Pediatric Pearls: Management of Fever in Infants 8 to 60 Days Old

  • The Research

    The long-anticipated AAP Clinical Practice Guideline on the Management of the Well-Appearing Febrile  Infant was released July 19, 2021. It is well worth a read with particular attention to the 3 algorithms included, which provide the main action points for the statement.

    To understand the appropriate use of the algorithms, the following comments are important:

    1. This guideline applies only to well-appearing term infants aged 8 to 60 days who do not have underlying conditions, risk factors for infection, or the presence of a focal bacterial infection (aside from otitis media).
    2. The guideline leans heavily on the use of inflammatory markers, with a preference for procalcitonin. If procalcitonin is not available, the combination of C-reactive protein and absolute neutrophil count is used. A temperature greater than 38.5 °C is also considered a positive inflammatory marker. Finally, the total white blood cell (WBC) count is not of sufficient discriminatory value to be used for risk stratification.
    3. The approach is different in each of the 3 age groups: 8 to 21 days of age, 22 to 28 days of age, and 29 to 60 days of age.
    4. Because the incidence of urinary tract infection (UTI) is significantly higher than bacteremia or meningitis, the evaluation of a urine specimen is at the top of each algorithm. For febrile infants aged 29 days or older, the urine for urinalysis may be obtained by bag, spontaneous void, or stimulated void. If the urinalysis is negative for leukocyte esterase or WBCs, then a catheterized urine culture does not need to be obtained.

    Algorithm 1: Infants aged 8 to 21 days generally require a full diagnostic evaluation and empiric antibiotic therapy in the hospital.

    Algorithm 2: Select infants aged 22 to 28 days may not require a full evaluation or admission but only if they are at low risk, have adequate follow-up, and the risks of not doing a full evaluation are discussed with the family.

    Algorithm 3: Many infants aged 29 to 60 days can be safely managed without a lumbar puncture (LP), empiric antibiotic therapy, or hospital admission. In particular, if the urinalysis and inflammatory markers are both negative (which does not include infants with fever greater than 38.5 °C), the algorithm recommends against LP, antibiotics, or admission. The guideline does not comment on the need for evaluation in emergency departments vs in community-based practices.

    The guideline recommends abandoning the term “serious bacterial infection” and instead prefers a discussion of UTI, bacteremia, and meningitis separately.

    The Bottom Line - Any infant who does not appear well, any infant who is preterm, or any infant with risk factors for infection requires a full diagnostic evaluation. If you have the interest and time, and particularly if you are a community-based provider and might consider not sending a febrile infant to the emergency department, a careful read of the guideline and review of the algorithms is well worth your time.