pediatric fever 61 to 90 daysMANAGEMENT

PEDIATRIC-SPECIFIC PRESENTATIONS · 12 SECTIONS

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435 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/attcp44

Triage and immediate risks

›Initial risk sorting

›Ill appearance

›Lethargy

›Poor perfusion

›Respiratory distress

›Persistent tachycardia

›Hypotension

›Apnea

›Cyanosis

›Seizure

›High risk context

›Prematurity

›Significant comorbidity

›Immunodeficiency

›Indwelling device

›Recent antibiotics

›Focal bacterial infection

›Fever definition

›Rectal temperature >=38.0 C at home or clinical setting

›Reported fever with reliable measurement treated as fever

Stabilization and sepsis pathway

›Time critical stabilization

›If shock physiology, activate pediatric sepsis pathway

›IV or IO access

›Blood culture before antibiotics if no delay

›Broad spectrum antibiotics within 60 minutes of shock recognition

›If respiratory failure, airway escalation

›Bag mask ventilation readiness

›High flow nasal cannula or CPAP per local capability

›If septic shock, fluid and vasoactives

›Isotonic crystalloid bolus 10 to 20 mL/kg

›Reassess after each bolus

›Additional boluses to total 40 to 60 mL/kg in first hour if no fluid overload and ICU available

›If ongoing shock after fluids, initiate vasoactive infusion

›Epinephrine or norepinephrine as first line based on physiology and local practice

