The document discusses fever in infants and children. It notes that fever is common in young children and can be caused by minor or life-threatening infections. While most pediatric infections are viral, some may be bacterial. The medical history, physical exam, and complementary tests usually allow for prompt diagnosis and reassurance or treatment as needed. For febrile infants under 3 months, further testing such as blood and urine cultures as well as lumbar puncture may be required depending on factors like age, appearance, and symptoms to check for potential serious bacterial infections. Management depends on risk level, with higher risk infants often needing admission and parenteral antibiotics.

1. An Approach to Fever
in Infants & Children
DR. Sreeram Reddy M
Professor and HOD
Department of peadiatrics ,PIMS

2. Why Is The Topic Important?
• 20-35% of urban pediatric ED visits: – “Fever Phobia”
• 65% of children visit their pediatrician with complaint of
fever before their 2nd birthday.
• Diagnoses range from minor to life-threatening
• Multiple conflicting recommendations, guidelines, and
algorithms.

3. To Work Up or Not to Work Up?
•Do all febrile children with no
obvious infection site need To be
investigated??

4. Definition
• Fever: elevated body temperature due to
change in hypothalamic set point
• Hyperthermia: elevated body
temperature due to environmental heat,
dehydration, overclothing, excessive
internal heat production
12/3/1389 4

5. Significant Fever: Definition
Temperature of 38.0 ̊ rectally at rest:
– 0-2 months risks increase at 38.0 ̊
(the occurrence of Serious Bacterial Infection
(SBI) increases from < 1% to 5% at 38.0° C)
– 3-36 months risks increase at 39.0 ̊
Fever Without Source: FWS
“Fever without source is an acute febrile illness in
which the etiology of the fever is not apparent after a
careful history and physical exam.”

6. • In children, fever is generally a sign of infection.
• Fever due to other causes including malignancy is rare.
• The prognosis for the most common forms of paediatric
infections is usually excellent; these infections are much more
likely to be viral (rhinitis, pharyngitis, laryngitis, bronchitis,
bronchiolitis, gastroenteritis, exanthems) than bacterial
(pneumonia, urinary tract infections [UTIs], sinusitis, tonsillitis,
otitis).

7. The medical history, physical examination
when necessary, a few additional complementary tests
usually lead to a prompt diagnosis
Reassurance Treatment

8. Neither the medical history, the physical examination, nor
complementary tests indicate a bacterial infection that can
potentially lead to serious complications.
How can a fever of viral origin be differentiated from one of
bacterial origin? Do all febrile children with no obvious
infection site need a blood culture? Should antibiotics be
administered before the results of the blood culture have
been received?

9. 12/3/1389 9

10. 12/3/1389 10

11. Reliable Temperature
Measurement
• All measurements are estimates of the
body’s true core temp—central
circulation=aorta and pulmonary artery.
• RECTAL—gold standard
• Esophageal—accurate but impractical
• Tactile and axillary—inaccurate, varies
considerably with environmental temperature
• Tympanic—inaccurate in age <3 years

12. Benefits of fever
• The hypothalamus will not allow the temp to
rise above 41.5ºC(107ºF).
• WBCs work best and kill the most bacteria at
38-40ºC(100.4-104ºF).
• Neutrophils make more superoxide anion,
and there is more and increased activity of
interferon.
• Coxsackie and polio virus replication is
directly inhibited.

13. Fever Pitfalls
• Bundling:
• – Bundling can lead to a rise in skin temperature and eventually
rectal temperature.(Study 1: Cheng, 1993, Study 2: Grover,
1994)
• Route of Measurement:
– Tympanic/axillary don’t correlate well with rectal temps
(Craig, 2000; Craig, 2002; Jean-Mary, 2002)
• Antipyretics:
– No correlation between disease etiology/severity and response
to antipyretics (Baker, 1987; numerous others)
• Tactile temperatures:
– Sensitivity 83%
– Specificity 76% (Hooker, 1996; Graneto, 1996)
• Afebrile on presentation:
– 6 of 63 infants 0-3 months with bacteremia/meningitis afebrile
in clinic after being febrile at home (pantell, 2004)
( * No comment on whether or not antipyretics were
given)

