Pediatric Fever

Key considerations: Meningitis, Sepsis / Bacteremia, Urinary Tract Infection (pyelonephritis)

Cannot miss

history: Duration and degree of fever; Associated symptoms: URI, GI, rash, irritability; Immunization status — partially immunized?; Sick contacts, daycare attendance; Fluid intake and urine output; Prior UTI or renal anomalies; exam: General appearance: playful vs toxic-appearing; Fontanelle: bulging, flat, sunken; ENT: red TMs, pharyngeal erythema; Lungs: tachypnea, retractions, crackles; Abdomen: tenderness, organomegaly; Skin: rash, petechiae, capillary refill; labs: CBC with differential; Blood culture; Urinalysis and urine culture (catheterized specimen <2 years); CRP and/or procalcitonin; CSF analysis if <28 days or ill-appearing; BMP if dehydrated; imaging: CXR if tachypneic or respiratory findings; Renal ultrasound if first febrile UTI in infant; bedside: Core temperature (rectal preferred in infants); Point-of-care glucose

immediate: Full sepsis workup for any neonate <28 days with fever ≥38°C; IV access and empiric antibiotics if toxic-appearing at any age; Antipyretics for comfort: acetaminophen 15mg/kg or ibuprofen 10mg/kg (>6 months); general: Apply Rochester / Philadelphia / Step-by-Step criteria for risk stratification in febrile infants; Serial clinical reassessment; specific: diagnosis: Neonatal fever (<28 days); steps: Full sepsis workup: blood, urine, CSF cultures; Ampicillin + gentamicin (or cefotaxime) empirically; Admit to NICU or monitored bed; Add acyclovir if HSV risk factors; diagnosis: Febrile UTI; steps: Ceftriaxone 50mg/kg IV or IM; Transition to oral antibiotics when tolerating; Renal ultrasound for first febrile UTI <2 years; diagnosis: Kawasaki Disease; steps: IVIG 2g/kg single infusion; High-dose aspirin 80-100mg/kg/day divided q6h until afebrile; Echocardiogram at diagnosis, 2 weeks, 6-8 weeks; Cardiology consult

admit: All neonates <28 days with fever; Toxic-appearing child at any age; Febrile infant 29-60 days unless meets low-risk criteria; Suspected Kawasaki disease; Unable to tolerate oral intake; discharge: Well-appearing child >90 days with identifiable viral source; Low-risk febrile infant 29-60 days with reliable follow-up in 24 hours; Adequate oral intake and reliable caregivers; consults: Pediatric infectious disease if complex; Cardiology for Kawasaki disease

In neonates <28 days, fever is SEPSIS until proven otherwise — always do full workup and admit
Rochester criteria identify low-risk febrile infants 29-60 days: well-appearing, no focal infection, WBC 5-15k, UA negative
Kawasaki disease: fever ≥5 days + 4 of 5 criteria (conjunctivitis, mucous membrane changes, rash, extremity changes, cervical lymphadenopathy)
Bundling and overbundling can cause fever in neonates — but NEVER assume this without full workup

AAP Febrile Infant Guidelines 2021, Pediatric Emergency Medicine (Fleisher & Ludwig). Last reviewed: 2024-11-01