›Avoid dopamine when norepinephrine available

Age band framing for 61 to 90 days

›Risk framing

›Invasive bacterial infection prevalence reported <1.5% bacteremia

›Bacterial meningitis prevalence reported <0.25%

›Minimum evaluation threshold

›Urinalysis

›Urine culture

›Option for expanded risk stratification

›Same approach as 29 to 60 days pathway when desired

›Shared decision making when multiple safe options exist

02History/hx49

Key history elements

›Febrile infant core history

›Fever timeline

›Duration

›Highest measured temperature

›Antipyretic response

›Appearance and function

›Feeding volume change

›Wet diapers change

›Activity change

›Consolability

›Infection focus clues

›Cough

›Rhinorrhea

›Tachypnea

›Vomiting

›Diarrhea

›Dysuria surrogate

›Foul urine

›Rash

›Ear tugging

›Exposure risks

›Sick contacts

›Daycare

›Travel

›Animal exposures

›Pregnancy and birth history

›Gestational age

›GBS status

›Maternal fever or chorioamnionitis

›Prolonged rupture of membranes

›NICU course

›Medical background

›Prior UTIs

›Known urinary tract anomalies

›Congenital heart disease

›Immunodeficiency

›Indwelling lines

›Medications and vaccines

›Recent antibiotics

›Recent immunization within 48 hours

Red flags for HSV or meningitis

›CNS and HSV risk signals

›Seizure

›Persistent irritability

›Lethargy

›Poor feeding

›Vesicular lesions

›Maternal genital HSV near delivery

›Mucocutaneous lesions

›Unexplained hepatitis signs

03Physical Exam/exam45

Vital signs and general appearance

›Global severity markers

›Perfusion

›Capillary refill

›Mottling

›Cool extremities

›Work of breathing

›Retractions

›Grunting

›Nasal flaring

›Apnea

›Hydration

›Mucous membranes

›Tears

›Fontanelle fullness or sunken

›Neuro status

›Tone

›Responsiveness

›Consolability

Source oriented exam

›Source search

›Skin and soft tissue

›Cellulitis

›Abscess

›Omphalitis

›HEENT

›Otitis media signs

›Oral lesions

›Lungs

›Focal crackles

›Wheeze

›Heart

›New murmur

›Poor pulses

›Abdomen

›Distension

›Tenderness

›Hepatosplenomegaly

›GU

›Suprapubic tenderness

›Scrotal swelling

›MSK

›Limb pseudoparalysis

›Joint swelling

›Meningeal irritation

›Bulging fontanelle

›Nuchal rigidity

04Differential Diagnosis/ddx36

Life threatening and bacterial causes

›High consequence diagnoses

›Bacteremia

›ICD-10 R78.81 bacteremia

›Bacterial meningitis

›ICD-10 G00.9 bacterial meningitis

›Sepsis and septic shock

›ICD-10 A41.9 sepsis

›ICD-10 R65.21 severe sepsis with septic shock

›Urinary tract infection

›ICD-10 N39.0 urinary tract infection

›Pneumonia

›ICD-10 J18.9 pneumonia

›Bacterial gastroenteritis with dehydration

›ICD-10 A09 infectious gastroenteritis

›Osteomyelitis or septic arthritis

›ICD-10 M86.9 osteomyelitis

›ICD-10 M00.9 septic arthritis

›Skin and soft tissue infection

›ICD-10 L03.90 cellulitis

Viral and noninfectious mimics

›Common alternatives

›Viral URI

›ICD-10 J06.9 acute upper respiratory infection

›Bronchiolitis

›ICD-10 J21.9 bronchiolitis

›Influenza

›ICD-10 J10.1 influenza with respiratory manifestations

›SARS-CoV-2 infection

›ICD-10 U07.1 COVID-19

›Roseola

›ICD-10 B08.20 exanthem subitum

›Post immunization fever

›ICD-10 R50.83 postvaccination fever

›Kawasaki disease

›ICD-10 M30.3 Kawasaki disease

›Urosepsis from obstructive uropathy

›Hydronephrosis history

05Laboratory Tests/lt32

Minimum evaluation for 61 to 90 days

›Minimum labs

›Urinalysis

›Catheter specimen preferred

›Pyuria threshold commonly >5 WBC per hpf

›Urine culture

›Catheter specimen

›Colony count interpretation per local lab standards

Expanded risk stratification labs

›Risk stratification labs

›CBC with differential

›Absolute neutrophil count

›ANC thresholds used in decision tools

›Inflammatory markers

›CRP mg/L

›CRP <=20 mg/L used in Step-by-Step low risk criteria

›Procalcitonin ng/mL

›PCT <0.5 ng/mL used in Step-by-Step low risk criteria

›Blood culture

›Pre antibiotic collection when feasible

Sepsis and critical illness labs

›Shock workup adjuncts

›Venous blood gas

›pH

›pCO2 mmHg

›Lactate mmol/L

›Trend for resuscitation response

›Glucose mmol/L

›Hypoglycemia trigger for dextrose therapy

›Electrolytes

›Sodium mmol/L

›Potassium mmol/L

›Liver enzymes when HSV or hepatitis concern

›ALT

›AST

06Diagnostic Tests/dt49

Scoring Systems

›Febrile infant decision tools

›Step-by-Step approach for 22 to 90 days

›Well appearing required

›Urinalysis negative for leukocytes

