fever without a source in children 3 to 36 months of age

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FEBRILE ILLNESS IN CHILD

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Fever without a source in children 3 to 36 months of age Author Coburn H Allen, MD Section Editors Gary R Fleisher, MD Sheldon L Kaplan, MD Deputy Editor James F Wiley, II, MD, MPH Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Feb 2013. | This topic last updated: Dec 17, 2012. INTRODUCTION Fever is a common symptom among children seeking medical care. Most children undergo evaluation for a febrile illness before their third birthday, and nearly one-third of pediatric outpatient visits are for fever [1-3].

When the history and physical examination cannot identify a specific source of fever in an acutely ill, nontoxic-appearing child less than three years of age, the illness is often called fever without a source (FWS). Alternative terms are fever without localizing signs (FWLS) or fever without a focus. This topic will review the etiology, evaluation, and management of the child 3 to 36 months of age with fever of less than seven days duration. Fever in newborns, infants younger than three months, and fever of unknown origin (7 days) are reviewed separately. (See "Evaluation and management of fever in the neonate and young infant (less than three months of age)" and "Approach to the child with fever of unknown origin" and "Etiologies of fever of unknown origin in children".) BACKGROUND Fever of concern In children 3 to 36 months of age, the diagnosis of fever is based upon core temperature, which is measured most accurately rectally. The history of an elevated temperature recorded at home should be considered equivalent to that taken in a medical facility. Fever 39C (102.2F) or higher is the threshold above which evaluation for a source of occult infection, including urinary tract infection (UTI), may be warranted [4]. (See 'Occult sources of infection' below.) The majority of children with fever have either a self-limited viral infection or a recognizable source of bacterial infection. However, research in the 1970s identified a population of wellappearing febrile young children who had occult bacteremia [5,6]. Subsequent studies demonstrated that some of these children went on to develop serious focal bacterial infections, such as pneumonia and meningitis [7,8]. Although laboratory testing identified a group of children at an increased risk for occult bacteremia, many who were not bacteremic received presumptive treatment with broad spectrum antibiotics while awaiting definitive blood culture results. The introduction of vaccines to prevent Haemophilus influenzae type b (Hib) and pneumococcal disease has dramatically lowered the incidence of occult bacteremia and, as a result, changed the issues facing the clinician who is evaluating a young child with fever. (See 'Impact of vaccines' below.) Population of interest This topic will focus on the evaluation and management of wellappearing, immunocompetent children 3 to 36 months of age with fever 39C (102.2F) of less than seven days duration and no focus of infection identified by a complete physical examination. The evaluation of the febrile infant younger than three months is discussed separately. (See "Evaluation and management of fever in the neonate and young infant (less than three months of age)".) Immunization status The approach to the child who has fever without a source is greatly determined by immunization status.

