001;108(2):311–6.
- Harper M. Update on the management of the febrile infant. Clin Pediatr Emerg Med 2004;5(1):5–12.
- Kramer MS, Etezadi-Amoli J, Ciampi A, et al. Parents’ versus physicians’ values for clinical outcomes in young febrile children. Pediatrics 1994;93:697–702.
- Baker MD, Avner JR. The febrile infant: what’s new? Clin Pediatr Emerg Med 2008;9(4):213–20.
- American College of Emergency Physicians Clinical Policies Committee, American College of Emergency Physicians Clinical Policies Subcommittee on Pediatric Fever. Clinical policy for children younger than three years presenting to the emergency department with fever. Ann Emerg Med 2003;42(4):530–45.
- Slater M, Krug SE. Evaluation of the infant with fever without source: an evidence based approach. Emerg Med Clin North Am 1999;17(1):97–126
- Centers for Disease Control and Prevention. Recommended childhood and adolescent immunization scheduledUnited States, July-December 2004. MMWR Morb Mortal Wkly Rep 2004;53(13):Q1–3.
- Craig JV, Lancaster GA, Taylor S, et al. Infrared ear thermometry compared with rectal thermometry in children: a systematic review. Lancet 2002;360(9333):603–9.
- Craig JV, Lancaster GA, Williamson PR, et al. Temperature measured at the axilla compared with rectum in children and young people: systematic review. BMJ 2000; 320(7243):1174–8.
- Greenes DS, Fleisher GR. When body temperature changes, does rectal temperature lag? J Pediatr 2004;144(6):824–6.
- Greenes DS, Fleisher GR. Accuracy of a noninvasive temporal artery thermometer for use in infants. Arch Pediatr Adolesc Med 2001;155(3):376–81.
- Jean-Mary MB, Dicanzio J, Shaw J, et al. Limited accuracy and reliability of infrared axillary and aural thermometers in a pediatric outpatient population. J Pediatr 2002;141(5): 671–6.
- Grover G, Berkowitz CD, Thompson M, et al. The effects of bundling on infant temperature. Pediatrics 1994;94(5):669–73.
- Banco L, Veltri D. Ability of mothers to subjectively assess the presence of fever in their children. Am J Dis Child 1984;138(10):976–8.
- Graneto JW, Soglin DF. Maternal screening of childhood fever by palpation. Pediatr Emerg Care 1996;12(3):183–4.
- Hooker EA, Smith SW, Miles T, et al. Subjective assessment of fever by parents: comparison with measurement by noncontact tympanic thermometer and calibrated rectal glass mercury thermometer. Ann Emerg Med 1996;28(3):313–7.
- Pantell RH, Newman TB, Bernzweig J, et al. Management and outcomes of care of fever in early infancy. JAMA 2004;291(10):1203–12.
- Kuppermann N, Fleisher G, Jaffe D. Predictors of occult pneumococcal bacteremia in young febrile children. Ann Emerg Med 1998;31(6):679–87.
- Stanley R, Pagon Z, Bachur R. Hyperpyrexia among infants younger than 3 months. Pediatr Emerg Care 2005;21(5):291–4.
- Trautner BW, Caviness AC, Gerlacher GR, et al. Prospective evaluation of the risk of serious bacterial infection in children who present to the emergency department with hyperpyrexia (temperature of 106F or higher). Pediatrics 2006;118(1):34–40.
- Teach SJ, Fleisher GR. Duration of fever and its relationship to bacteremia in febrile outpatients 3 to 36 months old: the occult bacteremia study group. Pediatr Emerg Care 1997; 13(5):317–9.
- Baker MD, Fosarelli PD, Carpenter RO. Childhood fever: correlation of diagnosis with temperature response to acetaminophen. Pediatrics 1987;80(3):315–8.
- Baker RC, Tiller T, Bausher JC, et al. Severity of disease correlated with fever reduction in febrile infants. Pediatrics 1989;83(6):1016–9.
- Huang SY, Greenes DS. Effect of recent antipyretic use on measured fever in the pediatric emergency department. Arch Pediatr Adolesc Med 2004;158(10):972–6.
