The management of fever in young infants aged <2 months has been a subject of interest for many years. In the mid-1980s and early 1990s, investigators at university medical centers located in Rochester, Philadelphia, and Boston independently conducted large, rigorous investigations of the reliability of risk stratification parameters and safety of outpatient management of fever in selected low-risk febrile infants, with or without empiric antibiotic administration.1,–3 Although these assessment protocols used many of the same parameters, they differed from each other in small but important ways. In particular, the Rochester criteria included infants <1 month old and did not mandate a lumbar puncture. All criteria have been shown to be highly reliable with a sensitivity of identifying infants who had serious bacterial illness of 92% to 99% and negative predictive values close to 100%. Thus, these strategies provided a fairly reliable means of identifying febrile infants...
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December 2016
Commentary|
December 01 2016
Management of Fever in Young Infants: Evidence Versus Common Practice
M. Douglas Baker, MD;
aPediatric Emergency Medicine, Johns Hopkins Children’s Center, Baltimore, Maryland; and
Address correspondence to M. Douglas Baker, MD, Pediatric Emergency Medicine, Bloomberg Children’s Center, Suite G-1509, 1800 Orleans St, Baltimore, MD 21287. E-mail: mbaker28@jhmi.edu
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Jeffrey R. Avner, MD
Jeffrey R. Avner, MD
bPediatric Emergency Medicine, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
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Address correspondence to M. Douglas Baker, MD, Pediatric Emergency Medicine, Bloomberg Children’s Center, Suite G-1509, 1800 Orleans St, Baltimore, MD 21287. E-mail: mbaker28@jhmi.edu
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Pediatrics (2016) 138 (6): e20162085.
Article history
Accepted:
September 06 2016
Citation
M. Douglas Baker, Jeffrey R. Avner; Management of Fever in Young Infants: Evidence Versus Common Practice. Pediatrics December 2016; 138 (6): e20162085. 10.1542/peds.2016-2085
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Comments
RE: Management of Fever in Young Infants
I thank Drs. Greenhow, Hung and Pantell for presenting their data on 1380 febrile, full-term infants 7 to 90 days old(1)
A commentary(2) on this valuable article by Drs. Baker and Avner emphasizes that:
1. Bacteremia (1%) and bacterial meningitis (0.4%) are infrequent in febrile infants under 90 days of age;
2. Febrile infants with proven viral infection may also have serous bacterial infection (SBI); and
3. Occasionally, well-appearing febrile infants have SBI.
They believe this scientific evidence compels full evaluation —urine, blood and CSF cultures-- in every febrile young infant, and are dismayed that many clinicians do not practice accordingly.
I respect the knowledge and experience of Drs. Baker and Avner. However, I am certain that an experienced pediatrician can, after evaluating a child, either find a lower (or higher) risk of SBI than the aggregate 14% found by Greenhow et al.
UTIs comprise over 90% of SBI’s in febrile infants and great effort should be made to diagnose these. But the incidence of other serious infections (bacteremia and meningitis) is quite low.
Bacteremia among 7-28 day old and 1-3 month old febrile infants was present in 7% and 2.9%, respectively, of those with blood cultures, with meningitis found in 0.5% and 1.6% of those with CSF cultures(1). These numbers would be lower if every child had received all cultures, since ill-appearing infants were most likely to have cultures obtained.
In febrile children under 90 days of age with documented viral infections, the risk of bacteremia (1%) and meningitis (no cases found) is also very low(3).
Similarly, of 91 well-appearing febrile infants 4-8 weeks old, one (1.1%) had a positive blood culture and none had meningitis(4).
Another approach to febrile infants follows: Children who are ill-appearing and irritable do get a full evaluation. Children who are not ill-appearing or irritable are carefully evaluated by the clinician. A urine culture is obtained on those infants without an apparent source; in those with obvious viral infection, either urine is cultured then or a plan for obtaining a culture is made for those still febrile in another 2-3 days. Non-ill-appearing children with negative urinalysis and those with a viral illness may be observed without cultures or antibiotics, with close follow up assured. Following this algorithm for children 7-90 days of age, the risk of missing a case of bacteremia or meningitis is likely lower than rates noted by Drs. Baker and Avner (bacteremia—1%, meningitis—0.4%)
Follow up of patients, typically reliable in private practice but not always so in ER settings, allows reassessment of children whose condition worsens or does not improve.
Thoughtful pediatricians reading the literature cited may reach different conclusions. Which is a higher priority? The effort to miss no case of serious illness or avoiding sepsis workups (with possible hospital admission and precautionary antibiotics) on over 90 febrile infants for every one case of bacteremia or meningitis diagnosed?
No pediatrician wants to “ignore the evidence” and put infants at risk of poor outcomes.
1. Greenhow, TL, Hung YY, Pantell RH. Management and Outcomes of Previously Healthy, Full-Term, Febrile Infants Ages 7 to 90 Days. Pediatrics. 2016; 138(6):e20160270.
2. Baker MD, Avner JR. Management of Fever in Young Infants: Evidence Versus Common Practice. Pediatrics. 2016; 138(6):e20162085.
3. Byington CL, Enriquez FR, Hoff C, et al. Serious Bacterial Infections in Febrile Infants 1 to 90 Days Old With and Without Viral Infections. Pediatrics. 2004; 113(6): 1662-1666.
4. Baker MD, Avner JR, Bell LM. Failure of Infant Observation Scales in Detecting Serious Illness in Febrile, 4- to 8-Week Old Infants. Pediatrics. 1990; 85(6):1040-1043.
Harold S. Raucher, M.D.
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