pediatric fever 0 to 28 daysMANAGEMENT

PEDIATRIC-SPECIFIC PRESENTATIONS · 12 SECTIONS

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473 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Bronchiolitis Croup Emergency delivery Febrile seizure Intussusception Kawasaki disease Neonatal jaundice Neonatal sepsis Nursemaid's elbow Pediatric fever 0 to 28 days Pediatric fever 29 to 60 days Pediatric fever 61 to 90 days Pyloric stenosis

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp57

Triage priorities

›High-risk age group

›0 to 28 days with rectal temperature 38.0 C or higher

›Serious bacterial infection risk even if well appearing

›Treat as sepsis until proven otherwise

›Immediate escalation triggers

›Apnea

›Cyanosis

›Poor perfusion

›Lethargy

›Seizure

›Hypotension

›Initial monitoring

›Continuous pulse oximetry

›Cardiac monitor

›Noninvasive blood pressure cycling

›Temperature trend

Stabilization

›Airway and breathing

›Supplemental oxygen for SpO2 below local target

›Bag-mask ventilation for apnea or inadequate ventilation

›Early airway support for recurrent apnea or shock

›Circulation

›Vascular access within 5 minutes

›Peripheral IV

›If delayed, intraosseous

›Fluid resuscitation

›If shock, isotonic crystalloid 10 mL/kg bolus

›Reassess after each bolus

›Additional boluses up to 40 mL/kg in first hour if persistent shock and no fluid intolerance

