synposis of AFP's "Evaluation of Fever in Infants and Young Children"

This is a synposis of  Evaluation of Fever in Infants and Young Children

JENNIFER L. HAMILTON, MD, PhD, FAAFP, Drexel University College of Medicine, Philadelphia, Pennsylvania

SONY P. JOHN, MD, Chester County Hospital, West Chester, Pennsylvania

Am Fam Physician. 2013 Feb 15;87(4):254-260.

     A sick kid is always a big concern. With the progress of vaccinations, infections which were once common killers, such as S. pneumoniae and H. influenzae, are now rare. The two most common causes of fever in children under 3 years old these days are UTIs and pneumonia. It is important to remember that UTIs are more common in boys than girls at this age.
     The most accurate way to determine a fever in children under 3 is with a rectal temperature of at least 100.4'F (38'C). Other areas of measurement are not as reliable.  Physical exam is another important part of the diagnosis. Changes in the child's behavior, circulation, breathing, rash, seizures, skin elasticity, parental concerns, as well as the physician's own instinct are important factors in the assessment. Even if the child is afebrile when you check, and the mom says it was high at home, the patient still must treated as urgent.
     According to this article, the WBC and absolute neutrophil counts are something worth paying attention to. The test is important for patients less than a month old, but for those older, the usefulness is questionable. Bacteremia is not that common a cause of fever comparatively .  It is still recommended in current guidelines, thus it still should be done. Inflammatory markers, such as CRP and procalcitonin, have a better sensitivity and specificity than the WBC count, although the cost and availability may prohibit the usage.
     Lumbar puncture is a test that was once very common, but is now used less due to the effectiveness of vaccinations against meningitis. it is not recommended for patients older than 3 months unless there are also neurological signs. Some signs are nuchal rigidity and petechiae.
     Chest x ray is another test that should be considered if the patient is older than 1 month old, has a fever greater than 102.2'F, and a WBC count above 20,000 per mm3, (good thing you went ahead with the WBC count, huh). Respiratory signs wouldn't hurt either.
     Diarrhea would trigger a stool culture and fecal WBC count.
     Treatment depends a lot on antibiotic resistance patterns in the area. Neonates can be treated with ampicillin and gentamicin. A third generation cephalosporin can be substituted for ampicillin if E.coli resistance is a concern. If the patient is older than 1 month with urinary findings, Cefotaxime or cefixime may be used. If the patient is older than 3 months and pneumonia is suspected, you can try amoxicillin or azithromycin.