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FOCUSED SHIFT VIEW

Pediatric Fever

Age decides the workup; appearance decides the urgency.

Open full pathway
Educational first-pass aid. Reassess the patient, confirm doses and use local protocols.

1 · First minutes

  1. Three questions: How old? Immunized? Well-appearing? (Judge appearance between fever spikes.)
  2. Ill-appearing any age, and all 0–7 days: full sepsis evaluation.
  3. AAP 2021 for well-appearing 8–60 days: 8–21 d LP + antibiotics; 22–28 d LP if markers up; 29–60 d may skip LP if well with normal markers.

2 · Escalate now if

  • Any fever ≥38°C in an infant ≤21 days, or ill appearance at any age
  • Toxic appearance, inconsolability, lethargy
  • Petechial/purpuric rash or bulging fontanelle
  • Grunting, retractions, apnea, or cyanosis
  • Unable to feed or reduced wet diapers
  • Fever >5 days (think Kawasaki, including incomplete)

3 · Immediate workup

  • Rectal temperature in infants; urine collection (catheter or SPA <2 y when a culture is needed)
  • POCUS/lung US for pneumonia/effusion in trained hands

4 · Don’t miss

  • Neonatal / young-infant sepsis
    Ill-appearing at any age = full workup + empiric antibiotics. 0–7 days (outside the AAP CPG) and well-appearing 8–21 days: urine, blood, LP, and parenteral antibiotics. 22–28 days: urine, blood, inflammatory markers; LP if any IM is abnormal. 29–60 days: LP may be omitted if well-appearing with normal IMs (AAP 2021).
  • Meningitis / bacteremia
    Toxic appearance, petechiae, bulging fontanelle — antibiotics and LP pathway.
  • UTI (hidden source)
    Especially girls <24 months and uncircumcised boys <12 months — catheterized specimen (or SPA); bag urine is a screen only.
  • Kawasaki disease
    ≥5 days of fever + ≥4 of: bilateral nonexudative conjunctivitis, rash, mucositis, extremity changes, cervical nodes — or incomplete Kawasaki with labs/echo. Do not wait for day 5 when the clinical picture is convincing; seek pediatric/cardiology assessment (AHA 2024).
  • HSV in the young infant
    Vesicles, seizures, CSF RBC/pleocytosis, hepatitis in the neonate — empiric acyclovir.

5 · Disposition lane

Admit

8–21-day-old infants on empiric antibiotics; 22–28-day-olds pending cultures; UTI needing IV therapy; bronchiolitis with feeding or respiratory distress; uncertain appearance.

ICU / urgent therapy

Meningitis/septic shock, Kawasaki needing IVIG, intussusception pre/post reduction, neonatal HSV.