›Vasoactive support

›If fluid-refractory shock, epinephrine infusion per local protocol

›If cold shock with low cardiac output, epinephrine favored

›If warm shock with low SVR, norepinephrine favored

›Glucose and temperature

›Hypoglycemia threshold 2.6 mmol/L

›Dextrose bolus if 2.6 mmol/L or lower

›D10W 2 mL/kg IV

›Hypothermia and hyperthermia as sepsis markers

Sepsis bundle timing

›Time zero

›First documented rectal temperature 38.0 C or higher

›First clinician recognition of sepsis physiology

›Antibiotics

›Within 60 minutes of sepsis recognition

›After cultures if no delay

›Lumbar puncture timing

›Before antibiotics if stable and no delay

›After antibiotics if unstable or delayed access

Key concepts

›Neonatal fever framework

›Immature immunity

›Subtle early signs

›Higher invasive bacterial infection risk than older infants

›Common invasive pathogens

›Escherichia coli

›Group B Streptococcus

›Listeria monocytogenes

›Viral pathogens with high consequence

›HSV risk highest in first weeks of life

›Enterovirus consideration in season

02History/hx56

Fever characterization

›Fever details

›Highest temperature

›Method of measurement

›Antipyretic exposure

›Time course

›Onset time

›Duration

›Trend

›Vaccines

›Immunization in prior 48 hours

›Birth hepatitis B timing

Symptoms and functional change

›Feeding and hydration

›Intake decrease

›Emesis

›Wet diaper count

›Respiratory

›Cough

›Tachypnea

›Apnea

›Neurologic

›Lethargy

›Irritability

›Seizure activity

›Gastrointestinal

›Diarrhea

›Blood in stool

›Abdominal distension

›Skin and soft tissue

›Rash

›Vesicles

›Umbilical redness

›Genitourinary

›Foul urine

›Poor feeding with no localizing signs

Perinatal and maternal risk

›Birth history

›Gestational age

›NICU stay

›Complications

›Maternal infections

›GBS status and intrapartum prophylaxis

›Chorioamnionitis

›HSV history

›Peripartum genital lesions

›Neonatal risk factors

›Prematurity

›Prolonged rupture of membranes

›Central lines

›Recent antibiotics

Exposure and environment

›Sick contacts

›Household viral illness

›Daycare exposures

›Travel and outbreaks

›Known influenza or RSV circulation

›Social risk

›Barriers to return

›Caregiver reliability

03Physical Exam/exam51

Appearance and vitals

›General appearance

›Toxic appearance

›Weak cry

›Poor tone

›Vital signs interpretation

›Fever 38.0 C or higher

›Hypothermia as sepsis marker

›Tachycardia out of proportion to fever

›Tachypnea

›Hypotension late sign

›Perfusion

›Capillary refill

›Central pulses

›Mottling

Focused system exam

›HEENT

›Bulging fontanelle

›Conjunctivitis

›Otitis signs

›Respiratory

›Work of breathing

›Focal crackles

›Grunting

›Cardiovascular

›Murmur

›Hepatomegaly

›Differential pulses

›Abdomen

›Distension

›Tenderness

›Organomegaly

›Skin

›Petechiae or purpura

›Vesicular lesions

›Cellulitis

›Omphalitis

›MSK

›Pseudoparalysis

›Joint swelling

›Long bone tenderness

›Neuro

›Tone abnormalities

›Irritability

›Seizure

PITFALLS

›Misleading well appearance

›Early meningitis may look well

›Early bacteremia may have minimal signs

›Partially treated infection

›Antipyretics masking fever severity

›Recent antibiotics masking culture yield

›Temperature measurement error

›Non-rectal measurements underestimating fever

04Differential Diagnosis/ddx32

Life-threatening

›Invasive bacterial infection

›Bacteremia

›ICD-10 R78.81

›Bacterial meningitis

›ICD-10 G00.9

›Neonatal sepsis

›ICD-10 P36.9

›HSV infection

›Disseminated HSV

›HSV CNS disease

›Pneumonia

›ICD-10 J18.9

›Urinary tract infection

›ICD-10 N39.0

›Osteomyelitis or septic arthritis

›Osteomyelitis ICD-10 M86.9

›Septic arthritis ICD-10 M00.9

Other important causes

›Viral illness

›RSV

›Influenza

›SARS-CoV-2

›Enterovirus

›Congenital infection

›TORCH considerations

›Serious noninfectious

›Congenital heart disease with decompensation

›Inborn error of metabolism

›Adrenal crisis

›Localized bacterial

›Omphalitis

›Cellulitis

›Abscess

05Laboratory Tests/lt57

Core sepsis labs

›Baseline evaluation set

›Blood culture

›Antibiotics after collection if feasible

›Complete blood count with differential

›ANC interpretation context dependent

›WBC alone insufficient to rule out invasive infection

›CRP

›Early illness may be normal

›Serial trend more informative

›Procalcitonin

›Higher specificity for invasive bacterial infection than WBC in many pathways

›Interpretation limited in immediate neonatal period

›Chemistry

›Electrolytes

›Creatinine and urea

›Glucose mmol/L

›Blood gas if ill

›pH

›Lactate mmol/L

›PaCO2 mmHg

›PaO2 mmHg

Urine testing

›Urine assessment

›Urinalysis

›Leukocyte esterase

›Nitrites

›Microscopy WBC

›Urine culture

›Sterile collection method required

›Catheter specimen

›Suprapubic aspirate

›Bag urine not acceptable for culture

CSF testing

›Lumbar puncture panel

›CSF cell count with differential

›CSF glucose mmol/L

›Paired serum glucose

›CSF protein

›CSF Gram stain and culture

›CSF viral PCR as indicated

›HSV PCR

›Enterovirus PCR if available

Additional labs by presentation

›Respiratory symptoms

›Viral PCR panel per local availability

›Diarrhea

›Stool culture and PCR when bloody or severe

›Hyperbilirubinemia or cholestasis

›Total and direct bilirubin

›Coagulopathy suspicion

›INR

›aPTT

›Fibrinogen

›Platelet trend

PITFALLS

›False reassurance

›Normal inflammatory markers early

›Normal urinalysis with early pyelonephritis

›Contamination risk

›Blood culture contaminants in low-volume draws

›Urine culture contamination with nonsterile collection

06Diagnostic Tests/dt44

Scoring Systems

›Risk stratification tools context

›Many tools designed for older infants

›Neonates 0 to 28 days generally managed as high risk regardless of score

›Rochester criteria

›Historical low-risk tool

›Limited modern validation for neonates

›Philadelphia and Boston criteria

›Older criteria including routine LP

›Not aligned with current biomarker era

›Step-by-Step and PECARN febrile infant rules

›Developed for infants up to 60 to 90 days in various cohorts

›Youngest age groups typically treated as high risk in pathways

›Guideline alignment

›AAP guideline focuses on 8 to 60 days

›Institutional pathways often treat 0 to 21 days as mandatory full sepsis evaluation and admission

