PEDIATRICS Vol. 92 No. 1 July 1993, pp. 1-12
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Practice Guideline for the Management of Infants and Children 0 to 36 Months of Age With Fever Without Source

Larry J. Baraff MD1, David L. Schriger MD, MPH1, James W. Bass MD2, Gary R. Fleisher MD3, Jerome O. Klein MD4, George H. McCracken Jr MD5, and Keith R. Powell MD6

1 From the UCLA Emergency Medidne Center, Los Angeles, California
2 From the Tripler Army Medical Center, Honolulu, Hawaii
3 From the Children's Hospital, Massachusetts
4 From the Boston City Hospital, Boston, Massachusetts
5 From the University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
6 From the University of Rochester, Rochester, New York

Study objective. To develop guidelines for the care of infants and children from birth to 36 months of age with fever without source.

Participants and setting. An expert panel of senior academic faculty with expertise in pediatrics and infectious diseases or emergency medicine.

Design and intervention. A comprehensive literature search was used to identify all publications pertinent to the management of the febrile child. When appropriate, meta-analysis was used to combine the results of multiple studies. One or more specific management strategies was proposed for each of decision nodes in draft management algorithms. The draft algorithms, selected publications, and the meta-analyses were provided to the panel, which determined the final guidelines using the modified Delphi technique.

Results. All toxic-appearing infants and children and all febrile infants less than 28 days of age should be hospitalized for parenteral antibiotic therapy. Febrile infants 28 to 90 days of age defined at low risk by specific clinical and laboratory criteria may be managed as outpatients if close follow-up is assured. Older children with fever less than 39.0°C without source need no laboratory tests or antibiotics. Children 3 to 36 months of age with fever of 39.0°C or more and whose white blood cell count is 15 000/mm3 or more should have a blood culture and be treated with antibiotics pending culture results. Urine cultures should be obtained from all boys 6 months of age or less and all girls 2 years of age or less who are treated with antibiotics.

Conclusion. These guidelines do not eliminate all risk or strictly confine antibiotic treatment to children likely to have occult bacteremia. Physicians may individualize therapy based on clinical circumstances or adopt a variation of these guidelines based on a different interpretation of the evidence.

Key Words: practice guidelines • fever without source • bacteremia

Submitted on February 8, 1993
Accepted on March 16, 1993




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