15. Relevant Age Groups
and development
• 0………4w NEONATES
• 0………………..8w
• 4w……….……………….12w
• 12w………..3y
• > 3 years old
• Age stratification of risk for
• serious bacterial infections [SBI]

16. Neonates
• The majority of febrile neonates presenting to the ED
have a nonspecific viral illness
• 12% have serious bacterial infections (SBI)
• Infected by more virulent bacteria
• More likely to develop serious sequelae from viral
infections
• GBBS is associated with high rates of
meningitis(39%), non-meningeal foci(10%), and
sepsis(7%)
• The most common bacterial infections are UTI and
occult bacteremia

17. Neonatal
• Physical examination is felt to be unreliable in detecting
many serious bacterial infections. Meningitis should
always be considered—up to 10% appear well, only 15%
have a bulging fontanelle, and 10-15% have nuchal
rigidity. So, a high index of suspicion is important!!! ~20%
will not have fever initially.
– Hyperthermia or hypothermia
– Lethargy or irritability
– Poor feeding or vomiting
– Apnea
– Dyspnea
– Jaundice
– Hypotension
– Diarrhea or abdominal distension
– Bulging fontanelle
– seizures

18. Neonatal
Early Onset<7 Days
Group B Strep
E. Coli
Listeria Monocytogenes
Enterobacteriaceae
Enterococcus
Strep viridans
Strep Pneumoniae
Hemophilus influenza nt
Herpes simplex
Later Onset>7 Days
Group B Strep
Listeria Monocytogenes
Enterobacteriaceae
Strep Pneumoniae
Neisseria meningitidis
Herpes simplex

19. Neonatal
• Risk Factors
– Preterm
– Membrane rupture: before labor onset or
prolonged>12 hours
– Chorioamnionitis or maternal peripartum fever
– UTI
– Multiple pregnancy
– Hypoxia or Apgar score <6
– Poverty or age <20
• 1/3-1/2 neonatal sepsis will have no risk
factors!

20. Neonatal
• Screening tests: WBC<5000 or >20,000, PMN
<4000, I:T>.2, Plt<100,000, CRP>1, LFTs
elevated(suggest HSV)
• So, if <28 days of age and rectal temp> 38ºC
– Admit
– Blood Culture
– Urine Culture—cath specimen
– Lumbar Puncture
• Cell count, protein, glucose, culture, PCR
– Parenteral Antibiotics
• Ampicillin + Gentamicin(Cefotaxime), consider
Acyclovir(primary maternal infxn, esp if delivered vaginally,
PROM, fetal scalp electrodes, skin eye or mouth lesions,
seizures, CSF pleocytosis)

21. Infants 1 to 3 months
• Causes
– HSV(17% are 15 days to 6 weeks of age)
– Bacterial sepsis/meningitis
• Group B Strep, S. Pneumoniae, H. influenza, N. meningitidis,
Enterobacteriaceae
– Bone and joint infections
– UTI
– Bacterial enteritis(esp Salmonella)
– Pneumonia
– Enterovirus sepsis/meningitis(July-October)
• The risk of bacteremia/meningitis is 3.3%, pneumonia,
bone/joint infections and bacterial enteritis is 13.7%
– 30-50% of those who are ultimately diagnosed with bacterial
meningitis have been seen by a physician within the prior
week(usually 1-2 days before) and were diagnosed as having a
trivial illness and discharged on oral antibiotics.

24. Pediatric Fever Algorithm
Non toxic appearing, 28 – 90 days and “Low Risk”
No
Blood Culture,
Urine Culture,
CSF Cx, antibx
+/-CXR
Yes
ADMIT
Outpatient Management
Option 1
Blood Cx, Urine Cx,
CSF Cx, ceftriaxone
50 mg/kg IV/IM, re-
eval in 24 hours
Option 2
Blood Cx, Urine
Cx, Re-eval in 24
hours
Fever  38°C
BY DR M OSAMA HUSSEIN MD

25. Rochester Criterias for infants
under 3 months
• Term
• Previously healthy
• Non-toxic
• No focus
• No previous ATB
• 15 000 WBC
• 1500 bands
• 5 WBC/hpf in stool
• 10 WBC/hps in spun
urine
Ron Dagan, Identification of infants unlikely to have serious bacterial infection although
hospitalized for suspected sepsis, J Pediatr 1985;107;855-860