- Torrey SB, Henretig F, Fleisher G, et al. Temperature response to antipyretic therapy in children: relationship to occult bacteremia. Am J Emerg Med 1985;3(3):190–2.
- Yamamoto LT, Wigder HN, Fligner DJ, et al. Relationship of bacteremia to antipyretic therapy in febrile children. Pediatr Emerg Care 1987;3(4):223–7.
- Bonadio WA. The history and physical assessments of the febrile infant. Pediatr Clin North Am 1998;45(1):65–77.
- Bonadio WA, Hennes H, Smith D, et al. Reliability of observation variables in distinguishing infectious outcome of febrile young infants. Pediatr Infect Dis J 1993;12(2):111–4.
- 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 1987;110(1):26–30.
- McCarthy PL, Lembo RM, Baron MA, et al. Predictive value of abnormal physical examination findings in ill-appearing and well-appearing febrile children. Pediatrics 1985;76(2): 167–71Knight C, Glennie L. Early recognition of meningitis and septicaemia. J Fam Health Care. 2010. 20(1):6-8.
- Eagles D, Stiell IG, Clement CM, et al. International survey of emergency physicians’priorities for clinical decision rules. Acad Emerg Med 2008;15(2):177–82.
- Greenes DS, Harper MB. Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatr Infect Dis J 1999;18(3):258–61
- Carson SM. Alternating acetaminophen and ibuprofen in the febrile child: examination of the evidence regarding efficacy and safety. Pediatr Nurs. 2003 Sep-Oct. 29(5):379-82.
- Pruijt 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. 2013 Apr. 66(4):453-7.
- 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. 2006 Feb. 160(2):197-202.
- 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. 2009 May. 13(27):iii-iv, ix-x, 1-163.
- Noyola DE, Fernandez M, Kaplan SL. Reevaluation of antipyretics in children with enteric fever. Pediatr Infect Dis J. 1998 Aug. 17(8):691-5.
- 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). 2008 Nov. 47(9):907-11.
- 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. 1985 May. 3(3):190-2.
- Brown JC, Burns JL, Cummings P. Ampicillin use in infant fever: a systematic review. Arch Pediatr Adolesc Med. 2002 Jan. 156(1):27-32.
- 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. 2003 May. 111(5 Pt 1):964-8.
- Sadow KB, Derr R, Teach SJ. Bacterial infections in infants 60 days and younger: epidemiology, resistance, and implications for treatment. Arch Pediatr Adolesc Med. 1999 Jun. 153(6):611-4.
- Cohen C, King A, Lin CP, Friedman GK, Monroe K, Kutny M. Protocol for Reducing Time to Antibiotics in Pediatric Patients Presenting to an Emergency Department With Fever and Neutropenia: Efficacy and Barriers. Pediatr Emerg Care. 2015 Mar 27.
- 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.
- Ishimine P. Fever without source in children 0 to 36 months of age. Pediatr Clin North Am. 2006 Apr. 53(2):167-94.
- 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. 1988 Mar. 112(3):355-60.
- 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. 1992 Jan. 120(1):22-7.
- Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics of fever in selected infants. N Engl J Med. 1993 Nov 11. 329(20):1437-41.
- Wasserman GM, White CB. Evaluation of the necessity for hospitalization of the febrile infant less than three months of age. Pediatr Infect Dis J. 1990 Mar. 9(3):163-9.
- Barkin RM, Zukin DD. Marx JA, Hockberger RS, Wall RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5th ed. 2002:2233-45.
- The Evolving Approach to the Young Child Who Has Fever and .., http://emergency.med.ufl.edu/files/2013/02/evolving-approach-to-fever.pdf (accessed June 27, 2016).
- Policy Clinical Guideline – SA Health. https://www.sahealth.sa.gov.au/wps/wcm/connect/812ad70040d041b4972cbf40b897efc8/Fever+without+Focus_Apr2015.pdf?MOD=AJPERES (accessed June 27, 2016)
- How to take a child’s temperature – Europe PMC Article …. http://europepmc.org/articles/PMC2819919