This document discusses fever without a focus in older children. It notes that while most fevers in children are due to benign viral infections, some may be caused by more serious bacterial infections. A thorough history, physical exam, and diagnostic testing when indicated can help establish the cause. Common viral infections include respiratory and gastrointestinal viruses. Potential bacterial infections include otitis media, strep throat, and urinary tract infections. Occult bacteremia must also be considered. Treatment involves supportive care for viral infections and antibiotics only for confirmed or suspected bacterial infections.

1. Fever Without a Focus in
the Older Child
BY:
Dr, WALAA SALAH MANAA
CONSULTANT OF PEDIATRIC & INFECTION.
‫الشـيخ‬ ‫كـفر‬ ‫حمـيات‬ ‫مـستشفى‬

3.  Fever is the most common reason for
a child to seek medical care.
 While most infants and children have
benign viral causes of fever, a small
percentage will have more serious
infections.
 Unlike the situation in infants <2 mo
of age, in older children with fever,
pediatricians depend more easily on
symptoms and physical examination
findings to establish a diagnosis.

4.  Diagnostic testing, including
laboratory testing and radiographic
studies, is not routinely indicated
unless diagnostic uncertainty exists
after examination or the patient
appears critically ill.
 Occult infections, such as urinary
tract infection, may be present, and
screening for such infections should
be guided by patient age, patient
gender, and degree of fever.

5. Diagnosis
 The many potential causes of fever in older
infants and children can be broadly
categorized into:
 viral and bacterial infections,
as well as the less common
 inflammatory,
 oncologic,
 endocrine,
 Drugs

6. Viral Infections
 Viral infections are the most common cause of
fever, and the prevalence of specific viral
infections varies by season.
1. In the summer and early fall, enteroviruses
(e.g., coxsackieviruses) predominate, usually
presenting as HFMD, herpangina, aseptic
meningitis, or a variety of other manifestations.
2. In the late fall and winter, viral upper and lower
respiratory tract infections such as respiratory
syncytial virus (RSV) and influenza and
gastrointestinal (GI) viruses such as norovirus and
rotavirus are common.

7. Viral Infections
 Parainfluenza virus is a common
cause of laryngotracheobronchitis
(croup) and occurs primarily in the
fall and spring, affecting mostly
infants and toddlers.
 Varicella is a less common cause
of fever than in the past because
of childhood vaccination but still
occurs, with the highest incidence
in winter and early spring.

8. Bacterial Infections
 Although viral infections are the
most common cause of fever in
older infants and children and
are often diagnosed based on
symptoms and physical
examination findings, bacterial
infections also occur.
 Common bacterial infections
include acute otitis media and
streptococcal pharyngitis (strep
throat) .

10. Occult Urinary Tract Infection
• Among children 2-24 mo old
without symptoms or physical
examination findings that identify
another focal source of
infection, the prevalence of
(UTI) may be as high as 5–10%.
• The highest risk of UTI occurs
in females and uncircumcised
males, with a very low rate of
infection (<0.5%) in circumcised
males.

11. Occult Bacteremia
 Occult bacteremia is defined as a
positive blood culture for a pathogen
in a well appearing child without an
obvious source of infection.

12. General Approach
 The general approach to fever in the
older child begins with an assessment of
the child's overall appearance and vital
signs.
A detailed history of the present illness
and a thorough physical examination
should be performed to identify the
cause of the fever.

13. Overall Appearance and Vital Signs
 Children who are ill or
appear toxic or who have
abnormal vital signs (e.g.,
tachycardia, tachypnea,
hypotension)
 require rapid assessment,
including a focused physical
examination to evaluate
for the presence of an
invasive bacterial
infection.

14. Symptoms
 Patients with prolonged fever may
harbor occult infections, UTI, bone or
soft tissue infections, or have an
inflammatory or oncologic condition.
 Kawasaki disease should be considered
among children with prolonged fever.
 Presence of weight loss or night sweats
may indicate leukemia,
lymphoma,brucelosis or tuberculosis .

15. Physical Examination
 A complete examination should include an
assessment of neck pain and mobility, which
may be limited in children with meningitis .
 the examiner should palpate carefully for
the presence of lymphadenopathy .
 Erythema and exudate of the tonsils with
palatal petechiae suggest streptococcal
pharyngitis

16.  Erythema, bulging, and
decreased mobility of the
tympanic membrane are the
cardinal signs of acute
otitis media.
 Diffuse crackles and
wheezes on auscultation of
the lungs occur with acute
viral bronchiolitis, while
focal crackles or decreased
breath sounds are more
consistent with pneumonia.

