Fever Without a Focus 

  • Author: Robert W Tolan Jr, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: May 12, 2011
 

Background

Infants or young children who have a fever with no obvious source of infection present a diagnostic dilemma. Health care providers see these patients on a daily basis. As many as 20% of childhood fevers have no apparent cause.[1] A small but significant number of these patients may have a serious bacterial infection; the risk is greatest among febrile infants and children younger than 36 months, making proper diagnosis and management important. Physical examination and patient history do not always identify patients with occult bacteremia or serious bacterial infection. Serious infections that are not recognized promptly and treated appropriately can cause significant morbidity or mortality.

This article focuses primarily on infants and young children aged 2-36 months and reflects the significant changes in the care of the febrile infant and child over the past 10 years. The article Fever in the Young Infant addresses the diagnosis and treatment of febrile infants younger than 2 months.

Fever is defined as a rectal temperature that exceeds 38°C (100.4°F). Direct the initial evaluation of these patients toward identifying occult bacteremia or other serious bacterial infections. Address the following questions:

  • What laboratory studies are indicated for various age ranges?
  • Which patients need in-depth evaluation and treatment?
  • Which patients need treatment with antibiotics?
  • Which patients should be hospitalized?
  • Which patients can be sent home safely and what follow-up is appropriate for them?
  • Are the diagnosis and treatment modalities for each patient cost-effective?
  • What is the potential morbidity associated with testing and treatment?
  • What are the parental (and patient) preferences for testing and treatment?

A great deal of time and effort has been spent on research to help identify the febrile infant and young child with a serious bacterial infection. However, evaluation and treatment of febrile infants and young children vary, despite nationally published treatment guidelines.

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Pathophysiology

Meningitis, pneumonia, urinary tract infection (UTI), human herpesvirus 6 (HHV-6), and bacteremia are serious etiologies of fever in infants and young children.

Neonates' immature immune systems place them at greater risk of systemic infection. Hematogenous spread of infection is most common in this age group or in patients who are immunocompromised. For these same reasons, infants who have a focal bacterial infection have a greater risk of developing metastatic infection or bacteremia.

The following are among the most common bacterial etiologies of serious bacterial infection in this age group:

Historically, approximately 2.5-3% of highly febrile children younger than 3 years have occult bacteremia, which is typically caused by S pneumoniae.[2] The advent of conjugate pneumococcal vaccine has resulted in a decrease in pneumococcal occult bacteremia and other disease.[3] Viral infections are common in the young child as well; however, exclude serious bacterial infection prior to assuming a viral etiology for the fever.[4]

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Epidemiology

Frequency

United States

Fever accounts for 10-20% of pediatric visits to health care providers.

Mortality/Morbidity

Patients with no easily identified source of infection have a small but significant risk of a serious bacterial infection. If not recognized and treated appropriately and promptly, this can cause morbidity or mortality.

Age

This article focuses on the diagnosis and treatment of febrile children aged 2-36 months.

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Proceed to Clinical Presentation
 
 
Contributor Information and Disclosures
Author

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi Pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

Specialty Editor Board

Ashir Kumar, MD, MB  Professor Emeritus, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University

Ashir Kumar, MD, MB is a member of the following medical societies: American Association of Physicians of Indian Origin and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Mark R Schleiss, MD  American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

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Table. Summary of the Yale Observation Scale
Observation Items1 (Normal)3 (Moderate Impairment)5 (Severe Impairment)
Quality of cryStrong with normal tone or contentment without cryingWhimpering or sobbingWeak cry, moaning, or high-pitched cry
Reaction to parent stimulationBrief crying that stops or contentment without cryingIntermittent cryingContinual crying or limited response
ColorPinkAcrocyanotic or pale extremitiesPale or cyanotic or mottled or ashen
State variationIf awake, stays awake; if asleep, wakes up quickly upon stimulationEyes closed briefly while awake or awake with prolonged stimulationFalls asleep or will not arouse
HydrationSkin normal, eyes normal, and mucous membranes moistSkin and eyes normal and mouth slightly drySkin doughy or tented, dry mucous membranes, and/or sunken eyes
Response (eg, talk, smile) to social overturesSmiling or alert (< 2 mo)Briefly smiling or alert briefly (< 2 mo)Unsmiling anxious face or dull, expressionless, or not alert (< 2 mo)
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