›Procalcitonin <0.5 ng/mL

›CRP <=20 mg/L

›ANC <=10000 per microL

›Low risk invasive bacterial infection reported about 0.7%

›Aronson score when procalcitonin unavailable

›Age <21 days point assignment

›Temperature bands point assignment

›ANC threshold point assignment

›Urinalysis positive point assignment

›Low score to identify low probability invasive bacterial infection

›PECARN rule for <=60 days

›Included for reference when extending local practice

›Urinalysis negative criteria

›ANC <=4090 per microL

›Procalcitonin <=1.71 ng/mL

MRI

›MRI use cases

›Suspected spinal infection

›Discitis

›Epidural abscess

›Suspected osteomyelitis when x-ray nondiagnostic

›Early marrow edema detection

›CNS infection complications

›Encephalitis patterns when stable for transport

›Practical constraints

›Need for sedation in many infants

›Limited role in initial febrile infant workup

›CT indications

›Focal neurologic deficit

›Consider intracranial pathology before LP when signs of elevated ICP

›Concern for deep neck infection

›Airway compromise

›Abdominal catastrophe concern

›NEC unlikely at 61 to 90 days but considered in complex patients

›Radiation minimization

›Prefer ultrasound when feasible

Ultrasound

›Ultrasound applications

›Renal and bladder ultrasound

›Known urinary tract anomaly

›Recurrent UTI

›Poor response to therapy

›Lung ultrasound

›Alternative to chest radiograph in selected settings

›Point of care cardiac ultrasound in shock

›Ventricular function estimate

›Pericardial effusion

07Disposition/dispo28

Admission and observation criteria

›Hospital care triggers

›Ill appearance

›Persistent abnormal perfusion

›Respiratory support requirement

›High risk labs

›Abnormal inflammatory markers in expanded pathway

›Positive blood culture

›Suspected meningitis

›CSF pleocytosis

›Seizure

›Bulging fontanelle

›Unsafe outpatient setting

›No reliable follow-up within 24 to 48 hours

›Caregiver inability to return promptly

Discharge criteria for low risk 61 to 90 days

›Outpatient pathway

›Clinically well

›Feeding adequate

›Hydration adequate

›No respiratory distress

›Minimum testing completed

›Urinalysis reviewed

›Urine culture sent

›Low risk assessment

›Meets low risk criteria if expanded pathway used

›Isolated UTI acceptable for outpatient care when well

›Follow-up plan

›Reassessment within 24 to 48 hours

›Culture result review system

08Treatment/t59

Empiric antibiotics for suspected bacterial infection

›Empiric antimicrobial strategy

›Well appearing low risk with no source

›Supportive care only option when low risk and close follow-up available

›Observation in ED option when uncertainty remains

›Suspected UTI without meningitis concern

›Oral option for low risk

›Cefixime

›8 mg/kg per dose every 24 hours

›Max dose per local formulary

›Parenteral option

›Ceftriaxone

›100 mg/kg per dose every 24 hours

›Avoid in significant hyperbilirubinemia history

›Suspected bacteremia without meningitis concern

›Ceftriaxone

›100 mg/kg per dose every 24 hours

›Culture directed narrowing when available

›Suspected meningitis

›Ceftriaxone

›100 mg/kg per dose every 24 hours

›Meningitis dosing per local pathway if divided dosing preferred

›Vancomycin add on

›15 mg/kg per dose every 6 hours

›Trough guided dosing per local protocol

Antivirals and special pathogens

›HSV concern pathway

›Acyclovir

›20 mg/kg per dose every 8 hours

›Renal dosing adjustment

›HSV testing bundle

›Surface swabs if lesions

›CSF HSV PCR when LP performed

›ALT elevation support

Supportive care

›Symptom management

›Acetaminophen

›15 mg/kg per dose every 6 hours

›Max daily dose per local formulary

›Hydration

›Oral rehydration when tolerated

›IV isotonic fluids when poor intake

›Oxygen

›Target SpO2 >=92% per local standard

Septic shock management

›Pediatric sepsis resuscitation

›Fluids

›Isotonic crystalloid 10 to 20 mL/kg bolus

›Repeat to 40 to 60 mL/kg in first hour with ICU availability and no overload

›Vasoactives

›Epinephrine infusion

›Start 0.05 to 0.1 mcg/kg/min

›Titrate every 5 to 10 minutes to perfusion targets

›Norepinephrine infusion

›Start 0.05 to 0.1 mcg/kg/min

›Titrate every 5 to 10 minutes to perfusion targets

›Monitoring

›Frequent reassessment for fluid overload

›Urine output target >=1 mL/kg/hour

›Lactate trend mmol/L when obtained

›Evidence framing

›Surviving Sepsis Campaign pediatric guideline supports 10 to 20 mL/kg boluses with titration

