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  • The risk of bacteremia appears to have been modified dramatically by the use of more advanced broad-spectrum antibiotics, advanced diagnostic testing, and immunization against Hemophilus influenza and Streptococcus pneumoniae. A positive blood culture is nearly as likely to be due to a contaminant as to a real pathogen.
  • Given the extremely low risk of bacteremia and its sequelae, the best expectant therapy in the well-appearing child is close observation and follow-up pending culture results.
  • Tachycardia and tachypnea may be the only indications of a serious illness in an otherwise well-appearing febrile child.
  • Signs of clinical toxicity include altered or decreased mental status; significantly abnormal vital signs; dyspnea; color changes, such as cyanosis and pallor; and hypoxia, as measured by pulse oximetry. These children require immediate stabilization including airway management, oxygen, intravenous access and administration of saline fluid bolus, temperature management, rapid examination, laboratory evaluation and immediate empiric antibiotic therapy, pending further diagnosis.
  • Well-appearing febrile infants who have no identifiable source and normal leukocyte count, chest radiograph and urinalysis, and who are fully immunized may be safely discharged with symptomatic care for close follow-up of cultures without presumptive antibiotic therapy.
  • In the nontoxic child with no obvious clinical syndrome, risk factors for serious bacterial infection need to be determined, including fever greater than 39°C; age <2 months; unimmunized status; chronic diseases such as asthma, congenital heart disease, and CSF shunts; and immunocompromised patients.
  • When risk factors are present, a workup should be performed including a complete blood count with leukocyte and immature neutrophil count and markers of inflammation including C-reactive protein, blood culture, and urinalysis and urine culture in established risk groups. Lumbar puncture and spinal fluid analysis should be performed in those children who appear to have or are at risk for meningitis.
  • In those with no identified source, the chart should clearly reflect cardiorespiratory stability, adequate feeding behavior, adequate urine output, and alertness at the time of discharge. Follow-up must be arranged before discharge with symptomatic care only.


Fever is the most common complaint for children presenting to the emergency department (ED), representing more than 20% of all presenting complaints annually.1 The evaluation of fever in the pediatric patient is complicated by age-related variations such as patient's ability to communicate, immune system development, immunization status, the presence of fever in both minor and serious illness, and parental perception of seriousness. Similarly, advances in the understanding of clinical assessment, diagnostic modalities, and treatment regimens are ongoing. As a result, the classic approach to febrile children by age group is under constant revision.26 While little disagreement exists regarding the management of neonates younger than 30 days, considerable disagreement and practice variation exists for children 30 days to 36 months of age. In children older than 36 months, there are more reliable clinical findings and the risk of disseminated bacterial infection is low. As a result, clinical evaluation, diagnostic testing, and treatment focus on a specific source of infection and therefore there is greater agreement among practitioners. In addition, older febrile patients who have a viral illness require no ...

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