Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the Emergency Department With Fever

Publication Date: January 1, 2016
Last Updated: March 14, 2022

Recommendations

Infants and children at increased risk for urinary tract infection include females younger than 12 months, uncircumcised males, nonblack race, fever duration greater than 24 hours, higher fever (≥39°C), negative test result for respiratory pathogens, and no obvious source of infection. Although the presence of a viral infection decreases the risk, no clinical feature has been shown to effectively exclude urinary tract infection. Physicians should consider urinalysis and urine culture testing to identify urinary tract infection in well-appearing infants and children aged 2 months to 2 years with a fever ≥38°C (100.4°F), especially among those at higher risk for urinary tract infection. (C)
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Physicians can use a positive test result for any one of the following to make a preliminary diagnosis of urinary tract infection in febrile patients aged 2 months to 2 years: urine leukocyte esterase, nitrites, leukocyte count, or Gram’s stain. (B)
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  1. Physicians should obtain a urine culture when starting antibiotics for the preliminary diagnosis of urinary tract infection in febrile patients aged 2 months to 2 years.
  2. In febrile infants and children aged 2 months to 2 years with a negative dipstick urinalysis result in whom urinary tract infection is still suspected, obtain a urine culture.
(C)
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In well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (≥38°C [100.4°F]) and no obvious source of infection, physicians should consider obtaining a chest radiograph for those with cough, hypoxia, rales, high fever (≥39°C), fever duration greater than 48 hours, or tachycardia and tachypnea out of proportion to fever. (B)
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In well-appearing immunocompetent infants and children aged 2 months to 2 years presenting with fever (≥38°C [100.4°F]) and wheezing or a high likelihood of bronchiolitis, physicians should not order a chest radiograph. (C)
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  1. Although there are no predictors that adequately identify full-term well-appearing febrile infants aged 29 to 90 days from whom cerebrospinal fluid should be obtained, the performance of a lumbar puncture may still be considered.
  2. In the full-term well-appearing febrile infant aged 29 to 90 days diagnosed with a viral illness, deferment of lumbar puncture is a reasonable option, given the lower risk for meningitis. When lumbar puncture is deferred in the full-term well-appearing febrile infant aged 29 to 90 days, antibiotics should be withheld unless another bacterial source is identified. Admission, close follow-up with the primary care provider, or a return visit for a recheck in the Emergency Department is needed. (Consensus recommendation)
(C)
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Recommendation Grading

Overview

Title

Well-Appearing Infants and Children Younger Than 2 Years of Age Presenting to the Emergency Department With Fever

Authoring Organization

Publication Month/Year

January 1, 2016

Last Updated Month/Year

August 1, 2023

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This clinical policy from the American College of Emergency Physicians addresses key issues for wellappearing infants and children younger than 2 years presenting to the emergency department with fever

Target Patient Population

Infants and children younger than 2 years old with fever

Inclusion Criteria

Female, Male, Child, Infant

Health Care Settings

Emergency care

Intended Users

Paramedic emt, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management

Diseases/Conditions (MeSH)

D010372 - Pediatrics, D007223 - Infant, D005334 - Fever

Keywords

pediatric, fever, infant

Source Citation

Ann Emerg Med. 2016;67:625-639