Clinical Policy for Children Younger Than
Three Years Presenting to the Emergency
Department With Fever
June 11, 2003.

I. Are there useful age cutoffs for different diagnostic and
treatment strategies in febrile children?

Level A recommendations. Infants between 1 and 28
days old with a fever should be presumed to have a
serious bacterial infection.

II. Does a response to antipyretic medication indicate a lower
likelihood of serious bacterial infection in the pediatric
patient with a fever?

Level A recommendations. A response to antipyretic
medication does not change the likelihood of a child
having serious bacterial infection and should not be
used for clinical decisionmaking.

III. What are the indications for a chest radiograph during the
workup of pediatric fever?

Level B recommendations. A chest radiograph should be
obtained in febrile children aged younger than 3 months
with evidence of acute respiratory illness.

Level C recommendations. There is insufficient evidence
to determine when a chest radiograph is required in a
febrile child aged older than 3 months. Consider a
chest radiograph in children older than 3 months with
a temperature greater than 39°C (>102.2°F) and a WBC
count greater than 20,000/mm3.
A chest radiograph is usually not indicated in febrile
children aged older than 3 months with temperature
less than 39°C (<102.2°F) without clinical evidence of
acute pulmonary disease.

IV. Which children are at risk for urinary tract infection?

Level A recommendations. Children aged younger than
1 year with fever without a source should be considered
at risk for urinary tract infection.

Level B recommendations. Females aged between 1 and
2 years presenting with fever without source should be
considered at risk for having a urinary tract infection.

V. What are the best methods for obtaining urine for urinalysis
and culture?

Level B recommendations. Urethral catheterization or
suprapubic aspiration are the best methods for diagnosing
urinary tract infection.

VI. What is the appropriate role of urinalysis, microscopy, and
urine cultures?

Level B recommendations. Obtain a urine culture in
conjunction with other urine studies when urinary tract
infection is suspected in a child aged younger than 2
years because a negative urine dipstick or urinalysis
result in a febrile child does not always exclude urinary
tract infection.

VII. What is the prevalence of occult bacteremia in children
aged 3 to 36 months, and how frequently does it result in
significant sequelae?

1. The current prevalence of occult bacteremia among
febrile children aged 3 to 36 months is most likely between
1.5% and 2%.
2. Preliminary studies indicate that approximately
5% to 20% of patients aged 3 to 36 months with occult
bacteremia will develop significant sequelae (eg, pneumonia,
cellulitis, septic arthritis, osteomyelitis, meningitis,
sepsis). Approximately 0.3% of previously well
children (aged 3 to 36 months) who have a fever without
source will develop significant sequelae; however,
only 0.03% will develop sepsis or meningitis.

VIII. What is the appropriate role of empiric antibiotics among
previously healthy, well-appearing children aged 3 to 36
months with fever without a source?

Level B recommendations. Consider empiric antibiotic therapy for
previously healthy, well-appearing children, aged 3 to 36 months,
with fever without a source with a temperature of 39.0 degreesC
or greater (102.2 degreesF) when in association with a WBC count
of 15,000/mm3 or greater if obtained.

Level C recommendations. In those cases when empiric
antibiotics are not prescribed for children who have
fever without a source, close follow-up must be ensured.