When should a 17‑month‑old child with COVID‑19 and persistent fever be taken to the hospital?

When to Hospitalize a 17-Month-Old with COVID-19 and Persistent Fever

A 17-month-old child with COVID-19 should be taken to the hospital immediately if fever persists ≥24 hours at ≥38.0°C (100.4°F), or if any concerning clinical features develop, including respiratory distress, abnormal vital signs, neurologic changes, gastrointestinal symptoms, or signs suggesting Multisystem Inflammatory Syndrome in Children (MIS-C). 1

Critical Fever Thresholds for Hospital Evaluation

The specific fever criteria that mandate urgent evaluation vary by guideline organization, but all converge on the need for prompt assessment when fever persists:

• CDC criteria: Temperature ≥38.0°C for ≥24 hours (or subjective fever for ≥24 hours) in the context of COVID-19 exposure requires evaluation for MIS-C 1
• WHO criteria: Fever persisting for ≥3 days raises concern for MIS-C and warrants hospital assessment 1
• Royal College of Paediatrics criteria: Persistent fever ≥38.5°C with COVID-19 exposure should prompt immediate evaluation 1

Immediate Hospitalization Indicators

Any of the following clinical features mandate immediate hospital admission, regardless of fever duration: 1, 2, 3

• Respiratory distress of any severity (increased work of breathing, retractions, grunting) 1, 2
• Abnormal vital signs including tachycardia or tachypnea for age 1
• Neurologic changes such as altered mental status, confusion, encephalopathy, focal neurologic deficits, meningismus, or papilledema 1, 2
• Signs of shock or hypotension 1
• Significant dehydration or inability to maintain oral hydration 1, 2
• Features suggestive of Kawasaki disease (conjunctivitis, oral mucosal changes, rash, extremity changes) 1

MIS-C: The Critical Concern with Persistent Fever

Multisystem Inflammatory Syndrome in Children (MIS-C) is a potentially life-threatening complication that typically occurs 2-6 weeks after SARS-CoV-2 infection and presents with persistent fever plus multisystem involvement. 1, 4, 3

Clinical Features Raising Concern for MIS-C:

• Gastrointestinal symptoms: Abdominal pain, vomiting, or diarrhea 1, 3
• Mucocutaneous findings: Rash (polymorphic, maculopapular, or petechial), conjunctivitis without exudate, oral mucosal changes (red/cracked lips, strawberry tongue) 1, 3
• Extremity changes: Swollen hands or feet 1
• Cervical lymphadenopathy 1, 3

Laboratory Thresholds Mandating Hospital Admission:

If initial screening labs are obtained, the following results require immediate hospitalization: 1, 4, 3

• Markedly elevated inflammatory markers: CRP ≥10 mg/dL (commonly >20 mg/dL in MIS-C) 1, 3
• Evidence of cardiac involvement: Abnormal EKG findings, elevated troponin T, or elevated BNP/NT-proBNP 1, 4
• Evidence of renal or hepatic injury (even mild) 1
• Cytopenias: Lymphopenia, thrombocytopenia, or neutrophilia 1, 3
• Hyponatremia or hypoalbuminemia 1, 3

Structured Diagnostic Approach for Persistent Fever

Tier 1 Screening (Can Be Done Outpatient if Child Appears Well):

For a well-appearing 17-month-old with stable vital signs and persistent fever, initial screening may include: 1

• Complete blood count with differential 1
• Complete metabolic panel 1
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) 1
• SARS-CoV-2 PCR and serology (both are essential, as PCR may be negative weeks after infection) 1, 3

Tier 2 Evaluation (Requires Hospitalization):

If Tier 1 screening shows concerning results, proceed immediately to hospital admission for: 1, 4

• Cardiac assessment: EKG and echocardiogram (mandatory, as 20-55% of MIS-C cases develop left ventricular dysfunction and ~20% develop coronary artery abnormalities) 1, 4
• Cardiac biomarkers: Troponin T and BNP/NT-proBNP 1, 4
• Additional inflammatory markers: D-dimer, ferritin, LDH, IL-6, fibrinogen, procalcitonin 1, 4, 3

Outpatient Management Criteria (When Safe to Monitor at Home)

Outpatient management may be appropriate ONLY if ALL of the following are met: 1, 2, 3

• Child appears well with stable vital signs 1
• No respiratory distress 1, 2
• Normal mental status 1, 2
• Adequate hydration 1, 2
• No concerning physical examination findings 1
• Close clinical follow-up can be ensured within 24-48 hours 1, 2, 3
• Family can reliably monitor for warning signs and return immediately if any develop 2, 3

Critical Pitfalls to Avoid

• Do not assume a negative SARS-CoV-2 PCR rules out MIS-C: MIS-C typically occurs 2-6 weeks after initial infection when PCR is often negative; serology is essential 1, 3
• Do not underestimate cardiac risk: Up to 20% of MIS-C cases develop atrioventricular block, and coronary artery abnormalities occur in ~20% of cases 1, 4
• Do not delay evaluation based on fever duration alone: While WHO criteria specify ≥3 days, CDC criteria of ≥24 hours should guide urgent assessment in the context of other concerning features 1
• Rapid decompensation can occur: Some MIS-C patients deteriorate quickly, and specific risk factors for severe progression are not fully defined, so maintain a low threshold for admission 1, 3

Multidisciplinary Team Requirement

Once MIS-C is suspected or confirmed, immediate consultation is required with: 1, 4

• Pediatric rheumatology 1, 4
• Pediatric cardiology 1, 4
• Pediatric infectious disease 1, 4
• Pediatric hematology 1, 4