Fever with focus in

well appearing child

<3years
Table of contents
Definitions
Epidemiology
History and Examination
Common organisms
Differential diagnosis according to age
Investigations and Interpretations
Define fever without a focus
Criteria for investigation, treatment and management strategies for the
neonate,young infants and older infants
Local protocol for fever without a focus
Summary
Fever
20% of pediatric emergency dept visits
35% of ambulatory visits
5%-10%-20% percent of febrile children have
fever without an apparent source of infection
after history and physical examination.
Fever
Hypothalamus is the thermoregulatory center
for the body
Fever results when a shift in the hypothalamic
set point causes a controlled elevation of body
temperature above the normal range
Normal set point for humans has a daily
circadian rhythm ranging 36C-37.8C with peak
occurring in the afternoon
Fever
Fever production begins when an infectious agent,
toxin, immune complex, or other inflammatory agent
stimulates macrophages or endothelial cells to
produce endogenous pyrogens, such as interlukin-1
and tumor necrosis factor.
Pyrogens hypothalamus PGE2 and AA metabolite
raise thermostat set point (thermoregulatory
neurons)
Data Collection
History
Associated symptoms and behaviors
Onset and duration of fever
Degree of temperature-method and anatomic
site
Medications
Environmental exposures
Similar symptoms in siblings
Data Collection
Birth and nursery history (STD, TORCH, GBS,
ROM)
Date of last immunizations (MMR-fever and rash
7-10 days afterwards)
Temperature assessment- rectal temps best
assess core temperature
Bundled infants- rectal temp >38C may not
attributable to bundling

Data Collection
Fever by History at home who is afebrile on
presentation: manage as fever documented in
acute care setting
General appearance-acute illness observation
scale
Response to antipyretics-may hinder ability to
assess the child
Physical Examination
SpO2 better predictor of pulmonary infection
Toxic appearance (irritability, poor perfusion,
lethargy)
Signs of infection (omphalitis, arthritis, cellulitis,
herpes lesions)
Meningitis change in sleep pattern, decreased
po, paradoxical irritability, bulging fontanelle (late
sign).
Use of Yale Observation Scale (McCarthy, 1980-
Yale Observation Scale
Indications
Assessment of febrile child ages 3-36 months
Predicts serious infection (Occult bacteremia)
Quantifies "Toxic Appearance" in children


CRITERIA FOR FEVER WITHOUT FOCUS
By using clinical and laboratory findings we can
limit the number of infants hospitalized
unnecessarily and identify infants who may be
managed as outpatients
Infants and young children have been assigned to
different management strategies by age group
neonates (birth to 28 days)
young infants (29 to 90 days)
older infants and young children (3 to 36 months).
 Philadelp Rocheste Boston
hia r

Age 29-60d <60days 28-89d

Temp >38.2C >38C >38C

History Not Term No

specified infant immuniza
No tions <
perinatal 48h
Abx No
No antimicro
underlyin bial <
g disease 48h

Not Not
hospitaliz dehydrat
ed longer ed
than the
mother

Physical Well- Well- Well-

Exam appearin appearin appearin
g g g
Unremark No ear, No ear,
able soft soft
exam tissue or tissue, or
bone bone
infection infection