What is the management of pediatric fever?

Management of Pediatric Fever

The management of pediatric fever should be age-stratified, with neonates (<28 days) requiring full sepsis evaluation and admission, infants 29-90 days requiring risk stratification, and children >2 months evaluated based on clinical appearance and specific risk factors for serious bacterial infection. 1

Age-Based Approach to Fever Management

Neonates (0-28 days)

• All febrile neonates require:
  • Complete sepsis evaluation (blood, urine, CSF cultures)
  • Hospital admission
  • Parenteral antibiotic therapy 1
  • High risk of severe bacterial infection (9%) 1

Young Infants (29-90 days)

• Risk stratification is appropriate:
  • Obtain blood cultures from all central venous catheter lumens 2
  • Consider peripheral blood cultures concurrently 2
  • Consider urinalysis and urine culture (high prevalence ~5%) 1, 2
  • Consider lumbar puncture if:
    • Child is unduly drowsy, irritable, or systemically ill
    • Age <18 months (especially <12 months)
    • Prolonged seizure or incomplete recovery within one hour 2
  • Low-risk infants may be managed as outpatients with close follow-up 1

Children (2-24 months)

• Evaluate for urinary tract infection (most common SBI, 5-7% prevalence) 2
  • Higher risk in uncircumcised males (up to 20%) 2
• Consider chest radiography only in symptomatic patients 2
• Various clinical decision rules exist (Rochester, Philadelphia, Boston, Pittsburgh criteria, Yale Observation Scale) but no consensus on the most useful prediction rule 2

Diagnostic Approach

1. Temperature Measurement:

   • Rectal temperature is the gold standard (>38°C/100.4°F defines fever) 1
   • Axillary or tympanic measurements are less reliable 1
   • Consider recent antipyretic use which may mask fever 1

2. Clinical Assessment:

   • Evaluate general appearance, activity level, and hydration status
   • Look for signs of serious infection: cyanosis, poor circulation, petechial rash, inconsolability 1
   • Assess for localizing signs of infection 1

3. Laboratory Testing:

   • For children without source:
     • 13% with temperature 38-39°C receive testing
     • 36% with temperature ≥39°C receive testing 3
   • Consider combination of diagnostic tests with procalcitonin 2
   • Urinalysis and culture for suspected UTI 2

Treatment Recommendations

1. Antipyretic Management:

   • Treat fever to promote comfort and prevent dehydration 2
   • Paracetamol (acetaminophen) is preferred 2
   • Avoid physical cooling methods (fanning, cold bathing, tepid sponging) as they cause discomfort 2
   • Ensure adequate fluid intake 2

2. Antibiotic Therapy:

   • For high-risk patients: Use monotherapy with antipseudomonal β-lactam or carbapenem 2
   • Reserve addition of second Gram-negative agent or glycopeptide for:
     • Clinically unstable patients
     • Suspected resistant infection
     • Centers with high rates of resistant pathogens 2
   • For low-risk patients: Consider oral antibiotics if tolerated 2

3. Follow-up Care:

   • Close monitoring is essential, especially for outpatient management
   • Consider discontinuing empiric antibiotics at 72 hours in low-risk patients with:
     • Negative blood cultures
     • Afebrile for at least 24 hours 2

Special Considerations

• Febrile Seizures:

  • Excellent prognosis for neurological development after simple febrile seizures 2
  • Risk of subsequent epilepsy after a single febrile seizure is about 2.5% 2
  • Risk of recurrence is about 30% overall, higher in younger children 2

• Immunocompromised Children:

  • Require more aggressive evaluation and management
  • Consider empiric antifungal therapy after 96 hours of persistent fever despite antibiotics in high-risk patients 2

• Parent Education:

  • Provide explanation about fever and its management
  • Instructions about antipyretic use
  • Clear return precautions
  • Reassurance when appropriate 2

Remember that while most febrile illnesses in children are viral and self-limited 4, careful assessment is needed to identify those at risk for serious bacterial infections, with urinary tract infections being the most common cause of serious bacterial illness in children 2, 4.