Febrile Illness – Emergency Management in Children Document ID CHQ-GDL-00707 Version no. 2.0 Approval date 23/11/2016 Executive sponsor Executive Director Medical Services Effective date 23/11/2016 Author/custodian Director, Paediatric Emergency Medicine Review date 23/11/2019 Supercedes 1.0 Applicable to All CHQ HHS clinical staff Authorisation Executive Director Hospital Services Purpose This procedure provides clinical practice guidelines to guide clinicians involved in the emergency management of fever in infants and children. It aims to identify those at risk of serious bacterial or other significant illness who need timely treatment, whilst avoiding unnecessary investigations in the majority. Scope This procedure applies to all staff involved in the care and management of children who present with fever as their primary complaint. This guideline is not intended to be used for prolonged fever of greater than one week, when a broader differential diagnosis must be considered. Management of fever in the neutropenic paediatric oncology patient is beyond the scope of this guideline and should be managed according to the specific Oncology Guideline. Sepsis must be considered in every paediatric patient with fever (Refer to Sepsis- Recognition and Early Emergency Management in Children Guideline) Procedure Fever is one of the most common reasons for paediatric presentations to emergency services and provides diagnostic and management challenges to clinical staff. Infection remains the leading cause of death in children under the age of 5 years. Fever definition and measurement A practical definition of fever is temperature ≥38°C measured at home or in hospital. In children under the age of 4 weeks body temperature should be measured with an electronic thermometer in the axilla. In children aged 4 weeks to 5 years body temperature should be measured by an electronic thermometer in the axilla, chemical dot thermometer in the axilla or infra-red tympanic thermometer. Forehead chemical
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Febrile Illness – Emergency Management in Children
Document ID CHQ-GDL-00707 Version no. 2.0 Approval date 23/11/2016
Executive sponsor Executive Director Medical Services Effective date 23/11/2016
Author/custodian Director, Paediatric Emergency Medicine Review date 23/11/2019
Supercedes 1.0
Applicable to All CHQ HHS clinical staff
Authorisation Executive Director Hospital Services
Purpose
This procedure provides clinical practice guidelines to guide clinicians involved in the emergency management of fever in infants and children. It aims to identify those at risk of serious bacterial or other significant illness who need timely treatment, whilst avoiding unnecessary investigations in the majority.
Scope
This procedure applies to all staff involved in the care and management of children who present with fever as their primary complaint. This guideline is not intended to be used for prolonged fever of greater than one week, when a broader differential diagnosis must be considered.
Management of fever in the neutropenic paediatric oncology patient is beyond the scope of this guideline and should be managed according to the specific Oncology Guideline. Sepsis must be considered in every paediatric patient with fever (Refer to Sepsis- Recognition and Early Emergency Management in Children Guideline)
Procedure
Fever is one of the most common reasons for paediatric presentations to emergency services and provides diagnostic and management challenges to clinical staff. Infection remains the leading cause of death in children under the age of 5 years.
Fever definition and measurement
A practical definition of fever is temperature ≥38°C measured at home or in hospital.
In children under the age of 4 weeks body temperature should be measured with an electronic thermometer in the
axilla. In children aged 4 weeks to 5 years body temperature should be measured by an electronic thermometer in
the axilla, chemical dot thermometer in the axilla or infra-red tympanic thermometer. Forehead chemical
resulting in an elevated body temperature. The thermoregulatory centre then raises and maintains the body
temperature to the new set point. This may negatively stress some children with pre-existing cardiac, respiratory or
neurological diseases, and gives most children a degree of malaise. However fever is thought to be a generally
beneficial adaptive response that promotes the immune response and inhibits the invading pathogen, potentially
reducing the duration of certain infections.
Epidemiology of fever
Febrile illnesses comprise approximately 20% of paediatric emergency presentations.10,11 Most (80%) have a readily identifiable source of the fever.12 Of the remaining 20%, most will have a self-limiting viral infection, however a small proportion will have a serious bacterial infection (SBI) or be febrile from conditions such as Kawasaki disease, vaccination reactions, arthritis or connective tissue disorders, malignancies, drug fever, or inflammatory bowel disease. Post vaccination fever usually begins within 24 hours of immunisation and lasts for 2-3 days. Teething does not cause fever > 38.5 oC
In a large Australian children’s hospital study, 7.5% of febrile children <5 years old had a SBI; 3.4% had a urinary tract
infection (UTI); 3.4% pneumonia; 0.4% bacteraemia and 0.1% meningitis.13 Pyrexia of unknown origin (PUO)14 is any
fever lasting 10 - 21 days without cause identified on history, examination and basic investigations.
