Pediatric Fever Workup in Urgent Care Setting
The approach to pediatric fever workup in urgent care settings should be age-stratified, with neonates (<28 days) requiring complete sepsis evaluation and referral for admission, infants 29-90 days requiring risk stratification, and children >3 months evaluated based on clinical appearance and specific risk factors. 1
Age-Based Approach
Neonates (<28 days)
- Complete sepsis workup required for ALL febrile neonates:
- Blood culture
- Urinalysis and urine culture
- Lumbar puncture for CSF analysis and culture
- Chest radiograph if respiratory symptoms present
- Disposition: Immediate referral for hospital admission and empiric parenteral antibiotics
Infants 29-90 days
- Risk stratification approach:
High-risk infants (ill-appearing, abnormal vital signs, concerning exam findings):
- Complete sepsis evaluation similar to neonates
- Referral for admission
Low-risk infants (well-appearing with normal exam):
- Blood culture
- Urinalysis and urine culture
- Consider lumbar puncture based on clinical judgment 2
- Possible outpatient management with close follow-up if all criteria met
Children >3 months
Well-appearing children:
- Focused evaluation based on clinical presentation
- Urinalysis and urine culture for children <24 months with fever without source
- Consider CBC with differential if temperature ≥39°C (102.2°F)
Ill-appearing children:
- More comprehensive evaluation including blood culture, urinalysis, and other tests as indicated
- Referral for admission if severely ill
Diagnostic Testing
Laboratory Tests
Urinalysis and urine culture: Indicated for:
- All febrile infants <90 days
- Children 3-24 months with fever without source
- Higher risk for UTI: girls <24 months, uncircumcised boys <12 months, children with urinary symptoms 1
Blood work:
- CBC with differential and blood culture for all infants <90 days with fever
- Consider for children >3 months with temperature >39°C (102.2°F) and no source 2
Lumbar puncture:
- Required for all febrile neonates <28 days
- Consider for infants 29-90 days based on clinical assessment
- May be deferred in well-appearing infants 29-90 days diagnosed with a viral illness 2
Imaging Studies
- Chest radiograph:
- Indicated for febrile children <3 months with evidence of acute respiratory illness
- Consider for children >3 months with temperature >39°C (102.2°F) and WBC >20,000/mm³
- Usually not indicated in febrile children >3 months with temperature <39°C (102.2°F) without clinical evidence of pulmonary disease 2
Important Clinical Considerations
Response to Antipyretics
- Response to antipyretic medication does NOT indicate a lower likelihood of serious bacterial infection 2
- Continue evaluation based on age and risk factors regardless of fever reduction
Common Pitfalls to Avoid
- Failing to recognize high-risk infants: All febrile neonates <28 days require full sepsis workup and admission
- Overreliance on clinical appearance: Even well-appearing infants <90 days may have serious bacterial infections
- Missing urinary tract infections: UTIs are the most common serious bacterial infection in young children with fever without source 3
- Inadequate follow-up arrangements: Close follow-up is essential for any febrile child managed as an outpatient
Special Populations
- Immunocompromised children: Require more aggressive evaluation and management
- Children with indwelling catheters: Consider catheter-related infections
- Children with sickle cell disease: Higher risk for serious bacterial infections
Follow-up Recommendations
- All febrile infants <90 days discharged from urgent care should have follow-up within 24 hours
- Clear return precautions should be provided to caregivers
- Document all follow-up arrangements in the medical record
By following this age-stratified approach and focusing on appropriate diagnostic testing based on risk factors, urgent care providers can effectively evaluate febrile children while minimizing unnecessary testing and interventions.