Pediatrics
Clinical policy for children younger than three years presenting to the emergency department with fever

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Introduction

Fever is among the most common presenting complaints of children and infants presenting to the emergency department (ED).1 Fever represents a normal physiologic response that may result from the introduction of an infectious pathogen into the body and is hypothesized to play a role in fighting and overcoming infections.2, 3 In some cases, fever is a response to a serious or potentially life-threatening infection. The challenge for emergency physicians is differentiating the vast majority of pediatric patients presenting with a fever who will have an uneventful course from the indeterminate few who have serious infections with the risk of long-term morbidity and mortality.

The evaluation and management of the febrile child is evolving at a rapid pace as a result of: (1) the amount of research conducted, (2) the introduction of Haemophilus influenzae type b (HIB) vaccine, (3) Streptococcus pneumoniae vaccine, and (4) ever-evolving diagnostic technology and therapies. The full extent of the impact of these ongoing changes, particularly of the introduction of the HIB and pneumococcal vaccines, is not yet known. However, there is a general consensus that the incidence of serious bacterial infections will likely decrease significantly over the next several years.

This policy is a revision of the 1993 American College of Emergency Physicians (ACEP) pediatric fever policy.4 In an attempt to maximize the usefulness of this policy to the practicing emergency physician, this revision is organized into discrete “critical questions” that were believed by committee members to represent some of the most pressing and controversial issues faced when evaluating a child or infant with a fever. The scope of the policy has been broadened to include children aged 1 day to 3 years. Fever is defined as a rectal temperature greater than 38°C (>100.4°F).4 The reliability of other methods of temperature measurements is lower and must be considered in the context of the clinical setting.

This policy is not intended to be all encompassing and is intended as a guideline. It represents evidence for answering important questions about these critical diagnostic and management issues. Recommendations in this policy are not intended to present the only diagnostic and management options that the emergency physician can consider. ACEP clearly recognizes the importance of the individual physician's judgment. Rather, this guideline defines for the physician those strategies for which medical literature exists to provide strong support for answers to the critical questions addressed in this policy.

Section snippets

Methodology

This clinical policy was created after careful review and critical analysis of the peer-reviewed literature. A MEDLINE search of English-language articles published between 1985 and 2003 was performed using key words focused on in each critical question. Abstracts and articles were reviewed by subcommittee members, and pertinent articles were selected. These articles were evaluated, and those addressing the questions considered in this document were chosen for grading. Subcommittee members also

Are there useful age cutoffs for different diagnostic and treatment strategies in febrile children?

Historically, physicians caring for children with a fever have long recognized the importance of a child's age when making decisions regarding diagnostic testing and treatment options. Infants in the first few months of life have decreased opsonin activity, macrophage function, and neutrophil activity.6 Furthermore, common pathogens vary by age group, and children's physical and behavioral response to illness varies with their age, as evidenced by the failure of observation scales in infants

Urinary tract infections in young children with fever

Urinary tract infection is an important cause of fever in young children. Fever, bacteriuria, and pyuria in children without other definitive sources of infection should be presumed to be symptoms of urinary tract infections. Using renal nuclear scans, it is estimated that 75% of children aged younger than 5 years with a febrile urinary tract infection have upper tract disease or pyelonephritis.46, 47, 48, 49, 50, 51 On the basis of limited data, it is estimated that renal scarring can occur in

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    Policy statements and clinical policies are the official policies of the American College of Emergency Physicians and, as such, are not subject to the same peer review process as articles appearing in the journal. Policy statements and clinical policies of ACEP do not necessarily reflect the policies and beliefs of Annals of Emergency Medicine and its editors.

    This clinical policy was developed by the ACEP Clinical Policies Committee and the Clinical Policies Subcommittee on Pediatric Fever. For a complete listing of subcommittee and committee members, please see page 542.

    Approved by the ACEP Board of Directors June 11, 2003.

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