Pediatric Fever

Fever without a source

Most common sources

  • Lungs
  • Urine
  • CNS
  • Abdomen
  • Skin


  • Tmax (rectal)
  • Resp symptoms
  • Rash
  • Seizures
  • Urine/stools
  • Pain
  • Exposures
  • PMH
    • Perinatal
      • Adjust age (chronologic age in weeks – [40 – gestational age in weeks])
      • Mother GBS status
      • Maternal fever/tachycardia/abdominal pain (chorioamnionitis)
      • Mother HSV
      • Birth weight/APGAR
      • Post-partum course
    • Immunocompromised (cancer, asplenia, HIV), history of infections/multiplications
    • Vaccinations
  • Meds (antipyretics, antibiotics)
    • Mother's medications if breastfeeding (may pass through breastmilk)
  • Allergies

Physical Exam

  • Alertness (AVPU)
  • ABCs
    • Airway patent/maintainable
    • Breathing (RR, O2sat, WOB, auscultation)
    • Circulation (BP, HR, cyanosis, cap refill, femoral pulses, distal pulses, auscultation)
  • Temp rectal
  • HEENT / hydration status
  • Neuro
    • Fontanelle
    • Pupils
    • Tone/Reflexes
  • Abdominal
  • MSK
    • Joints
    • Ambulation (limp)
  • Skin

Red Flags

  • Cyanosis, poor peripheral circulation
  • Petechial rash
  • Inconsolability
  • Parental and physician concern

Work-up <60d if no focal infection found

  • CBC, CRP
  • Urinalysis and Urine culture
  • Blood culture
  • Consider
    • Procalcitonin
    • LP (cell count, culture, Gram stain, protein, glucose, and viral studies)
      • Optional in >1 month old and low risk (see below)
    • CXR
      • Optional if suspect bronchiolitis OR absence of resp sx and >2 months
    • Stool culture if diarrhea
    • NPA for respiratory virus (influenza)

Low Risk Invasive Bacterial Infection (IBI)

Using previously described predictions rules (Step-by-Step and PECARN), may consider avoiding LP/antibiotics in well-appearing 29-60 day old with

  • Rectal T<38.6 °C
  • UA negative (neg LE/NI with <5WBC on hpf)
  • Procalcitonin ≤0.5 ng/mL
  • ANC <4000/microL
  • CRP <20

Note: However these labs were rapidly available <60 minutes

Work up 61-90d if no focal infection found

  • Healthy, vaccinated, well-appearing, low-risk
    • UA
      • If negative, close out-patient follow-up
      • If positive, oral antibiotics with close outpatient follow-up

In >90d, rule out UTI

    • <3 years old, if fever with unclear source
    • >3 years old, consider testing if presence of dysuria, urinary frequency, hematuria, abdominal/back pain, daytime incontinence


  • Empiric IV antibiotics and fluids
    • <1 month
      • Ampicillin (100-200mg/kg/d IV divided q6h) + Cefotaxime 50mg/kg IV q8h or Gentamycin 2.5mg/kg IV q8h or Tobramycin 6mg/kg IV q24h with dose adjustments
    • >1month, urinary findings
      • Cefotaxime 50mg/kg IV q8h
    • 1-3 months
      • Non-meningitic: Ceftriaxone 50mg/kg/day IV divided q12-24h
      • Meningitis: Ceftriaxone 100mg/kg/day IV divided q12-24h
      • Add ampicillin for Listeria or enterococcus concern
      • Add vancomycin for MRSA if concern
  • Consider empiric antivirals (acyclovir), especially if suspect HSV meningitis
  • Antipyretic may help for prognostication and examination
    • Ibuprofen 10mg/kg TID
    • Acetaminophen 15mg/kg QID

Prolonged Fever

  • Rule out Kawasaki
  • Fever ≥ 5 days (if any of the 4 below criteria present at any time during illness, diagnose on day 4 of illness)
    • Conjunctivitis (bilateral nonexudative)
    • Rash (polymorphic)
    • Adenopathy (Cervical lymph node >1.5cm)
    • Strawberry tongue (oral mucous membranes changes, also injected/fissured lips, injected pharynx)
    • Hands and feet edema (acute)/desquamation (convalescent)
  • Other useful findings: Redness/crust formation at BCG vaccination site (50% will have this)
  • Consider labs (WBC, platelet, AST, ALT, CRP, ESR, Urinalysis for pyuria, consider viral testing for alternative diagnoses)
  • Treat with ASA and IVIG to prevent coronary artery aneurysms