Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Strategies for the evaluation of fever in neonates and infants (less than three months of age)

INTRODUCTION

Fever is a prominent symptom of many different disease processes. Neonates and young infants may manifest fever as the only sign of significant underlying infection. Clinically distinguishing those with a serious febrile illness from those who are mildly ill may be difficult [1]. This has led to an aggressive approach to fever in this age group, usually including diagnostic tests, empiric antibiotics and, often, hospital admission.

A systematic approach to evaluating infants with fever without a source in this age group would ideally identify the patient with a serious bacterial illness (SBI) and minimize the testing and treatment of the patient with a mild illness. Several strategies for identifying the infant with fever who has an SBI have been proposed and tested. The strengths and limitations of these protocols, as well as the utilization of proposed guidelines are discussed here.

The definition, immunologic vulnerability, and etiology of fever in infants less than three months of age, as well as the evaluation and management of fever in these patients, are discussed elsewhere. (See "Definition and etiology of fever in neonates and infants (less than three months of age)" and "Evaluation and management of fever in the neonate and young infant (younger than three months of age)".)

TRADITIONAL STRATEGIES

Several studies have attempted to identify patients who can be managed safely as outpatients with or without empiric antibiotic treatment [2]. There is some variation among them regarding inclusion criteria, inpatient or outpatient population, and whether or not antibiotics were given expectantly. This has led to confusion in the literature and a lack of consensus regarding the optimal approach to young infants with fever. Furthermore, even when guidelines have been proposed, they have not been consistently followed by many practitioners in the community [3-5]. (See 'Problems with these approaches' below.)

Nevertheless, these studies established the safety of treating a select population of young infants as outpatients. The sum of these studies suggests that the incidence of serious bacterial infection (SBI) among infants categorized as low risk after a full evaluation is 2.2 percent (range, 0 to 6.3 percent) [2]. When limited to studies that prospectively identified infants at low risk of SBI (algorithm 1) and performed outpatient observation with no antibiotics, the frequency of SBI varied from 0.5 to 1.1 percent in studies that either did or did not include lumbar puncture as part of the initial evaluation, respectively [6]. (See "Evaluation and management of fever in the neonate and young infant (younger than three months of age)", section on 'Evaluation and management'.)

            

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2014. | This topic last updated: May 9, 2013.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Bonadio WA. Incidence of serious infections in afebrile neonates with a history of fever. Pediatr Infect Dis J 1987; 6:911.
  2. Huppler AR, Eickhoff JC, Wald ER. Performance of low-risk criteria in the evaluation of young infants with fever: review of the literature. Pediatrics 2010; 125:228.
  3. Goldman RD, Scolnik D, Chauvin-Kimoff L, et al. Practice variations in the treatment of febrile infants among pediatric emergency physicians. Pediatrics 2009; 124:439.
  4. Bergman DA, Mayer ML, Pantell RH, et al. Does clinical presentation explain practice variability in the treatment of febrile infants? Pediatrics 2006; 117:787.
  5. Pantell RH, Newman TB, Bernzweig J, et al. Management and outcomes of care of fever in early infancy. JAMA 2004; 291:1203.
  6. Baraff LJ. Management of fever without source in infants and children. Ann Emerg Med 2000; 36:602.
  7. Dagan R, Sofer S, Phillip M, Shachak E. Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serious bacterial infections. J Pediatr 1988; 112:355.
  8. Baker MD, Bell LM, Avner JR. Outpatient management without antibiotics of fever in selected infants. N Engl J Med 1993; 329:1437.
  9. Baskin MN, O'Rourke EJ, Fleisher GR. Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. J Pediatr 1992; 120:22.
  10. Jaskiewicz JA, McCarthy CA, Richardson AC, et al. Febrile infants at low risk for serious bacterial infection--an appraisal of the Rochester criteria and implications for management. Febrile Infant Collaborative Study Group. Pediatrics 1994; 94:390.
  11. McCarthy CA, Powell KR, Jaskiewicz JA, et al. Outpatient management of selected infants younger than two months of age evaluated for possible sepsis. Pediatr Infect Dis J 1990; 9:385.
  12. Kadish HA, Loveridge B, Tobey J, et al. Applying outpatient protocols in febrile infants 1-28 days of age: can the threshold be lowered? Clin Pediatr (Phila) 2000; 39:81.
  13. Ferrera PC, Bartfield JM, Snyder HS. Neonatal fever: utility of the Rochester criteria in determining low risk for serious bacterial infections. Am J Emerg Med 1997; 15:299.
  14. Baker MD, Bell LM. Unpredictability of serious bacterial illness in febrile infants from birth to 1 month of age. Arch Pediatr Adolesc Med 1999; 153:508.
  15. Chiu CH, Lin TY, Bullard MJ. Application of criteria identifying febrile outpatient neonates at low risk for bacterial infections. Pediatr Infect Dis J 1994; 13:946.
  16. Schwartz S, Raveh D, Toker O, et al. A week-by-week analysis of the low-risk criteria for serious bacterial infection in febrile neonates. Arch Dis Child 2009; 94:287.
  17. Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research. Ann Emerg Med 1993; 22:1198.
  18. American College of Emergency Physicians Clinical Policies Committee, American College of Emergency Physicians Clinical Policies Subcommittee on Pediatric Fever. Clinical policy for children younger than three years presenting to the emergency department with fever. Ann Emerg Med 2003; 42:530.
  19. Baraff LJ. Editorial: Clinical policy for children younger than three years presenting to the emergency department with fever. Ann Emerg Med 2003; 42:546.
  20. Belfer RA, Gittelman MA, Muñiz AE. Management of febrile infants and children by pediatric emergency medicine and emergency medicine: comparison with practice guidelines. Pediatr Emerg Care 2001; 17:83.
  21. Young PC. The management of febrile infants by primary-care pediatricians in Utah: comparison with published practice guidelines. Pediatrics 1995; 95:623.
  22. Roberts KB. Young, febrile infants: a 30-year odyssey ends where it started. JAMA 2004; 291:1261.