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Understanding Pediatrics: Fever without Focus in Children 3-36 months

Author: Kevin Ren

So, a young child presents to the ED with a fever of 41 degrees! But on a quick review of systems – nothing. No cough, vomiting, diarrhea, earache, or dysuria. The parents say that other than the fever, they’re totally fine. On a quick inspection, the child does not look sick at all, sitting calmy in their parent’s lap. What do you do?

Epidemiology

  • Up to 45% of children with fever have no source on clinical exam

History and Physical

  • Head to toe approach to confirm there’s no focus
    • Eyes – pain, redness
    • Ears – discharge, pain
    • Sore throat
    • Cough
    • Dyspnea
    • Nausea/vomiting
    • Diarrhea
    • Painful urination/CVA tenderness
    • Skin infections
    • Joint pain
  • Ask about child’s
    • Oral intake, change in activity/behavior, wet diapers
  • If no sxs, or no change in behavior, we have a case of fever with no focus
  • Ask about immunization status – completely or incompletely immunized
  • PMHx – ask about immunocompromise, sickle cell, etc.

Etiologies

  • Self-limiting viral infection (majority of cases)
  • Occult UTI (asxs bacteruria)
  • Occult pneumonia
  • Occult bacteremia = most serious etiology we must rule out

Approach

  • Goal = rule out occult bacteremia
  • Key hx question = is the child completely immunized?
    • Yes = <1% chance of occult bacteremia
    • No = 3-11% chance of occult bacteremia
  • If child is completely immunized
    • Just do UA, maybe CXR if suspicion is high
    • No bloodwork needed
  • If child is incompletely immunized
    • CBC-D
      • WBC > 15 or ANC > 10 → blood culture
      • WBC > 20 → CXR
    • Procalcitonin (limited evidence on utility)
    • UA with culture

For further reading, check out:

https://www.uptodate.com/contents/fever-without-a-source-in-children-3-to-36-months-of-age-evaluation-and-management?search=fever%20without%20focus&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1