MRI

›CNS imaging indications

›Focal neurologic deficit

›Persistent seizures

›Suspected HSV encephalitis with abnormal neuro exam

›Practical limitations

›Need for sedation in many neonates

›Not first-line in initial ED sepsis evaluation

›Interpretation pearls

›HSV temporal involvement possible

›Diffusion restriction in meningitis complications

›CT head indications

›Concern for intracranial hemorrhage

›Bulging fontanelle with focal deficits when MRI not available urgently

›CT chest indications

›Not routine for neonatal fever

›Reserved for complications or unclear severe respiratory disease

›Radiation considerations

›Neonatal dose sensitivity

›Strong preference for clinical evaluation and targeted imaging

Ultrasound

›POCUS for unstable neonate

›Cardiac function

›Volume status

›Pericardial effusion

›Abdominal ultrasound indications

›Suspected pyloric stenosis symptoms overlap with dehydration and fever

›Suspected intraabdominal source

›Renal ultrasound

›Not acute ED test for initial febrile neonate evaluation

›Consider after first febrile UTI per local guideline timing

07Disposition/dispo24

Admission and level of care

›Default disposition

›Inpatient admission for all febrile infants 0 to 28 days

›Parenteral antibiotics pending cultures

›PICU criteria

›Shock

›Need for vasoactives

›Respiratory failure

›Recurrent apnea

›Seizure or altered mental status

›Transfer criteria

›No pediatric inpatient capability

›Need for PICU not available

›Need for lumbar puncture under specialist support

Observation endpoints

›Culture monitoring

›Blood culture time to positivity local lab dependent

›Reassessment at 24 to 36 hours common inpatient practice

›Clinical trajectory

›Feeding improvement

›Afebrile without antipyretics

›Stable vitals and perfusion

Discharge exceptions

›ED discharge generally not appropriate in 0 to 28 days

›Consider only under specialist pathway

›Requires full evaluation including CSF in most protocols

›Requires reliable follow-up and return access

08Treatment/t65

Empiric antimicrobials

›Initial empiric regimen for sepsis without focal source

›Ampicillin

›50 mg/kg IV every 6 hours for sepsis dosing

›100 mg/kg IV every 6 hours if meningitis suspected

›Listeria and Enterococcus coverage

›Gentamicin

›4 to 5 mg/kg IV every 24 hours

›Therapeutic drug monitoring per local protocol

›Nephrotoxicity and ototoxicity risk monitoring

›Alternative regimen when meningitis suspected or Gram-negative meningitis risk

›Cefotaxime

›50 mg/kg IV every 6 to 8 hours depending on age and indication

›Preferred cephalosporin in neonates when needed

›Avoid ceftriaxone in neonates

›Bilirubin displacement risk

›Calcium precipitation risk

›Vancomycin indications

›Suspected MRSA

›Central line infection

›Severe skin and soft tissue infection

›Local resistance patterns

›15 mg/kg IV per dose with interval per gestational age and renal function

HSV coverage

›Acyclovir indications

›Vesicular rash

›Seizure

›Focal neurologic signs

›CSF pleocytosis with negative Gram stain

›Marked transaminitis

›Severe sepsis with no source

›Maternal HSV lesions near delivery

›Acyclovir dosing

›20 mg/kg IV every 8 hours

›Renal adjustment per creatinine and gestational age

›Hydration and renal monitoring

›HSV diagnostic bundle while on acyclovir

›CSF HSV PCR

›Blood HSV PCR if available

›Surface swabs PCR or culture per local protocol

›ALT and AST

Supportive care

›Fluids and perfusion targets

›Capillary refill improving

›Normalizing lactate trend

›Adequate urine output per weight and age

›Antipyretics

›Acetaminophen 10 to 15 mg/kg per dose

›Avoid ibuprofen in neonates

›Respiratory support escalation

›HFNC or CPAP per local neonatal protocols

›Intubation for apnea or shock physiology

Source-directed therapy

›UTI or pyelonephritis

›Continue neonatal empiric coverage until culture susceptibilities

›Narrowing once organism and sensitivities known

›Meningitis

›Antibiotic selection guided by Gram stain and culture

›Duration guided by organism and specialist input

›Omphalitis

›Broad coverage including staphylococci and Gram-negatives

