What is the approach to a 14-month-old child presenting to the emergency room (ER) with fever, including initial assessments, differential diagnoses, and red flags?

Approach to a 14-Month-Old with Fever in the Emergency Room

For a 14-month-old presenting with fever to the ER, perform a focused assessment for serious bacterial infection with particular attention to urinary tract infection, which accounts for >90% of serious bacterial illness in this age group. 1, 2

Initial Assessment

Vital Signs and Definition

• Fever is defined as temperature ≥38°C (100.4°F)
• Obtain rectal temperature (gold standard for young children) 1
• Assess other vital signs: heart rate, respiratory rate, blood pressure, oxygen saturation
• Calculate capillary refill time

History

• Duration and pattern of fever
• Associated symptoms (vomiting, diarrhea, cough, rash)
• Fluid intake and urine output
• Vaccination status
• Recent exposures (daycare, sick contacts)
• Travel history
• Previous medical conditions

Physical Examination

• General appearance (using pediatric assessment triangle)
• Level of hydration
• Respiratory status (work of breathing, retractions)
• Complete examination with focus on:
  • Ears, throat, and lymph nodes
  • Chest auscultation
  • Abdominal examination
  • Skin assessment for rashes or petechiae
  • Fontanelle assessment if still open
  • Joint examination for signs of swelling or pain

Red Flags Requiring Immediate Action 1

• Breathing difficulties
• Drowsiness or altered mental status
• Petechial rash
• Bulging fontanelle
• Neck stiffness
• Persistent vomiting (>24 hours)
• Poor feeding or decreased urine output
• Seizures
• Chronic comorbid disease
• Inconsolability or toxic appearance

Differential Diagnosis

Common Causes

• Viral infections (most common cause) 2
  • Upper respiratory infections
  • Viral gastroenteritis
  • Roseola
  • Hand, foot, and mouth disease

Bacterial Infections

• Urinary tract infection (highest priority - accounts for >90% of serious bacterial illness) 1, 2
• Otitis media
• Pneumonia
• Bacteremia/sepsis
• Meningitis
• Cellulitis/skin infections

Other Considerations

• Post-vaccination fever
• Kawasaki disease
• Periodic fever syndromes
• Malignancy (rare)

Diagnostic Workup

For All Febrile 14-Month-Olds

• Complete physical examination
• Assess hydration status

Laboratory Testing Based on Clinical Findings

• Urinalysis and urine culture (highest yield) 1
  • Indicated in this age group, especially for girls <24 months and uncircumcised boys <12 months
• Complete blood count if concerning features
• Blood culture if toxic appearance
• Chest radiography only if respiratory symptoms present 1
• Lumbar puncture if meningeal signs or altered mental status

Management

Supportive Care

• Ensure adequate hydration
• Treat fever for comfort using paracetamol (acetaminophen) 15 mg/kg 1
  • Avoid aspirin (risk of Reye's syndrome) 1
  • Ibuprofen is an alternative (avoid in dehydrated children) 3
• Remove excess clothing but avoid physical cooling methods 1, 4

Disposition Decision

• Discharge criteria:
  • Well-appearing
  • Good hydration
  • Reliable caregivers
  • No high-risk features
  • Ability for follow-up within 24-48 hours
• Admission criteria:
  • Toxic appearance
  • Dehydration requiring IV fluids
  • Suspected serious bacterial infection
  • Immunocompromised state
  • Social concerns about follow-up

Key Pitfalls to Avoid

• Do not use response to antipyretics to rule out serious bacterial infection 1
• Do not overlook UTI in this age group - it's the most common serious bacterial infection 1, 2
• Do not perform unnecessary chest radiography in asymptomatic patients 1
• Do not use aspirin for fever management in children under 16 years 1
• Do not forget to provide clear return precautions to parents 1

Remember that while viral infections are most common in this age group 2, 5, serious bacterial infections must be ruled out, with particular attention to urinary tract infections which are the predominant cause of serious bacterial illness in young children.