26. Rochester Criterias for infants
under 3 months
• Risk of 0.5-1.1% for SBI including
meningitis
• NPV 98,5%
Jaskiewicz JA, McCarthy CA, Richardson AC, et al: Febrile infants at low risk for serious bacterial
infection-an appraisal of the Rochester criteria and implications for management. Pediatrics
1994;94:390-396

27. Infants 1 to 3 months
Infants who are toxic and febrile have a much
higher risk of serious bacterial infection.
They should be admitted, have a full sepsis
workup, and given
antibiotics/antiviralsAmpicillin and
Cefotaxime.
Infants who are nontoxic and febrile who meet
all Rochester criteria can ‘safely’ be treated
as an outpatient. Generally, 1-2.9% of
children meeting these criteria will develop a
serious bacterial infection, 0.7% bacteremia,
0.14% meningitis.

28. Infants 1 to 3 months
• If all of the criteria are met, then there are 2
options for outpatient management:
– 1) Blood, Urine Cultures, LP, Ceftriaxone 50mg/kg IM
(to 1g), and return for reevaluation within 24 hours.
– 2) Blood, Urine Cultures and careful observation.
• Parents should have mature judgement, can
return within 30 minutes and have a thermometer
and a phone.
• IF NO LP IS DONE, DO NOT GIVE
CEFTRIAXONE AS IT WILL COMPROMISE F/U
IF THE PATIENT IS STILL FEBRILE

29. Management of children under
3 months by a paediatric specialist
Assess: look for life-threatening, traffic light and specific diseases symptoms and signs
Observe and monitor:
 temperature
 heart rate
 respiratory rate.
Perform:
 full blood count
 C-reactive protein
 blood culture
 urine test for urinary tract infection
 chest X-ray if respiratory signs are present
 stool culture if diarrhoea is present.
Admit, perform lumbar puncture and start parenteral antibiotics if the child is:
 younger than 1-month old
 1–3 months old appearing unwell
 1–3 months old and with a white blood cell count of less than 5 or greater than 15 x 109/litre
 Whenever possible, perform lumbar puncture before the administration of antibiotics

30. Infants 1 to 3 months
• Follow-up of low risk infants
– If all cultures negative: afebrile, well
appearingCareful observation
– Blood cultures negative: well appearing,
febrileCareful observation, may consider
second dose of Ceftriaxone
– Blood culture positiveadmit for sepsis workup
and parenteral antibiotics pending results
– Urine culture positive: if persistent feveradmit
for sepsis workup, parenteral antibiotics pending
results. If afebrile and welloutpatient antibiotics

31. Occult Bacteremia
5% of children with FWS have OCCULT
BACTEREMIA
– The presence of a positive blood culture in
kids who look well enough to be treated as
outpatients and in whom the positive
results are not anticipated.

32. Occult Bacteremia
• Streptococcus pneumonia is responsible for
2/3 to ¾ of all cases.
– Peak prevalence between 6 and 24 months
– Association with high fever(39.4ºC or 103ºF)
– High WBC count(>15,000)
– Absence of evident focal soft tissue infection.
• Neisseria meningitidis, Haemophilus
influenzae type b, and salmonellae account
for most of the remaining cases.

33. Risk of Occult Bacteremia
OB has a low prevalence, so even though WBC is a sensitive and
specific screening test, it has a low PPV. So the test does not
discriminate between children who have FWS who are
bacteremic and those who are not.
Therefore, blood culture is the gold standardstill has a high
number of false positives, take 24-48hrs, and most cases of
occult pneumococcal bacteremia clear without treatment.
Low Risk
Age >3yr
Temp <39.4ºC
WBC >5000 and
<15,000
High Risk
<2yr
>40ºC(104ºF)
<5000 or >15,000
Hx of contact with H. Flu
or N. meningitidis

34. Occult Bacteremia
• Empiric antibiotics should be targeted
against S. pneumoniae, N. meningitidis,
and H. influenza
– Amoxicillin
– Augmentin, Bactrim, 2nd or 3rd gen
Cephalosporins
– Single dose Ceftriaxone 50-75mg/kg
• Followup is essential!

