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Gokiert R, Cappelli M, Hnatko G, Newton AS. A systematic

review of crisis interventions used in the emergency department: recommendations for pediatric care and research.

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C, Lewis M. Improving child protection in the emergency

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tions for health care providers. Acad Emerg Med. 2010;17:

1 1 7-125.

Pediatric Fever

Shannon E. Sta ley, MD

Alisa A. McQueen, MD

Key Points

• Regardless of age, all toxic-appearing infants and chi ldren

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.

INTRODUCTION

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 arthri ­

tis, 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

• Management of well-appearing febrile infants aged

1 -3 months is determined by analyzi ng 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.

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.

CLINICAL PRESENTATION

� History

Elicit the duration, pattern, and maximum recorded temperature from caregivers. Young infants do not usually

have localizing symptoms and often present with nonspe ­

cific 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

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