Chapter 3

#### High-Yield Facts

• Children typically have four to six febrile illnesses in the first two years of life with most of these being nonspecific viral illnesses.

• Widespread vaccination for Haemophilus influenzae type b and Streptococcus pneumoniae has had a profound impact on the incidence of occult bacteremia and serious bacterial illness (SBI).

• Meticulous history and physical examination, most notably the initial visual inspection of the febrile infant or child is the foundation of accurate diagnosis.

• In the 28- to 56-day-old febrile infant, risk stratification criteria can be used to identify those at risk for SBI.

• Focusing parental attention to “controlling the fever” is generally impractical and misguided and contributes to fever phobia.

Fever is one of the most common complaints of children presenting to the emergency department (ED). In fact, children typically have four to six febrile illnesses in the first two years of life. In most cases, the etiology of the fever is either a benign, nonspecific viral infection or a self-limited focal bacterial infection such as otitis media or streptococcal pharyngitis. However, parents and practitioners are always concerned with the possibility of an underlying serious condition, such as meningitis or sepsis, and therefore often approach the febrile child with some degree of trepidation. In addition, the evaluation of the febrile child is complicated by age-related variations such as the patient's ability to communicate, immune system development, and immunization status. Therefore, it is important for the practitioner to understand the underlying pathophysiology of fever, the risk factors associated with serious bacterial illness (SBI), and the relative frequency of certain sepsis and sepsis-like conditions to develop a rational approach to management, including the appropriate use of laboratory testing and antibiotics.

The evaluation of the febrile child is often determined on presentation by either the age of the child, the presence of underlying chronic illness or immunocompromise. Due to the relative lack of clinical signs and an immature immune system, neonates have specific age-appropriate management strategies (see Chapter 2). However, there is practice variation for 28- to 56-day-old infants. They are either included with neonates or they are considered as a separate group and managed uniquely. Fever may be the only presenting symptom of serious bacterial illness in children with underlying illnesses such as sickle cell disease, immunodeficiency, or cancer as well as those children with indwelling devices such as a ventriculoperitoneal shunt or a central line. Therefore, the presence of fever in these children often requires laboratory testing and empiric antibiotic treatment until bacterial infection can be ruled out. However, the majority of well-appearing, otherwise healthy children, require only a thorough history and physical examination, and in the absence of a bacterial source of infection, can be managed by antipyretic therapy and observation until the course of the illness resolves. This chapter deals specifically with the otherwise healthy febrile child between the ages of 1 month and 3 years.

#### Normal Body Temperature

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