This is the current release of the guideline.

Clinical policies are scheduled for revision every 3 years; however, interim reviews are conducted when technology or the practice environment changes significantly.

Definitions for the strength of evidence (Class I-III) and strength of recommendations (A-C) are repeated at the end of the Major Recommendations.

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.
• Level B recommendations. None specified.
• Level C recommendations. None specified.

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 decision making.
• Level B recommendations. None specified.
• Level C recommendations. None specified.

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

• Level A recommendations. None specified.
• 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 degrees C (>102.2 degrees F) and a white blood cell (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 degrees C (<102.2 degrees F) without clinical evidence of acute pulmonary disease.

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.
• Level C recommendations. None specified.

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

• Level A recommendations. None specified.
• Level B recommendations. Urethral catheterization or suprapubic aspiration are the best methods for diagnosing urinary tract infection.
• Level C recommendations. None specified.

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

• Level A recommendations. None specified.
• 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.
• Level C recommendations. None specified.

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 A recommendations. None specified.
• 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 degrees C or greater (>102.2 degrees F) 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.

Definitions:

Strength of Evidence

Strength of evidence Class I – Interventional studies including clinical trials, observational studies including prospective cohort studies, and aggregate studies including meta-analyses of randomized clinical trials only

Strength of evidence Class II – Observational studies including retrospective cohort studies, case-controlled studies, and aggregate studies including other meta-analyses

Strength of evidence Class III – Descriptive cross-sectional studies; observational reports including case series and case reports; and consensus studies including published panel consensus by acknowledged groups of experts

Strength of Recommendation

Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on "strength of evidence Class I" or overwhelming evidence from "strength of evidence Class II" studies that directly address all the issues)

Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on "strength of evidence Class II" studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of "strength of evidence Class III" studies)

Level C recommendations. Other strategies for patient management based on preliminary, inconclusive, or conflicting evidence, or, in the absence of any published literature, based on panel consensus

There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2003 Oct

American College of Emergency Physicians - Medical Specialty Society

American College of Emergency Physicians

American College of Emergency Physicians (ACEP) Clinical Policies Subcommittee on Pediatric Fever

ACEP Clinical Policies Committee

Members of the Subcommittee on Pediatric Fever: Wyatt W. Decker, MD (Chair); Maureen D. McCollough, MD; John H. Myers, MD; Scott M. Silvers, MD

Members of the Clinical Policies Committee: William C. Dalsey, MD (Chair 2000-2002, Co-Chair 2002-2003); Andy S. Jagoda, MD (Co-Chair 2002-2003); Wyatt W. Decker, MD; Francis M. Fesmire, MD; Steven A. Godwin, MD; John M. Howell, MD; Shkelzen Hoxhaj, MD (EMRA Representative 2002-2003); J. Stephen Huff, MD; Alan H. Itzkowitz, MD (EMRA Representative 2000-2001); Edwin K. Kuffner, MD; Thomas W. Lukens, MD, PhD; Benjamin E. Marett, RN, MSN, CEN, CNA, COHN-S (ENA Representative 2002-2003); Thomas P. Martin, MD; Jessie Moore, RN, MSN, CEN (ENA Representative 2001-2002); Barbara A. Murphy, MD; Devorah Nazarian, MD; Scott M. Silvers, MD; Bonnie Simmons, DO; Edward P. Sloan, MD, MPH; Suzanne Wall, RNC, MS, CEN (ENA Representative 1999-2000); Robert L. Wears, MD, MS; Stephen J. Wolf, MD (EMRA Representative 2001-2002); Robert E. Suter, DO, MHA (Board Liaison 2000-2001); Susan M. Nedza, MD (Board Liaison 2001-2003); Rhonda Whitson, RHIA, Staff Liaison, Clinical Policies Committee and Subcommittees

Not stated

This is the current release of the guideline.

Clinical policies are scheduled for revision every 3 years; however, interim reviews are conducted when technology or the practice environment changes significantly.

None available

None available

This NGC summary was completed by ECRI on April 21, 2004. The information was verified by the guideline developer on June 10, 2004.