35. LOW AND HIGH-RISK CRITERIA COMMONLY
USED IN STUDIES OF FEVER WITHOUT SOURCE
• Low-risk Criteria High-risk Criteria
• Term gestation (37 weeks) Recurrent febrile illnesses
• Uncomplicated prenatal course Prematurity
• No recent (7d) antibiotic Congenital immune disease
• No recent surgery Sickle cell disease
• No chronic illness Asplenia
• No perinatal ATB Malignancy/chemotherapy
Recent steroid therapy
• Hospitalized = to mother HIV disease

36. Yale Observation Scale Score
• Quality of cry
• Alertness
• Color
• Hydration
• Response to
parents
• Response to others
• Score 6-10 well
• Score 11-15 mod
• Score > 15 toxic
McCarthy PL, Sharpe MR, Spiesel SZ, et al: Observation scales to identify serious illness in
febrile children. Pediatrics 1982; 70:802

37. Yale Observation Scale Score
• 6-10 well
• 11-15 mod
• > 15 toxic
• OB
• 2,5%
• 4,7%
• 5,7%

38. Management of children 3 months
to 5 years by a paediatric specialist
 Perform test for urinary
tract infection.
 Assess for pneumonia.
 Do not perform routine
blood tests or chest X-ray.
Perform (unless deemed unnecessary)
 urine test for urinary tract infection
 full blood count
 blood culture
 C-reactive protein.
Perform chest x-ray if fever higher than
39°C and white blood cell count greater
than 20 x 109/litre.
Consider lumbar puncture if child is
younger than 1-year old.
Perform:
 blood culture
 full blood count
 urine test for urinary tract infection
 C-reactive protein.
Consider the following, as guided by
clinical assessment:
 lumbar puncture in children of all ages
 chest X-ray
 serum electrolytes
 blood gas.
Consider admission. If admission is not
necessary but no diagnosis has been
reached, provide a safety net for the
parents/carers.
If no diagnosis is reached,
manage the child at home
with appropriate care
advice.
Assess: look for life-threatening, traffic light and specific diseases symptoms and signs

39. Bacteremia
Prevalence of Serious Bacterial Infection (SBI)
Infants 0-2 Months Old
• Febrile neonates: SBI = 13%
• Febrile infants 1 to 2 months of age: SBI = 10%
• Febrile infants younger than 3 months of age Urinary Tract
Infections account for 1/3 all bacterial diseases
Management of Fever In Infants and Children
Jeffrey R. Avner MD, M. Douglas Baker MD
Emergency Medicine Clinics of North America
Volume 20 • Number 1 • February 20

40. Predictors of bacteremia
• History
• Physical exam
• Gender
• Height of fever
• WBC
• ANC
• Bands
• Band/Neutrophils ratio
• PMN%
• ESR-CRP-cytokines
Daniel Isaacman, Predictors of bacteremia in febrile children 3-36 Mo of age, Pediatrics;106;5;Nov 2000
Nathan Kupperman, Predictors of occult bacteremia in young febrile children, Ann Emerg Med June 98;31;679-687

41. Bacteremia
• In a study performed in children between three and 36 months
with a rectal or tympanic temperature of 39°C or higher, the
incidence of various types of bacteremia was 1.6% .
• H influenzae was not among the isolated germs.
• Over 90% of all bacteremias are caused by pneumococcus .
• The remaining 10% are caused by various bacterial germs, such
as Neisseria meningitidis, nontyphoidal salmonella, group A
streptococcus, group B streptococcus, Escherichia
coli, Staphylococcus aureus and other more unusual germs .
Meningococcus is the most dangerous of them.

42. Bacteremia
• In the absence of treatment, bacteremias either resolve
spontaneously, persist or are complicated by other symptoms.
• The most serious complications arising from occult bacteremia
include septicemia, meningitis, pneumonia, arthritis,
osteomyelitis and cellulitis.
• The usual prognosis for pneumococcus bacteremia is excellent.
Most cases (90.3%) resolve completely without treatment.#
• Meningococcus bacteremia is rare but high risk. In the absence of
prompt treatment, the speed at which it develops can be rapid. Any delay in
treatment can be catastrophic for the child and have serious legal
repercussions for the physician . The immediate danger arising from
meningococcus bacteremia is that it may lead to purpura fulminans, with
irreversible septic shock and death.