Complete immunization In the discussion that follows, a completely immunized child has received the primary booster series of three immunizations with conjugate vaccines Streptococcus pneumoniae (PCV7 or PCV13), at least two doses of Haemophilus influenzae, type b (Hib), and remains on schedule. However, some experts consider two doses of PCV7 or PCV13 sufficient to prevent invasive Streptococcus pneumoniae infection. Patients who have not received the booster 12 to 15 months after the third Hib and either PCV7 or PCV13 are also considered to be at much lower risk of bacteremia. (See "Pneumococcal (Streptococcus pneumoniae) conjugate vaccines in children", section on 'Alternative or abbreviated schedule'.) Incomplete immunization In the discussion that follows, an incompletely immunized child has not received the primary booster series of three vaccinations with both Hib and either PCV7 or PCV13. Based on these criteria, any child under six months of age is incompletely immunized. CAUSES OF FEVER Fever can be caused by infectious and noninfectious processes. The vast majority of young children with fever have an infectious etiology. Noninfectious etiologies include drug fever, immunization reactions, central nervous system dysfunction, malignancy (eg, leukemia), and chronic inflammatory conditions (ie, inflammatory bowel disease and juvenile idiopathic arthritis). Although caretakers may sometimes attribute fever to teething, fever >38.5C is unlikely to be caused by teething [9]. (See "Anatomy and development of the teeth", section on 'Primary teeth eruption'.) The source of fever may be a recognizable bacterial or viral illness. In a study of a large cohort of children 3 to 36 months of age presenting to a primary care provider with a febrile illness, a readily identifiable presumed bacterial illness was diagnosed at the initial encounter in 56 percent of children, almost 90 percent of whom had otitis media [1]. A specific viral infection (eg, croup, bronchiolitis, varicella, roseola) was identified in an additional 4 percent of children [1]. Similarly, 6 percent of 21,216 children 3 to 36 months of age with fever 39C seen in the emergency department of an urban tertiary care children's hospital had a recognizable viral syndrome, 47 percent had FWS, and 47 percent had a specific bacterial infection requiring antibiotics or chronic illness (eg, immunocompromised state, central line) that affected the fever evaluation [10]. Serious bacterial infectious syndromes that occur in children 3 to 36 months of age include meningitis, pneumonia, and cellulitis. In one series (prior to the introduction of Hib and pneumococcal conjugate vaccines) of 996 febrile children less than 36 months of age, 6 months of age with FWS who are completely immunized, we suggest that girls 12 months of age and circumcised boys >6 months of age with FWS, all of whom have been completely immunized, we do not suggest routine laboratory evaluation. In addition, these children should not receive presumptive treatment with antibiotics (Grade 1B). However, urinalysis and urine culture should be obtained in those at high risk for UTI. (See 'Urine tests' above and 'Immunization complete' above.) Completely immunized children with fever 39C (102.2F) and an abnormal urinalysis should be treated for a urinary tract infection. (See 'Immunization complete' above and "Acute management, imaging, and prognosis of urinary tract infections in infants and children older than one month", section on 'Antibiotic therapy'.)

Clinical follow-up

We recommend that children with fever that persists for more than 48 hours or with a deterioration in clinical condition undergo repeat medical evaluation.

Culture follow-up Urine cultures

Patients with a positive urine culture require treatment tailored to the identified organism and their clinical status. (See "Acute management, imaging, and prognosis of urinary tract infections in infants and children older than one month", section on 'Overview'.)

Blood cultures

Children of 3 to 36 months of age with a positive blood culture for a presumed pathogen require reevaluation and management based on their appearance, persistence of fever, and specific isolate (algorithm 2). (See 'Positive blood cultures' above.) We suggest that the child who is well on follow-up, afebrile, and has an isolate from a preliminary report of a blood culture that is a likely contaminant, be followed on a daily basis as an outpatient without antibiotic treatment, pending the final identification of the organism (Grade 2C). (See 'Probable blood culture contaminant' above.)

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REFERENCES1. Finkelstein JA, Christiansen CL, Platt R. Fever in pediatric primary care: occurrence,

management, and outcomes. Pediatrics 2000; 105:260.2. Nelson DS, Walsh K, Fleisher GR. Spectrum and frequency of pediatric illness

presenting to a general community hospital emergency department. Pediatrics 1992; 90:5. 3. Krauss BS, Harakal T, Fleisher GR. The spectrum and frequency of illness presenting to a pediatric emergency department. Pediatr Emerg Care 1991; 7:67. 4. 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. 5. McGowan JE Jr, Bratton L, Klein JO, Finland M. Bacteremia in febrile children seen in a "walk-in" pediatric clinic. N Engl J Med 1973; 288:1309. 6. Teele DW, Pelton SI, Grant MJ, et al. Bacteremia in febrile children under 2 years of age: results of cultures of blood of 600 consecutive febrile children seen in a "walk-in" clinic. J Pediatr 1975; 87:227. 7. Shapiro ED, Aaron NH, Wald ER, Chiponis D. Risk factors for development of bacterial meningitis among children with occult bacteremia. J Pediatr 1986; 109:15. 8. Baraff LJ, Oslund S, Prather M. Effect of antibiotic therapy and etiologic microorganism on the risk of bacterial meningitis in children with occult bacteremia. Pediatrics 1993; 92:140. 9. Tighe M, Roe MF. Does a teething child need serious illness excluding? Arch Dis Child 2007; 92:266. 10. Greenes DS, Harper MB. Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatr Infect Dis J 1999; 18:258. 11. McCarthy PL. Acute infectious illness in children. Compr Ther 1988; 14:51. 12. Wright PF, Thompson J, McKee K

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