Initial Workup and Management for Fever in Children Over 5 Years Old
The initial workup for fever in children over 5 years old should focus on identifying the source of infection through targeted history, physical examination, and selective laboratory testing based on clinical presentation, with management primarily consisting of supportive care including appropriate antipyretics.
Clinical Assessment
History
- Duration of fever (persistent fever ≥10 days without improvement suggests bacterial sinusitis or other complications) 1
- Pattern of fever (double-sickening pattern with initial improvement followed by new fever is concerning) 1
- Associated symptoms:
- Respiratory (cough, nasal discharge, difficulty breathing)
- Gastrointestinal (vomiting, diarrhea, abdominal pain)
- Urinary (dysuria, frequency, foul-smelling urine)
- Neurological (headache, neck stiffness, altered mental status)
- Skin (rash, petechiae)
- Recent exposures, travel, or sick contacts
- Immunization status
- Past medical history
Physical Examination
- Vital signs (temperature, heart rate, respiratory rate, blood pressure)
- General appearance and level of activity
- Hydration status (skin turgor, mucous membranes, capillary refill)
- Complete examination focusing on:
- HEENT (ears, throat, sinuses)
- Respiratory system (work of breathing, auscultation)
- Abdomen (tenderness, organomegaly)
- Skin (rashes, petechiae)
- Neurological status
Laboratory and Imaging Studies
Laboratory Testing
- Not routinely indicated in well-appearing children over 5 years with identifiable source of infection
- Consider selective testing based on clinical presentation:
- Complete blood count (CBC) if concerned about bacterial infection
- Urinalysis and urine culture if urinary symptoms present
- Blood cultures if appears toxic or severely ill
Imaging Studies
- Chest radiograph is usually not indicated in febrile children with temperature <39°C without clinical evidence of pulmonary disease 2
- Consider chest radiograph in children with:
- Signs of respiratory distress
- Temperature >39°C AND WBC count >20,000/mm³ 2
Management Approach
Supportive Care
- Antipyretics should be administered primarily to improve the child's overall comfort rather than to normalize body temperature 3
Hydration
- Encourage oral fluids in small, frequent amounts
- Monitor urine output to ensure adequate hydration 1
Home Care Instructions
- Monitor for warning signs requiring immediate medical attention:
- Persistent high fever despite antipyretics
- Increased lethargy or decreased responsiveness
- Signs of dehydration (decreased urine output, dry mouth)
- Increased work of breathing
- Development of rash, especially non-blanching
Special Considerations
When to Consider Hospitalization
- Toxic appearance
- Inability to maintain hydration
- Underlying medical conditions that increase risk
- Social concerns about adequate home monitoring
When to Consider Antibiotics
- Clear source of bacterial infection identified
- Persistent fever >10 days without improvement
- Severe onset fever (≥39°C) with purulent nasal discharge for ≥3-4 consecutive days 1
Common Pitfalls to Avoid
- Overuse of antibiotics for likely viral infections
- Excessive focus on normalizing temperature rather than improving overall comfort 3
- Unnecessary laboratory testing in well-appearing children with likely viral illness
- Inadequate follow-up instructions for parents/caregivers
- Failure to recognize warning signs of serious bacterial infections
Remember that fever itself is not harmful but rather a physiologic mechanism with beneficial effects in fighting infection. The primary goal should be improving the child's overall comfort while monitoring for signs of serious illness 3.