43. AGE
• Bacteremia appears at all ages; however, it is more frequent in
infants between the ages of three and 36 months.
•
• Before the age of three months, the incidence of bacterial
disease in febrile infants is about 10% and that of bacteremia is
between 2% and 3%.
• As a rule, bacterial infections are more serious and insidious in
infants less than three months.
• This group, particularly the neonates, is more vulnerable and is
exposed to a greater variety of causal agents; group B
streptococcus and E coli being the two main ones.
• The main danger during the neonatal period is for UTI or
meningitis

44. Temperature
• the physician’s clinical judgement is usually based on the
temperature and the general appearance at the time of the
examination, not the temperature taken at home. This applies
to all children except those younger than three months. In the
case of normal temperature at the time of the examination but a history of fever, a
sepsis examination is indicated for neonates and possibly some infants between the
ages of one and three months or if there is the slightest appearance of toxicity
• The degree of temperature is an important but misleading
indicator.
• Bacteremia is more frequent in children with a temperature of
39°C or high .
• The absence of fever or the presence of a low grade fever does
not preclude the possibility of a serious infection .

45. Leucocytosis
• Bacterial infections are more likely than viral infections
to have a leukocytosis count of 15,000/mm3 or more, but
because viral infections are much more frequent than
bacterial infections, the majority of febrile children with
a high leukocytosis count have a viral infection.
• In healthy children from one to three years of age, the
normal white cell count varies between 6000 and
17,500/mm3;
• in children one month of age it varies between 5000 and
19,500/mm3 (36).
• It is rightly possible to wonder why the risk level for
bacteremia has been set at 15,000/mm3

46. leucocytosis
• The percentage and absolute number of total neutrophils
are more precise and useful than those of unsegmented
neutrophils (bands) ------- why ?
• Children between three and 36 months of age with an
absolute neutrophil count greater than 10,000
cells/m3 are at higher risk of occult pneumococcal
bacteremia: 8% compared with 0.8% for those with an
absolute neutrophil count less than 10,000 cells/m3.
• Conclusion : White blood cell count results can be
confusing for physicians when there is an obvious
discrepancy between the number of leukocytes and the
child’s general condition.

47. OTHER MARKERS OF INFECTION
ESR
CRP
IL8
PROCALCITONIN
CRP AND ESR NON SPECIFIC
PCT has the greatest sensitivity (85%) and specificity (91%) for
differentiating patients with systemic inflammatory response syndrome (SIRS)
from those with sepsis, when compared with IL-2, IL-6, IL-8, CRP and TNF-
alpha.[3] Evidence is emerging that procalcitonin levels can reduce unnecessary
antibiotic prescribing to people withlower respiratory tract infections
Conclusion: It is likely to make the decision more confusing
when there is a discrepancy between the general appearance
of the child and the C-reactive protein result and/or white blood
cell count.

48. CHEST X-RAYS
• An unexplained and persistent fever can be the only
manifestation of pneumonia.
• When faced with high fever and leukocytosis greater
than 20,000/mm3, the physician should suspect
pneumonia .
• Up to 26% of children younger than five years old with an
unexplained fever of 39°C or higher and leukocytosis
20,000/mm3 or higher, who have no respiratory
symptoms, may have a pneumonia that can only be
detected by a chest x-ray.
• In the absence of respiratory symptoms, chest x-rays
are usually normal.

49. UTIs
• Repeated spells of fever or normal tympanic membranes
following several alleged bouts of otitis media should lead the
physician to suspect UTI .
• The diagnosis of a UTI must be confirmed by a culture;
• Thus, febrile infants less than three months of age should either
be catheterized or have a bladder tap.
• Older febrile children who are not toilet-trained and who have a
risk factor for a UTI, such as UTI symptoms, UTI past history,
known renal anomalies, toxic appearance or who have positive
urine analysis by bag specimen should be catheterized .
• Febrile infants older than three months of age who are not
toilet-trained and are at low risk of UTI should have a bag
specimen taken initially

50. Antipyretics
• Antipyretics do not prevent febrile
convulsions and should not be used
specifically for this purpose.
• Do not routinely give antipyretic
drugs to a child with fever with the
sole aim of reducing body
temperature
• Do not administer paracetamol and
ibuprofen at the same time but
consider using the alternative agent
if the child does not respond to the
first drug.

