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Historically, most practitioners managed febrile 28- to 56-day-old infants identically as for neonates: a “sepsis” evaluation, hospitalization, and administration of empiric antibiotics. In the early 1990s, several screening tools were developed to aid in the identification of young infants who were at low risk for SBI and therefore could be spared both routine hospitalization and possible antibiotic therapy. These eponymous screening tools—in particular, the Boston,35 Philadelphia,36 and Rochester37 criteria—all employed slightly different inclusion criteria for risk stratification. Although variations of these management strategies have continued to gain acceptance, care must be taken to obtain all necessary clinical and laboratory parameters, as practitioners often deviate from the published algorithm that they believe they are following for management of the febrile neonate.38
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An ill-appearing 28- to 56-day-old infant requires a “sepsis” evaluation, hospitalization, and administration of empiric antibiotics. However, if well appearing, the risk can be stratified into high-risk or low-risk categories based upon a combination of clinical and laboratory findings. A useful set of low-risk clinical criteria is shown in Table 3-1. The decision to perform a lumbar puncture is contentious in those who meet all other low-risk criteria. Although there are no definitive data, some practitioners will defer or omit CSF examination given the very low risk of bacterial meningitis in this selected low-risk group. To that end, practitioners must judge each infant individually, taking into account the history, clinical appearance indicators such as social smile and reaction to parent stimulation (which are variable in this age group), as well as the reliability of the caretakers to observe the neonate and follow-up appropriately.
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The management of febrile children between 3 and 36 months of age is largely dependent on clinical appearance, risk factors for bacterial illness, and the presence or absence of an identifiable source of infection. For children who are clinically unstable, stabilization, including airway management, intravenous fluids, and oxygen administration, takes precedence. If a source is identified, such as UTI, pneumonia, skin, soft-tissue or bone infection, then directed antibiotic therapy is initiated. For those children who are septic or at high risk for SBI, empiric antibiotic therapy should begin as soon as possible, preferably within 1 hour of presentation. If meningitis is considered in an unstable child, the lumbar puncture should be deferred with the immediate initiation of antibiotic therapy for meningitis (see Chapter 58).
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In the well-appearing child who appears to have a specific clinical syndrome, rapid antigen testing may obviate additional laboratory investigation. These tests may include screening for influenza, RSV, and streptococcal antigen. UTI should still be ruled out in established risk groups.
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In the well-appearing child with no obvious clinical source of infection, the clinician should consider a variety of decision modifiers as well as risk factors for SBI. Risk factors include unimmunized state; chronic disease such as sickle cell disease, congenital heart disease, inborn errors of metabolism, or conditions requiring CSF shunts and immunocompromise. When risk factors are present, an evaluation should include a CBC with leukocyte and immature neutrophil count and markers of inflammation including CRP, blood culture as well as urinalysis and urine culture when indicated. Lumbar puncture should be performed in those children who appear to have or are at risk for meningitis. Imaging for pneumonia may also be indicated based on the presence of respiratory symptoms. In the well-appearing child with no risk factors and no illness warranting rapid screening, no investigations are needed. The diagnosis of presumptive viral syndrome may be made, followed by discharge with close follow-up.
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Most uncomplicated febrile illnesses last for 4 to 5 days.39 Children with fever lasting for more than 5 to 7 days, in whom a source of infection is not evident, should be assessed with a systematic focused approach. In these children, Kawasaki disease must be considered although infectious illness remains most likely. As the duration of the fever increases, the likelihood of rheumatologic and neoplastic etiologies increase.40
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Clinically unstable patients with the presence or risk of SBI should be admitted for stabilization and empiric or directed antibiotic therapy. In well-appearing infants and young children with an identified source, outpatient symptomatic and directed care may be initiated with close follow-up. In those with no identified source, the chart should clearly reflect cardiorespiratory stability, adequate feeding behavior, urine output, and alertness at the time of discharge. Instructions for seeking follow-up if there is no improvement must be provided as well as advice to return to the ED if there is deterioration.