17.  Focal tenderness in the right
lower quadrant of the abdomen
is suggestive of appendicitis ,
and suprapubic tenderness may
indicate UTI (cystitis ).
• Any focal bony tenderness may
reflect a diagnosis of
osteomyelitis, while erythema,
swelling, and limitation of range
of motion suggest a diagnosis of
septic arthritis.

18.  Abnormal gait or pain with
ambulation without focal findings
may also reflect a bone or joint
infection.
 A careful skin examination
should also be performed. The
presence of petechiae may
suggest meningococcal or other
invasive bacterial infection,
whereas viral exanthems are
typically associated with a
blanching macular or
maculopapular rash.

19. Evaluation

20. Laboratory Testing
 Laboratory testing is not
routinely indicated in the
well-appearing child without
a focus of infection on
examination.
 For children who are ill or
appear toxic or who have
vital sign abnormalities
indicative of an invasive
bacterial infection
(tachycardia, hypotension),
rapid laboratory evaluation
should be performed.

21.  Testing should include:
(CBC)
blood culture
urine culture
(CSF) cultures

22.  Influenza testing may be indicated within 48 hr of
symptom onset in certain higher-risk populations,
with
 immunosuppression,
 chronic respiratory disease
 cardiac disease,
 sickle cell disease,
 hospitalization, and age <2 yr influencing the decision to treat
with an antiviral agent.
 Viral testing may also be useful with prolonged fever to identify
a source of the fever and avoid extensive evaluation for
inflammatory conditions such as Kawasaki disease.

23.  Rapid strep testing of the oropharynx
is indicated for children ≥3 yr old with
signs of streptococcal pharyngitis on
examination.
 Febrile children 2-24 mo old
particularly females and uncircumcised
males, should undergo evaluation with
urine dipstick, urine microscopy, and
urine culture.

24.  Females and uncircumcised males 2-6
mo old with high fever or fever that
lasts ≥2 days, may undergo urine
testing even in the presence of
respiratory tract infection, given the
higher risk of UTI in this younger
group.

25. Imaging
 Chest radiography:
 Current guidelines recommend
presumptive antibiotic treatment for
pneumonia based on clinical grounds and
reserve the use of chest radiography
for children with
 Hypoxemia or
 Significant respiratory distress and for
 those who fail outpatient therapy.
 For hospitalized children to assess for
complicated pneumonia,including
empyema .

26.  The presence of drooling and
neck or throat pain in an infant
or toddler may be suggestive of
a retropharyngeal abscess,
which is usually confirmed by
imaging that may include a
lateral radiograph of the
soft tissue of the neck or
computed tomography
(CT) if clinical suspicion is
high.

27.  Abdominal (US) may be performed to assess for
appendicitis in children with fever and focal right lower
quadrant pain or abdominal pain that is severe.
• However, definitive imaging, including CT or MRI, may be
required if US is nondiagnostic or if clinical suspicion is high.

28. Management

29. General Management
 Children with viral infections generally
require supportive care only, except for
children at higher risk of severe or
complicated disease with influenza virus.
 Antibiotics should be reserved for children
with evidence of bacterial infection on
physical examination.

30.  A wait-and-see approach can be
considered for children with acute
otitis media , in whom a
prescription for antibiotics can be
provided to the family but
instructions given to not fill the
prescription unless severe or
worsening symptoms develop.
 Oral antibiotics can be prescribed
to young children >2 mo old with
UTI, although children who cannot
tolerate oral intake, are vomiting
or dehydrated, or appear toxic
require parenteral antibiotics and
hospitalization.

31.  Blood tests, including CBC
and blood culture, should be
considered to evaluate for
occult bacteremia in the
unimmunized or ill-appearing
child.
 One management strategy
for these children is to
administer a parenteral
antibiotic (e.g., ceftriaxone)
if leukocytosis is present
(≥15,000/μL) while awaiting
results of blood culture.

32.  Children who appear toxic or
who have signs of either
sepsis or bacterial meningitis
 require emergent treatment
with parenteral antibiotics as
well as adjunct therapies to
support the child's
hemodynamics.