1. BY: DRA.Fatma .s.al zahrani
The Febrile Infant
BY:
DRA.Fatma .s.al zahrani

2. The Febrile Infant Definition: Temperature >/= 38 C (100.4 F )
Rectal temp closely correlates with core body temperature
Ear/Axillary/Sticker temps are unreliable.
Temps vary depending upon time of day

3. The Febrile Infant Fever Without A Source (FWLF)
Acute febrile illness in which the etiology of the fever is not localized after the history and physical examination.

4. The Febrile Infant Pathogenesisof fever:
Pathogens → cytokine release →resets thermoregulation of hypothalamus→ maintains a higher body temperatur
Infants < 3 months less likely to have fever

5. The Febrile Infant What to do? Obtaining detailed History Age
Parents report of wellbeing
Parents report of specific symptoms
Height and presence of fever
Risk Factors (Prematurity,Immunocompromised)
Epidemiologic Factors (Sick contacts)

6. The Febrile Infant Physical Exam
Give anti pyretic to relax the child if irritable or in pain
Perform throughu physical examination.
Look for evidence of serious illness
Meningeal signs may not be apparent < 18mo

7. The Febrile Infant Approach 1)The high risk age is: 0 – 28 days
3 – 36 months

8. The Febrile Infant 2)Toxic Appearing
A clinical picture consistent with the sepsis
syndrome:
Lethargy
Poor Perfusion
Hypoventilation
Hyperventilation
Cyanosis

9. The Febrile Infant 3)Lethargy:
Poor eye contact &poor interaction with parents and people arround

10. The Febrile Infant Assessing Risk  Rochester Fever Criteria
 Yale Observation Scale (Clinical)

11. The Febrile Infant
Rochester Criteria for Febrile Infants Ages 60 – 90 Days
Criteria
Well appearing/Full term
No skeletal, soft tissue, skin, or ear infections
Previously healthy
WBC 5000 – 15,000
Bands <1500
UA: WBC’s < 10/hpf
If diarrhea: fecal Leukocytes <5/hpf
Interpretation
Well appearing febrile infant risk: 7-9%
All Rochester Criteria present: < 1%

12. The Febrile Infant Yale Observation Scale 3 - 36 Months
Quantifies “Toxic Appearance”
Quality of Cry
Reaction to parents
Arousability
Color
Hydration
Social Response
Interpretation: Risk increases with higher scores

13. The Febrile Infant Low Risk Infants Previously Healthy/Full term
No focal Bacterial Infection on PE
Good social situation
Nontoxic clinical appearance
Negative lab screening:
WBC 5000 – 15,000
< 1500 Bands
Normal UA
< 5 WBCs/hpf in stool if diarrhea present

14. The Febrile Infant Management: Infants 0 – 28 Days
ALL infants should be admitted , with full sepsis workup (Blood, Urine, CSF)
Empiric parenteral antibiotic therapy pending negative cultures.

15. The Febrile Infant Management: Infants 0 – 28 Days
Most common bacterial organisms
(Group B Strep,E. Coli,Listeria)
Antibiotic coverage
Ampicillin and Gentamicin OR
Ampicillin and Cefotaxime

16. The Febrile Infant Management: Infants 28 – 90 Days Febrile Infant
Toxic OR Nontoxic
High Risk OR Low Risk
Inpatient OR outpatient

17. The Febrile Infant Management: a)Infants 28 – 90 Days
Low Risk Outpatient
Full sepsis work up and empiric parenteral
antibiotic coverage (Ceftriaxone IV/IM)
Follow up within 24 hours
If CSF cx (+), admit for IV Abx treatment
If Blood cx (+) i) febrile/ill for IV Abx
ii) afebrile/well, may consider oral Abx outpt Rx
If Urine cx (+), i)febrile/ill for IV Abx,
ii) afebrile/well, consider oral Abx outpt Rx

18. The Febrile Infant Management: Infants 28 – 90 Days Admit Low Risk if:
Immature/Unreliable Parents
Unsure of follow up
No home telephone
Lack of Transportation

19. The Febrile Infant Management: Infants 28 – 90 Days Nontoxic High Risk
Admit
Full sepsis work up
+/- empiric parenteral antibiotics
Most Common Organisms
Late onset Group B Strep
Strep. Pneumoniae
H. Flu
N. Meningitidis

20. The Febrile Infant Management: Children 3 – 36 Months
Fever without source accounts for 14% of
outpatient visits
Mean probability of occult bacteremia 4%
Higher risk of bacteremia with temps >39C
Sensitivity of clinical evaluation greater
(89-92%) in this age group

21. The Febrile Infant Management: Children 3 – 36 Months
Nontoxic, Temp > 39 C (102.2 F)
Lab work not indicated if presumptive diagnosis is URI, or sick contacts with URI
- CBC w Diff, Blood Cx
-CXR indicated if signs of LRI, WBC > 15, Temp > 104
urine culture (catheter or suprapubic) is gold standard UA/Urine cx if males < 6 months and females < 2years

22. The Febrile Infant Management: Children 3 – 36 Months
Most Common Organisms
Strep. Pneumoniae
H. Flu
N. Meningitidis
Strep. Pyogenes
Staph
Salmonella

23. The Febrile Infant AntibioticTreatment: -Children 3 – 36 Months
Nontoxic, Temp > 39 C (102.2 F)
WBC > 15,000
UA (+)
Can treat with Abx without LP in this age
Group optional)

24. The Febrile Infant Treatment: Children 3 – 36 Months Ensure follow up
If Blood cx (+) i) febrile/ill f0r admission & IV Abx
ii) a febrile/well, consider outpt oral Abx
Most studies indicate that treatment with parenteral
Abx associated with least risk of further sequelae
If Urine cx (+) i) admit if febrile/ill for IV Abx

25. The Febrile Infant Summary
Guidelines is one way to assist physicians in managing infants and children with fever without a source .They are flexible and management may be individualized according to the case.