›Surgical consult for necrotizing infection concern

Treatment adjustments

›Narrowing strategy

›De-escalation with negative cultures and improving course

›Targeted therapy with identified pathogen

›Stop criteria for antibiotics

›Cultures negative at institutional time threshold

›Clinical well-being and feeding

›Specialist agreement for discharge planning

09Special Populations/sp19

Pregnancy

›Maternal postpartum context

›Maternal fever and chorioamnionitis history relevance

›Maternal HSV lesion history relevance

›Medication exposure through breast milk

›Generally compatible antibiotics used in neonates

›Breastfeeding support during hospitalization

Geriatric

›Not applicable group

›Pediatric-only condition framework

›Exclude from neonatal fever pathway use

Pediatrics

›Neonatal specific factors

›Corrected age consideration for prematurity

›NICU discharge infants higher baseline risk

›Febrile infant guideline context

›Many national guidelines stratify 0 to 21 days as mandatory full evaluation and admission

›22 to 28 days frequently treated similarly due to risk

›Procedural considerations

›Lumbar puncture positioning and analgesia

›Blood culture volume optimization per local lab

›Urine collection via catheter or suprapubic aspirate

10Background/b29

Epidemiology

›Fever burden in neonates

›Significant proportion viral

›Nontrivial invasive bacterial infection risk compared with older infants

›Most common serious bacterial infection

›UTI among well-appearing febrile infants

›Invasive bacterial pathogens in neonates

›E coli

›Group B Streptococcus

›Listeria monocytogenes

Pathophysiology

›Neonatal immune vulnerability

›Reduced opsonization and complement activity

›Limited neutrophil reserve in severe infection

›Hematogenous spread propensity

›Bacteremia seeding meninges

›Rapid progression without obvious focus

›HSV disease patterns

›Skin eye mouth disease

›CNS disease

›Disseminated disease with hepatitis and shock

Therapeutic Considerations

›Antibiotic selection rationale

›Ampicillin for Listeria and Enterococcus

›Aminoglycoside for Gram-negative synergy

›Cefotaxime when meningitis suspected or high Gram-negative concern

›Timing principle

›Earlier antibiotics in shock improves outcomes

›Cultures before antibiotics if no delay

›Biomarker limitations

›Single marker insufficient

›Trend and clinical picture primary in 0 to 28 days

11Patient Discharge Instructions/pdi25

Copy discharge instructions

›Post-hospital discharge guidance

›Follow-up timing

›Primary care visit within 24 to 48 hours after discharge

›Specialty follow-up if meningitis or HSV

›Feeding and hydration expectations

›Normal feeding frequency for age

›Wet diapers trending to baseline

›Return immediately for

›Temperature 38.0 C or higher

›Difficulty breathing

›Apnea

›Blue or pale color

›Poor feeding

›Fewer wet diapers

›Lethargy or unusual sleepiness

›Persistent vomiting

›New rash

›Seizure or abnormal movements

›Medication safety

›Only medications prescribed at discharge

›No ibuprofen unless specifically directed

›Acetaminophen dosing only if instructed

›Infection control

›Hand hygiene

›Limit sick contacts

12References/r14

Guidelines and society statements

›Febrile young infants 0 to 90 days guidance

›Canadian Paediatric Society position statement on well-appearing febrile infants 90 days or younger

›American Academy of Pediatrics guideline on well-appearing febrile infants 8 to 60 days

›NICE guideline NG143 fever in under 5s

›TREKK fever in young children and young infants resources referenced in Canadian pathways

›Neonatal HSV guidance

›CDC STI Treatment Guidelines neonatal herpes acyclovir dosing

›Canadian Paediatric Society neonatal HSV prevention and management statement

Evidence-based sources

›Febrile infant pathway evidence base

›AHRQ evidence review supporting AAP febrile infant guideline development

›Studies evaluating inflammatory markers in febrile infants

›Acyclovir dosing evidence

›Neonatal HSV dosing standard 60 mg/kg/day divided every 8 hours

›Safety literature on high-dose acyclovir in infants

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.