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Pediatric Fever

Age decides the workup; appearance decides the urgency.

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Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
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The jobAge decides the workup; appearance decides the urgency.

  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.
  4. Hunt the hidden source — urine in the young. Fever >5 days: Kawasaki, including incomplete.

Fever in a child is screened by three questions: How old?

Immunized? Well-appearing? The 2021 AAP guideline for well-appearing febrile infants 8–60 days stratifies 8–21, 22–28, and 29–60 days — “safely do less” in the older, well, immunized infant. Any ill-appearing infant, and all febrile neonates 0–7 days, still need neonatal sepsis assessment and empiric therapy; stabilization precedes LP. Always hunt the hidden source — urine in the young — and take seriously the child who “just doesn’t look right.”

Neonatal / young-infant sepsis Critical

Key: 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 Critical

Key: Toxic appearance, petechiae, bulging fontanelle — antibiotics and LP pathway.

UTI (hidden source) Critical

Key: Especially girls <24 months and uncircumcised boys <12 months — catheterized specimen (or SPA); bag urine is a screen only.

Kawasaki disease Critical

Key: ≥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 Critical

Key: Vesicles, seizures, CSF RBC/pleocytosis, hepatitis in the neonate — empiric acyclovir.

Intussusception Emergent

Key: Colicky pain, red-currant stool, drawing-up legs — US then air/contrast enema. Fever is not required.

Bronchiolitis / croup / viral URIs Common

Key: Supportive care; know the deterioration signs (apnea in young infants).

Post-vaccination fever Common

Key: Recent immunization does not exclude bacterial infection. Infants immunized within 48 h are outside the AAP 8–60-day algorithm: use age, examination and the local infant pathway; do not default to comfort care.

Tick what your patient has — the banner updates as you go.

Exact age in days, gestational age, immunization status, day-care/sick contacts

Temperature measured how/where? Antipyretics given when?

Appearance between fevers

feeding, activity, consolability

Specific symptoms

cough, vomiting, diarrhea, rash, reduced wet diapers

Maternal risks in neonates (GBS, prolonged rupture, maternal fever, HSV)

Overall appearance

toxic vs well — the most important sign, judged between fever spikes

Vitals with age-adjusted norms; capillary refill

Full undressed exam

rashes, fontanelle, ears, throat, chest

Hydration

mucous membranes, tears, urine output

Localizing signs

limp, ear pull, drooling + tripod (croup/epiglottitis)

Bedside

  • 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

Labs (age-gated, AAP 2021 for well-appearing 8–60 d)

  • 8–21 days: UA/culture, blood culture, LP ± IMs; empiric parenteral antibiotics
  • 22–28 days: UA/culture, blood culture, IMs (PCT, ANC, CRP); LP if IM abnormal
  • 29–60 days: UA/culture, blood culture, IMs; LP optional if IMs normal and well-appearing
  • >60 days / >3 months well-appearing: clinical ± urine; inflammatory markers to gate antibiotics per local pathway

Imaging

  • CXR if respiratory signs; US for intussusception suspicion (then air enema); echo if Kawasaki
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • Well-appearing, immunized child — and, if 29–60 days, normal IMs with a negative UA — with reliable caregivers and clear return precautions, per local pathway.

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.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Pediatric Fever:
    • 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. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • Age in days, immunizations, and appearance decide the workup — in that order.
  • AAP 2021: 8–21 d full including LP; 22–28 d LP if inflammatory markers are up; 29–60 d may skip LP if well with normal markers.
  • Urine is the hidden source in the young febrile infant.
  • Suspect Kawasaki with persistent fever and mucocutaneous signs; experienced clinicians may diagnose earlier than day 5. Incomplete presentations need the laboratory/echo pathway.

Pitfalls

  • “Well-looking” must be judged between fever spikes. The AAP CPG does not apply to ill-appearing, premature, or immunocompromised infants, or to 0–7 days of life.
  • Immunization status changes the risk of occult bacteremia in older infants — document it.
  • Fever without source in a young infant is a workup, not a diagnosis.
  • Antipyretics can mask a toxic child.
  • Rectal temperatures in neonates; axillary/tympanic under-read in the young.
  • Incomplete Kawasaki (fever + 2–3 criteria with inflammatory labs) is easy to miss and still needs echo/IVIG consideration.
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
Fever & SepsisSeizuresSore Throat & Neck

Selected guidance · source check 2026-09-07. These 1 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — pediatric fever
  • AAP 2021 CPG: Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old
  • NICE NG143 Fever in under 5s
  • AHA 2024 Kawasaki disease scientific statement
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