›Surviving Sepsis Campaign suggests norepinephrine over dopamine

09Special Populations/sp23

Pregnancy

›Pregnancy considerations

›Not applicable in 61 to 90 day infant

›Maternal pregnancy factors as exposure history

›Maternal fever

›HSV history

›GBS status

Geriatric

›Geriatric considerations

›Not applicable in 61 to 90 day infant

›Household exposure relevance

›Older caregiver influenza exposure

›COVID exposure

Pediatrics

›Pediatric specific considerations

›Age band 61 to 90 days

›Lower IBI prevalence than <=60 days

›UTI remains most common serious bacterial infection

›Prematurity and ex preterm

›Corrected age consideration for risk stratification

›Lower threshold for broader workup when corrected age <=60 days

›Post immunization fever

›Same minimum urine evaluation when fever >=38.0 C and no clear vaccine reaction

›Viral symptoms present

›Concomitant bacterial infection still possible

›Urine testing still indicated

10Background/b32

Epidemiology

›Epidemiology and risk

›Fever presentation frequency

›Significant proportion of infants <=90 days present for fever evaluation

›Invasive bacterial infection rates in 61 to 90 days

›Bacteremia reported <1.5%

›Bacterial meningitis reported <0.25%

›Serious bacterial infection distribution

›UTI most common bacterial diagnosis in well appearing febrile infants

Pathophysiology

›Infant susceptibility

›Immune immaturity

›Reduced opsonization

›Reduced antibody repertoire

›Rapid progression potential

›Early compensated shock common

›Late hypotension sign of decompensation

›UTI mechanisms

›Ascending infection from perineum

›Higher risk with urinary tract anomalies

Therapeutic Considerations

›Diagnostic tradeoffs

›Over investigation harms

›Traumatic LP risk

›Unnecessary admission

›Antibiotic exposure

›Under investigation harms

›Missed bacteremia

›Missed meningitis

›Shared decision making role

›Risk tolerance alignment between clinician and caregiver

›Follow-up reliability as key determinant

›Risk stratification utility

›Biomarker based tools allow selective LP and antibiotics in low risk infants

›Procalcitonin rises earlier than CRP and ANC in early infection

11Patient Discharge Instructions/pdi18

copy discharge instructions

›Febrile infant discharge bundle

›Home care

›Encourage feeding and fluids

›Acetaminophen dosing per weight if uncomfortable

›Follow-up

›Recheck with clinician within 24 to 48 hours

›Culture results review plan

›Return to ED now

›Trouble breathing

›Blue color or apnea

›Hard to wake

›Weak cry or markedly decreased activity

›Poor feeding

›No urine for 8 hours

›Persistent vomiting

›New rash that looks purple or bruised

›Seizure

›Fever persists beyond 48 hours or caregiver concern

12References/r20

Guidelines and key evidence

›Core references

›Canadian Paediatric Society position statement on well appearing febrile infants <=90 days with age based recommendations including 61 to 90 days

›61 to 90 days minimum urinalysis and urine culture recommendation

›Reported IBI prevalence thresholds for 61 to 90 days

›Surviving Sepsis Campaign international guidelines for management of sepsis and septic shock in children 2020

›Fluid bolus 10 to 20 mL/kg titrated to markers of cardiac output

›Vasoactive guidance including norepinephrine vs dopamine

›Step-by-Step validation study for febrile infants up to 90 days

›Low risk criteria incorporating urinalysis, procalcitonin, CRP, ANC

›EM Cases Febrile Infant risk stratification summary

›Step-by-Step criteria recap

›Pitfalls including reported fever and viral symptoms

›AAP clinical practice guideline for well appearing febrile infants 8 to 60 days as adjacent evidence base for biomarker risk stratification

Decision tools

›Decision support tools

›Step-by-Step approach calculator

›Clinical criteria and lab thresholds for 22 to 90 days

›PECARN low risk rule for <=60 days

›Urinalysis, ANC, procalcitonin thresholds

›Aronson score for settings without procalcitonin

›Point based risk estimation for invasive bacterial infection

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.