Management of the Young Febrile Child: A Commentary on Recent Practice Guidelines

Abstract

Recently published “practice guidelines”1,2 and randomized antibiotic trials3,4 reflect a climate of increased diagnostic testing, more frequent treatment, and more invasive (ie, parenteral rather than oral) treatment of febrile children 3 to 36 months of age. For children in this age group with a temperature ≥39.0°C, the guidelines1,2 suggest a white blood cell (WBC) count and provide two options with respect to obtaining a blood culture: all such children or those whose WBC count is ≥15 000/mm2. Culture of urine obtained by catheterization or suprapubic aspiration is recommended for all boys <6 months and all girls <24 months. The guidelines recommend empiric treatment with ceftriaxone, once again with two options: treat all such children or those whose WBC count is ≥15 000/mm2. These practice guidelines are based on a meta-analysis that pooled data from both randomized controlled trials and observational (nonexperimental) studies of clinical outcomes in young febrile children, and on the views of an expert panel chosen by the senior author.1,2 Although the guidelines have not been officially endorsed by any professional organization, they were developed by authors who are widely recognized in the field and thus could have an important impact on both clinical practice and health care policy. The clinical setting is that of a child with acute onset (≤4 days) of fever who does not appear “toxic” (ie, seriously ill) and has no apparent focus of bacterial infection (otitis media, pneumonia, osteomyelitis/septic arthritis, lymphadenitis, cellulitis, dysentery-like enteritis, or meningitis) after a history is obtained and a physical examination is performed. When confronted with such a child, the clinician must make a series of decisions: 1. Should she obtain diagnostic tests to identify an “occult” bacterial infection [such as pneumonia, bacteremia, meningitis, or urinary …