51. EMPIRICAL ANTIBIOTIC THERAPY
• may reduce the number of serious bacterial complications
• it does not prevent meningitis
• It has not been formally proven that the absence of treatment
has ever been the direct cause of a serious accident
• The scientific data are contradictory and unclear.
• The choice of antibiotics can also be debated.
• Oral antibiotic therapy cannot prevent the risk of meningitis, but
it can delay its diagnosis
• Too liberal a use of ceftriaxone will most likely lead to an
increase in the number of resistant strains of bacteria
• Ceftriaxone is not a panacea, nor is it total risk insurance. It is
an expensive drug that is administered intravenously or
intramuscularly in a painful way.

52. EMPIRICAL ANTIBIOTIC THERAPY
• The widespread use of pneumococcal immunization in
the near future will likely reduce the morbidity and
mortality associated with pneumococcal bacteremias .
This will decrease the difference in outcome between
the different approaches: observation in comparison to
the approach of empirical treatment for all patients or
based on an elevated white blood cell count
• Efficacious and widespread use of pneumococcal
immunization will likely favour the observational
approach based on clinical judgement

53. Home care instructions
Educate parent about appropriate wt-based med dose with
return demonstration
When discharged from ED follow up with primary care
provider within 24 hrs
When discharged from inpatient follow up with primary care
provider in 1-2 days
Reasons to call provider or return to ED

54. CONCLUSIONS
• There are no sufficiently reliable markers of bacterial
infection.
• The physician must therefore practice medicine that is
fraught with empiricism, but also based on sound scientific
arguments and on his or her own personal experience.
• The child’s general appearance, temperature and leukocyte
count are the best evaluation criteria.
• Practice guidelines never entirely compensate for a lack of
clinical judgement.

55. Let us practise
• 1. In infants younger than 3 months of age, the most
commonly occurring bacterial infection is:
• A. Group B Streptococcal infection
• B. Meningitis
• C. Neonatal sepsis
• D. Urinary tract infection

56. Q2
• 2. Which statement about temperature measurement in
infants less than 3 months of age is accurate?
• A. Bundling (swaddling) causes elevation in skin
temperature, but not in rectal temperature
• B. Fever that lowers quickly after antipyretic medication
indicates a less severe infection than a fever that is less
responsive to medication
• C. Temperature of 38.0°C (100.4°F) is defined as fever
• D. Tympanic measurement is closely correlated with
rectal measurement

57. Q3
• 3. The following asymptomatic infants come to the
emergency department with fever of unknown source.
Who will definitely have a lumbar puncture?
• A. 1 month old
• B. 5 month old
• C. 7 month old
• D. All of them

58. Q5
• A 3 week old infant presents with fever and cough. He
has no signs of respiratory distress and has been healthy
since birth. The nurse anticipates which of the following
orders?
• A. Blood culture
• B. Chest x-ray
• C. Lumber puncture
• D. All of the above

59. Q6
• A fully immunized 6 month old uncircumcised male infant
presents with cough, decreased feeding, temperature of
39.0°C (102.2°F) and a diagnosis of clinical bronchiolitis.
, the nurse anticipates which of the following orders?
• A. Blood culture
• B. Cath UA and culture
• C. Lumbar puncture
• D. RSV viral study

60. Q7
• A 2 year old presents with a fever of 39.1°C, is difficult to
arouse, and eating poorly. Based on the Pediatric Fever
Clinical Practice, the nurse anticipates which of the
following orders?
• A. Blood culture
• B. Cath UA and culture
• C. Lumbar puncture
• D. All of the above

61. Q8
• A 3 month old is discharged from the ED after work up
for fever of unknown source. The nurse’s parent teaching
should include the importance of a follow up
appointment with the baby’s primary care provider at:
• A. 24 hours
• B. 2-3 days
• C. 1 week
• D. Next well baby check at 4

62. Q9
• Fever of unknown origin is most dangerous in the following age
groups:
• A. 0-3 years
• B. 5-7 years
• C. 10-12 years
• D. 15-17 years

63. Finally
•Evaluation & management of fever of unknown source in
infants and
young children is challenging
 History & physical exam may provide few clues to guide
therapy
 Findings may be nonspecific
 Social interaction skill is limited
 Clinical scoring systems identifying those at low risk of
SBI have varying degrees of reliability in the very young.
(Avner & Baker,
2002)

64. Thank you