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🔥 FEVER IN CHILDREN - Emergency Physician Exam Guide
Source: Tintinalli's Emergency Medicine, Chapter 119
1. FEVER DEFINITIONS (Quick Recall)
| Threshold | Significance |
|---|---|
| ≥38°C (100.4°F) | Fever in infants; standard cutoff |
| ≥38.2°C (100.8°F) | Philadelphia Protocol threshold |
| <36°C (96.8°F) | Equally concerning (hypothermia) in neonate/infant <2-3 mo |
| ≥39°C (102.2°F) | Historical occult bacteremia cutoff (3-36 mo) |
| >41°C (105.8°F) | Increased SBI risk |
Temperature facts: Axillary = 0.6°C lower than oral = 0.6°C lower than rectal. Infrared thermometers: variable reliability.
2. ANTIPYRETICS (Exam Doses)
| Drug | Dose | Interval | Notes |
|---|---|---|---|
| Acetaminophen | 15 mg/kg/dose PO/PR | q4-6h (max 5x/day) | Max daily 80 mg/kg; also IV available |
| Ibuprofen | 10 mg/kg/dose PO | q6-8h | Max daily 40 mg/kg; only >6 months |
3. SERIOUS BACTERIAL ILLNESS (SBI) - Key Pathogens by Age
| Age | Common Organisms |
|---|---|
| <3 months | E. coli, Group B Strep, Listeria monocytogenes |
| >3 months | S. pneumoniae, N. meningitidis, S. aureus |
Most common SBI overall: UTI (3-8% of febrile infants <24 months)
Bacteremia/sepsis incidence: 1-3% in <3 months; 2-3% in 3-36 months
4. AGE-BASED MANAGEMENT TABLE (HIGH-YIELD)
0-28 days (Neonates) - ALWAYS ADMIT
- Workup: CBC + blood culture, UA + urine culture, CSF (cell count, Gram stain, culture), optional CXR
- Antibiotics:
- Ampicillin 50 mg/kg + Cefotaxime 50 mg/kg, OR
- Ampicillin + Gentamicin 2.5 mg/kg
- ⚠️ NEVER ceftriaxone <1 month (displaces bilirubin → worsens hyperbilirubinemia)
29-56 days (Philadelphia Protocol)
- Workup: Same as neonates
- Discharge if ALL met: WBC 5,000-15,000, <20% bands; UA negative; CSF WBC <10/mm³; negative CXR
- Admit + Ceftriaxone 50 mg/kg if any criterion fails; 100 mg/kg if meningitis signs
57 days to 6 months (>38°C)
- Urinalysis + urine culture only
- Discharge if negative; treat UTI with oral antibiotics outpatient
- If fails conservative criteria: admit + parenteral ceftriaxone
57 days to 6 months (>39°C)
- UA + urine culture alone (low-risk)
- If WBC >15,000: consider ceftriaxone 50 mg/kg + follow-up 24h
- If WBC >20,000: consider CXR + CSF
6-36 months
- UA + urine culture: girls 6-24 mo, boys 6-12 mo (uncircumcised)
- UTI in girls <8%; UTI in boys <2% (uncircumcised stays 2% up to 2 yrs)
- Discharge with antipyretics if negative
>36 months
- No routine workup
- Discharge + antipyretics
- Specific complaints guide targeted workup
5. THREE DECISION RULES FOR INFANTS <3 MONTHS (Comparison Table)
| Criterion | Rochester | Philadelphia | Boston |
|---|---|---|---|
| Age | <60 days | 29-56 days | 28-89 days |
| Fever cutoff | ≥38°C | ≥38.2°C | ≥38°C |
| WBC | 5,000-15,000; bands <1,500 | <15,000; band:neutrophil <0.2 | <20,000 |
| UA | WBC <10/hpf | WBC <10/hpf | WBC <10/hpf |
| CSF | Not included | WBC <8/hpf + negative Gram stain | WBC <10/hpf |
| Sensitivity for SBI | Lowest (misses 1%) | 98% (recommended) | ~95%, NPV 99.7% |
| LP required? | No | Yes | Yes |
Recommended protocol: Philadelphia - highest sensitivity, includes LP, no missed meningitis.
