Evaluation of the Febrile Infant

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The Febrile InfantSteven Lanski, MD FAAP Emory University School of Medicine Children’s Healthcare of Atlanta @ Egleston


ObjectivesReview the management options available when evaluating a febrile infant Review pertinent literature Management options Special cases


What Would You Do?Well appearing 3 week infant fever 38 at home afebrile during evaluation 2) Well appearing 7 month circumcised male with diarrhea for 5 days and fever 3 days, temp 39.1 in office 3) Tired appearing 4 y.o. female, temp 40.5, no source


EvaluationHistory Timeline and degree Associated symptoms Past medical conditions Decreased defense Hardware Physical Appearance Other source Skin involvement


GuidelinesExpert consensus Based on available evidence Regional variation Account for changing patterns and advances Limit unnecessary evaluations Invasive procedures False positives Maximize available resources


Management Based on Age Neonates 28-90 days 3 – 6 months 6 – 24 months >24 months


Published Practice Guidelines Baraff et al. Annuals Emerg Med and Pediatrics 1993 Expert consensus based on literature Fever > 38 (0-3 months) and > 39 (3-36 months) Infants at greatest risk during 0-3 months Rochester criteria selected as screening criteria


Rochester CriteriaDagan R, et al. Journal of Pediatrics 1985. Well appearing term infants Follow-up assured Temp > 38 WBC 5-15,000/mm3 Band count < 1500 /mm3 Urinalysis with < 10 WBC/hpf No evidence of ear, soft tissue or bone infection Modified (1988) if diarrhea present <5 WBC / hpf


Management < 28 daysNeonates frequently do not show early signs of serious bacterial infections (SBI) Rates of serious bacterial infection in febrile infants < 2 months is 8-14% Poor immunity Maternal pathogens (GBBS, E. coli) and Listeria Infants less than 28 days of age should have full evaluation and hospitalization with IV antibiotics Ampicillin and Cefotaxime or Gentamicin


Management 29-60 Days Work–up CBC/D, BCX, UA/UCX (consider CRP and LP) Stool and CXR based on history / exam Antibiotics and admission for patients with abnormal labs Positive UA, WBC >15,000, Band >1500 LP if not already done Ceftriaxone or Cefotaxime


Management 60-90 DaysAt risk for occult bacteremia Pneumococcus and HIB Exam may still be unreliable Beginning to develop immunity Limited investigations (blood and urine) Abnormal – management as previously described Low risk – follow-up within 24 hours with or without antibiotics Strongly consider LP if giving antibiotics


Management 3-6 monthsOccult Bacteremia remains a concern Exam more reliable in identifying children at risk particularly those with meningitis Pneumococcal vaccine begins to have protective effect to what extent ? Fever cut-off raises to >39


Management 3-6 month cont…In patients without well defined source ASOM, Bronchiolitis, Stomatitis, Croup, AGE… Screen blood and urine WBC >15,000 (send cultures) consider antibiotics (consensus recommendations) WBC >20,000 or ANC > 10,000 give antibiotics Follow-up within 24 hours


Invasive Pneumococcal Disease CDC: Active Bacterial Core Surveillance, eight states, 1998-2005 CDC: Active Bacterial Core Surveillance, eight states, 1998-2005


Management 6-24 monthsIn a fully immunized infant with fever > 39 Urine based on age and sex Circumcised males >6 months unnecessary unless clinical condition dictates Uncircumcised males until 1 year of age Females until 2 years Consensus recommends blood <36 months Prior to pneumococcal vaccine


Bronchiolitis and SBIKuppermann N. Arch Ped Adol Med 1997 Compared rates of bacteremia and UTIs in febrile children w/o bronchiolitis 432 children aged 0-24 months Children with bronchiolitis had fewer positive cultures Blood 0% vs 2.7% Urine 1.9% vs 13.6% (Titus and Wright – Peds 2004) No child < 2 months positive for bronchiolitis had a positive culture


UTI - Clinical Decision RuleGorelick M. Arch Ped Adol Med 2000 Risk factors T > 39 Fever > 2 days White race < 12 months Absence of another source All + UTI had at least 1 risk factor Using 2 risk factors as the screening requirement 0.8% probability of UTI in those screening negative 6.4% probability of a UTI in those screening positive


Special CasesPrematurity Immunocompromised Patients with hardware


Best Course of Action?Regional epidemiology Regional practice patterns Consensus guidelines Personal risk tolerance Risk minimizer vs Test minimizer


Children’s Healthcare of Atlanta Guidelines < 29 days


CHOA Guidelines 29 – 60 days


CHOA Guidelines 2-6 months


CHOA Guidelines >6-24 months



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Last Updated: 8th March 2018

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