Pediatric presentation
Fever in children
The commonest reason a child is brought in, and the one where age rewrites the workup.
What are you worried about?
- Serious bacterial infection in the young infant: bacteremia, meningitis, urinary tract infection
- Sepsis at any age: the ill-appearing child with poor perfusion
- Meningitis: irritability, a bulging fontanelle, neck stiffness in the older child, a non-blanching rash
- Kawasaki disease when the fever passes 5 days
Differential, by age
Newborn birth to 28 days
- Group B streptococcus and E. coli sepsis
- Herpes simplex virus
- Urinary tract infection
- Bacterial meningitis
Infant 1 to 12 months
- Viral illness
- Urinary tract infection
- Bronchiolitis
- Otitis media
- Occult bacteremia if unimmunized
Toddler 1 to 3 years
- Viral illness
- Otitis media
- Pneumonia
- Urinary tract infection
- Roseola, hand-foot-and-mouth disease
Preschool 3 to 5 years
- Viral pharyngitis
- Streptococcal pharyngitis
- Pneumonia
- Kawasaki disease
- Osteomyelitis or septic arthritis if limping
School age 6 to 11 years
- Streptococcal pharyngitis
- Pneumonia, including atypical
- Infectious mononucleosis
- Urinary tract infection in girls
Adolescent 12 to 17 years
- Infectious mononucleosis
- Pneumonia
- Sexually transmitted infection
- Systemic inflammatory disease presenting as fever
Key history
- Exact age, in days if under 3 months; gestational age and perinatal risk factors in the young infant
- How the fever was measured, its height and duration; antipyretics given and the response
- Feeding, wet diapers, activity and consolability, in the caregiver's words
- Localizing symptoms: cough, work of breathing, vomiting, diarrhea, rash, limp, ear pulling, dysuria
- Immunizations, sick contacts, daycare, travel, animal exposure
- Prior antibiotics, chronic disease, immune compromise, indwelling devices
Key examination
- Appearance before anything else: tone, interaction, consolability, gaze, cry (the Yale scale's domains)
- Age-adjusted vital signs, capillary refill and skin temperature
- Fontanelle in the infant; neck stiffness and Kernig's sign are unreliable under about 18 months
- Ears, throat, chest, abdomen, every joint, every limb, the skin fully undressed (petechiae, purpura)
- The perineum and the urine
Red flags
- Age under 28 days with a temperature of 38.0 or more, or hypothermia
- Ill appearance: lethargy, weak cry, inconsolability, poor eye contact
- Tachycardia or tachypnea for age that persists once the fever is treated
- Non-blanching rash, bulging fontanelle, neck stiffness, focal neurology
- Capillary refill above 2 to 3 seconds, mottling, cool peripheries, reduced urine output
- Fever of 5 days or more (Kawasaki disease), or fever in the immunocompromised
Initial investigations
- Under 28 days: blood culture, urine culture by catheter, cerebrospinal fluid, full blood count, inflammatory markers; empiric antibiotics
- 29 to 90 days: risk-stratified evaluation (inflammatory markers, urinalysis, blood culture; cerebrospinal fluid depending on the risk group)
- Older, well, immunized child: urinalysis if no source, nothing else routinely
- Ill-appearing at any age: cultures, lactate, blood gas, glucose, then antibiotics within the hour
- Chest X-ray only for respiratory signs; lumbar puncture only when meningitis is a question the examination cannot answer
How to interpret them
- Procalcitonin and C-reactive protein help stratify the febrile infant; neither replaces the examination
- A white cell count is a poor discriminator on its own in children
- A positive urinalysis in an infant needs a culture obtained by catheter or suprapubic aspirate, not a bag
- A cerebrospinal fluid with a high white count and low glucose is bacterial until cultures say otherwise
When the child is deteriorating
- Recognize compensated shock: rising heart rate, prolonged refill, cool skin, quiet child, normal pressure
- Oxygen, access, a fluid bolus of 10 to 20 mL/kg with reassessment after each, blood cultures then antibiotics
- Call for senior help early; a child who needs a second bolus needs a senior at the bedside
Cases and practice
Eighteen days old, warm, and not interested in feeding18 days old · A term newborn's parents bring him in because he feels hot and has slept through two feeds. He looks all right in the waiting room.He went stiff and shook, and now he will not wake up properly20 months old · A 20-month-old with a fever since the morning had a two-minute convulsion at home. His parents thought he was dying.
Conditions under this presentation
The adult frame, for contrast