6. SERUM BIOMARKERS
- Standard: WBC, ANC, band-to-neutrophil ratio
- Emerging: Procalcitonin - best current biomarker for bacterial infection
- CRP: widely studied but procalcitonin superior
- Predictors of SBI (in order): positive UA > WBC >20,000 > temp >39.6°C > WBC <4,100 > age <13 days
7. SPECIFIC INFECTIONS - QUICK PEARLS
UTI (Most common SBI)
- Girls: test if ≥2 of: white race, age <12 mo, temp >39°C, fever ≥2 days, no other source
- Uncircumcised boys: test if no focal infection
- Circumcised boys: test if ≥2 of: nonblack race, temp >39°C, fever >24h, no other source
Meningitis
- Incidence: ~1% in febrile infants <3 months
- ⚠️ Nuchal rigidity/Kernig/Brudzinski absent in children up to 2 years - unreliable signs
- Bulging fontanelle, inconsolability, increased irritability when held = key clues
- Any ill-appearing patient or <2 months with ANY CSF pleocytosis → admit + IV antibiotics
- If discharging older child with likely viral meningitis: give ceftriaxone 100 mg/kg IM/IV + 24h follow-up
Bacteremia (3-36 months)
- S. pneumoniae: 80% resolve spontaneously; 20% develop complications (meningitis, pneumonia, sinusitis)
- Vaccinations (Hib, PCV13) reduced occult bacteremia from ~8-17% to 0.5-0.7%
- Post-vaccine: routine CBC/CXR not indicated in well-appearing; urine testing only
Petechiae + Fever
- Most = viral (adenovirus)
- Purpura fulminans + hypotension + lethargy + meningismus = meningococcemia (act immediately)
Kawasaki Disease (children <5 years)
- Fever ≥5 days + strawberry tongue + conjunctivitis/iritis + red mucous membranes/cracked lips + lymphadenopathy + skin peeling
- Treatment: Aspirin + IV immunoglobulin
- Complication: coronary aneurysms
8. ANTIBIOTIC DOSES (Exam Favorite)
| Condition | Drug | Dose |
|---|---|---|
| Otitis media, Pneumonia, Sinusitis | Amoxicillin (high dose) | 30 mg/kg/dose TID |
| Penicillin allergy | Azithromycin | 10-12 mg/kg day 1 (max 500 mg), then 5-6 mg/kg days 2-5 |
| Cellulitis (MSSA) | Cephalexin | 20-25 mg/kg/dose QID x 10 days |
| Cellulitis (MRSA) | Clindamycin | 10 mg/kg/dose TID x 10 days |
| Group A Strep pharyngitis | Amoxicillin | 25 mg/kg BID x 10 days |
| Group A Strep (single dose) | Penicillin G benzathine | 50,000 units/kg IM (max 900,000 units) |
| Empiric bacteremia (SBI) | Ceftriaxone | 50 mg/kg IV/IM |
| Meningitis empiric | Ceftriaxone | 100 mg/kg |
9. LUMBAR PUNCTURE - KEY POINTS
Contraindications first: Correct thrombocytopenia/coagulation defects before LP. Resuscitate + give IV antibiotics before LP in hemodynamically unstable patients.
Needle sizes:
- Infants: 22G, 1.5 inch
- 2-8 years: 22G, 2.5 inch
-
8 years: 22G, 3.5 inch
Technique: L4-L5 interspace (level of iliac crests), needle toward umbilicus, bevel up.
CSF Tubes:
- Tube 1 → Cell count (WBC, RBC)
- Tube 2 → Protein + Glucose
- Tube 3 → Gram stain + Culture
Normal CSF Values:
| Parameter | 0-4 wk | 4-8 wk | >8 wk |
|---|---|---|---|
| WBC/mm³ | 0-9 | 0-9 | 0-9 |
| Glucose (mg/dL) | 30-60 | 40-70 | 50-80 |
| CSF/blood glucose ratio | ≥60% | ≥60% | ≥60% |
| Protein (mg/dL) | 15-45 | 15-45 | 15-45 |
Tip: Cincinnati method (early stylet removal after skin puncture) improves success rate.
10. POSITIVE BLOOD CULTURE MANAGEMENT
| Organism | Action |
|---|---|
| S. pneumoniae - afebrile + on antibiotics | Complete course; no re-admit needed |
| S. pneumoniae - afebrile + NOT on antibiotics | Usually no additional cultures/antibiotics unless focal infection develops |
| S. pneumoniae - febrile | Repeat culture + CBC ± UA ± LP; admit |
| N. meningitidis / MRSA | Always admit for parenteral antibiotics |
HIGH-YIELD EXAM MNEMONICS
"NEVER ceftriaxone <1 month" - displaces bilirubin
"Philadelphia = Best protocol" - 98% sensitive, includes LP, no missed meningitis
SBI predictors order: UA+ > WBC >20,000 > Temp >39.6 > WBC <4,100 > Age <13 days
Meningitis clues in infants: Inconsolable crying + increased irritability when HELD (paradoxical irritability)
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