Children One Month to 2 Years of

1. Treatment approach. Evaluation and management of this age group requires the most consideration. First, a compulsive search for the source of the fever must be performed. If found, treatment can proceed by clinical diagnosis as long as clinician recognizes that the diagnosed clinical syndrome does not necessarily eliminate more worrisome diagnoses.

2. Fever Without Localizing Signs (FWLS). If no source of infection is found, child fits into the diagnostic group of FWLS. Although most infants with FWLS have self-limited viral disease, a rare but real number of such patients are early in the course of a serious infection. Choices for therapeutic management include:

a. "Sepsis workup" on all such patients, with subsequent hospitalization and empiric antibiotic treatment. This aggressive approach will treat hundreds perhaps even a thousand such patients to avoid missing the single patient at the early stage of an illness, either viral or occult bacteremia, that is destined to go on to bacterial meningitis. This option is fraught with problems, including issues of medical complications (eg, phlebitis, medication errors) and the psychosocial disruption of hospitalization.

b. Evaluation and empiric treatment of all infants who are "toxic," while assuring close follow-up in FWLS infants who look well despite fever. Clinician may choose to perform acute phase testing, CBC and differential, C-reactive protein, and urine studies to add diagnostic comfort to the choice to follow patient expectantly. Follow-up in this instance requires that infant's parents or caregiver realize they are assuming a small risk in not hospitalizing child. Parents must be given appropriate information to enable them to recognize progression of the illness (irritability, lethargy, loss of interest in feeding, petechiae or purpura, seizures or neurologic alteration) and respond to those changes (return immediately for care). Follow-up when these elements cannot be put in place may require hospital-ization for observation without empiric treatment.

C. Children Older Than 2 Years of Age. Manage as for an older child. In this age group, child's response to serious illnesses is sufficiently developed to be recognized (eg, nuchal rigidity is a reliable finding of meningeal irritation).

D. Infant With Otitis Media. In an infant with otitis media, meningitis must be ruled out.The finding of a source of infection (eg, acute otitis media) in a highly febrile infant does not remove the onus on clinician to rule out serious deep infection. Although data suggest that a patient with one focus of infection is unlikely to have a second source of infection, the first diagnosis source does not protect patient from a second, more serious, source.

VI. Problem Case Diagnosis. Evaluation in the emergency department showed a febrile infant (103.1 °F) who was irritable but consolable by his parents. Physical findings were negative for an infectious focus. Lumbar puncture was deferred in favor of antipyretic treatment with acetaminophen to clarify role of fever in infant's altered behavior. Upon reevaluation 1 hour later, infant was laughing and actively engaged in play with his father. Information was provided to parents regarding risks and findings that warrant return and reevaluation, and infant was sent home. Phone follow-up found that fever persisted for the next 3 days but occasional antipyretic therapy confirmed infant's well-being. On the third day, infant developed a diffuse, blanching, erythematous macular rash. Fever and other symptoms simultaneously resolved. Diagnosis is roseola (herpesvirus 6).

VII. Teaching Pearl: Question. What are the key considerations when assessing an infant with high fever?

VIII. Teaching Pearl: Answer. Assessment is dependent on child's age. Most neonates require a sepsis workup, with admission and empiric antibiotic treatment. Patients beyond the neonatal period, but younger than 2 years, require concise review of the history to assess for altered risk indicators (immune compromise) and infectious contacts, and thorough physical exam to search for an infectious focus. Management is then based on the clinical syndrome (pneumonia, cellulitis, meningitis, FWLS) or degree of toxicity. Fever itself, rather then the source of the fever, may cause irritability and lethargy Antipyretic therapy may have its most substantive role in the ill but nontoxic infant in which defervescence allows a more effective assessment of infant's status. Patients older than 2 years of age can be managed based on their clinical syndrome and degree of toxicity as one would older children.

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