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Emergency And Acute Medicine – Pediatric Fever
Basics Description
Fever in children is defined as a rectal temperature of 38°C (100.4°F) or higher. Oral and tympanic temperatures are typically 0.6°C to 1°C lower than rectal measurements, and tympanic readings are unreliable in infants younger than six months. Axillary temperatures are generally inaccurate. Children who present afebrile but have a reliable history of documented fever should be considered febrile to the reported degree.
Etiology
Common causes of pediatric fever include bacteremia, viral illnesses often associated with exanthems, and localized infections. Vaccination against Haemophilus influenzae type B and Streptococcus pneumoniae has significantly reduced invasive disease caused by these organisms. Central nervous system causes include meningitis and encephalitis. Head and neck sources include otitis media, pharyngitis, cervical adenitis, sinusitis, mastoiditis, periorbital cellulitis, and deep neck space abscesses. Respiratory causes include croup, bronchiolitis, pneumonia, empyema, influenza, and epiglottitis. Additional etiologies include cardiac infections, urinary tract infections, gastrointestinal disease, osteomyelitis, septic arthritis, cellulitis, Kawasaki disease, neonatal herpes simplex virus infection, malignancy, drug reactions, heat-related illness, endocrine disorders, and inflammatory or autoimmune disease.
Diagnosis Signs And Symptoms
Clinical appearance is the most important factor in assessment. Airway, breathing, and circulation must be evaluated carefully, with special attention to hydration and perfusion. Toxic features include lethargy, poor feeding, delayed capillary refill, abnormal respirations, weak cry, hypotonia, and petechial or purpuric rash. Tachycardia and tachypnea may be the only early signs of serious illness. Fever increases heart rate by approximately ten beats per minute per degree Fahrenheit. Temperatures above 40°C are associated with increased bacteremia risk in children younger than twenty-four months, while temperatures above 42°C are more often noninfectious. Altered mental status may present as lethargy, irritability, or impaired interaction. Pneumonia should be suspected with tachypnea or hypoxia, and urinary tract infection should be considered in young females, uncircumcised males, and children with fever without a source. Febrile seizures may occur, and serious infection can be present even without fever. Antipyretics may improve clinical appearance without affecting underlying pathology, which can aid assessment. Approximately twenty percent of children will have fever without an identifiable source after initial evaluation.
Essential Workup
Oxygen saturation should be considered a mandatory vital sign. Resuscitation is initiated as needed. A focused history should include duration and pattern of fever, antipyretic use, immunization status, medical history, medications, birth history for infants younger than six months, exposures, feeding and elimination patterns, travel history, and review of systems. A thorough physical examination is performed to identify a source, and antipyretic therapy is initiated.
Diagnosis Tests And Interpretation
Laboratory evaluation may include a complete blood count with differential and urinalysis with culture in all male infants younger than six months, uncircumcised males younger than twelve months, and females younger than two years, using catheterized or suprapubic specimens. Blood cultures are obtained when bacteremia is suspected. Cerebrospinal fluid analysis is required for toxic children and neonates and considered selectively in older infants. Stool studies are indicated when bacterial diarrhea is suspected. Inflammatory markers such as C-reactive protein, erythrocyte sedimentation rate, and procalcitonin may provide supportive information. Chest radiography is indicated for tachypnea, hypoxia, or respiratory findings, with additional imaging guided by suspected source.
Treatment
Prehospital care focuses on stabilization and early antipyretic administration. Initial emergency department management prioritizes treatment of life-threatening conditions. Antipyretics are administered, while evaporative cooling has a limited role. Toxic-appearing children require immediate sepsis evaluation and empiric antibiotics. Neonates younger than twenty-eight days require full sepsis workup and admission with empiric antimicrobial therapy. Infants aged twenty-nine to ninety days are managed based on risk stratification, with selective laboratory evaluation, antibiotic use, and close follow-up. Children three months to three years of age are evaluated selectively, with focused testing based on clinical findings. Immunocompromised children, those with petechiae or purpura, sickle cell disease, malignancy, indwelling devices, or incomplete immunizations require aggressive evaluation and management.
Follow Up Disposition
Admission is required for toxic patients, neonates with fever, higher-risk infants who do not meet low-risk criteria, immunocompromised children, and those with unreliable follow-up. Discharge may be considered for well-appearing infants meeting low-risk criteria and older children who are nontoxic with reliable caregivers and follow-up. Clear return precautions and re-evaluation within twenty-four to forty-eight hours are essential.
Follow Up Recommendations
Children discharged with fever require close follow-up with a primary care provider and explicit instructions for return if symptoms worsen or new signs develop.
Key Clinical Insights And Common Errors
Fever is the most frequent presenting complaint in pediatric patients and may indicate life-threatening disease. Neonates require empiric treatment until serious infection is excluded. Older children may appear well despite significant illness, making subtle findings such as tachycardia, tachypnea, or altered mental status critically important. Inadequate follow-up and failure to recognize early signs of serious infection are common sources of error.
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