Serious bacterial infection (SBI)
SBI includes UTI, pneumonia, meningitis, bacteraemia, osteomyelitis, septic arthritis, skin and soft tissue infection or
bacterial enteritis; though only the first four are likely to present in an occult fashion with significant frequency. In
infants less than three months of age, hypothermia or temperature instability can be signs of SBI or other serious
illness.
UTI
This is a relatively common infection in febrile children <5 years. In the 1st year of life, 6.5% girls and 3.3% boys
(1.2% of circumcised vs. 8% of uncircumcised males) will have a UTI. In the 2nd year, the rates become 8.1% girls
and 1.9% boys15 and decrease thereafter. UTI is also the most common SBI causing fever without localising signs,
at approximately 5%.16
Pneumonia
About 3 - 4% all febrile children under 5 years13 and approximately 5% with fever without localising signs have a
pneumonia, though most will be viral in origin. Increasing pneumococcal immunisation may continue to decrease the
incidence of bacterial pneumonia due to the commonest bacterial agent, Streptococcus pneumoniae.
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Bacteraemia
The incidence of occult bacteraemia has fallen from over 10% to <0.5%12,18 of febrile children aged three months to
three years. This is largely due to effective immunisation against Haemophilus influenzae type b (HIB) &
Streptococcus pneumoniae. Rates are higher (approximately 2 - 10%) in non and pre-vaccinated children depending
on age. Meningococcaemia occurs in only 0.02% of young febrile infants <2 - 3 months,19,20 but approximately 15%
of these may not appear ill-looking.21 Other common pathogens, particularly in infants < 6 months, include
Salmonella species (which may be associated with diarrhoea) and E. Coli (which may accompany UTI).16
Meningitis
The incidence of meningitis is generally very low,13 but more common in younger infants, who may present with
subtle signs and symptoms.
Assessment
A well-taken history and thorough clinical examination should aim to identify:
a. children who have a focus of infection that may then be investigated and treated , and
b. children for whom no infective focus may be found and who may require further investigations and/or empirical
treatment according to their risk of SBI.
Factors that may assist in risk stratification include:
child’s age
immune status - incomplete immunisations, immune-compromise
signs of toxicity
current or recent use of antibiotics
presence of concerning signs and symptoms (e.g. petechial rash)
Age
Several meta-analyses15,23,24 have shown that febrile young infants <3 months have a high risk of SBI (7-24%). This
risk is greatest in the neonatal period and decreases progressively with increasing age. Young infants are more
likely to present with non-specific features (they lack the hypothalamic and immune system maturity to localise the
infection) and can deteriorate rapidly25. In addition to the pathogens seen in older children, Group B Streptococcus,
E. Coli, Herpes Simplex virus, and Listeria monocytogenes infections are more common in this period. Detecting
other viral infections (e.g. RSV) lowers but does not remove the risk of SBI (7% vs. 12.5% for SBI (mainly UTI) in
one large study.22 More recently a study26 found the incidence for SBI in infants one to three (1 - 3) months
decreased significantly if they had bronchiolitis, however the UTI rate was still 4%. A systematic review27 supported
the use of screening for UTI in bronchiolitic children aged one to three (1-3) months as this was the only SBI with
significant incidence (3.3%).
It is important to remember that babies less than 3 months may not necessarily mount a fever in response to SBI,
and that hypothermia or temperature instability can be signs of SBI.
Children aged three months to three years have a lower risk of SBI than the group under three months, and have
their immunity boosted with vaccinations. Occult bacterial infection is most commonly UTI, pneumonia or
bacteraemia. In this age group, the presence of a recognisable viral syndrome (including bronchiolitis) predicts a
very low incidence of bacteraemia (0.2%).28
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Older children (>3 years) have mature immune systems, are better able to verbalise and localise symptoms and are
at lower risk of SBI.
Immunisations & Immune status
The risk of occult bacteraemia (OB) and SBI has fallen in the last 20 years with the advent of several vaccines, in
particular the Haemophilus influenzae type b (HIB) and pneumococcal (PC) immunisations. Recent studies suggest
that OB rates have fallen to <0.5% in immunised children 3 - 36 months with fever without localising signs on history
or examination .12,18 HIB has all but been eliminated as a cause of bacteraemia and serious invasive infection.24
Streptococcus pneumoniae remains responsible for the majority of current cases of OB, but is thought to cause
invasive disease in less than 5% of these.29 In 2011, the 7 valent conjugate pneumococcal vaccine was replaced on
the National Immunisation Program with a 13 valent vaccine, covering most of the remaining invasive serotypes.
After two of the usual total three to four doses of these immunisations (usually achieved by four months of age in
Australia), there is >95% protection30 In addition the national program has increased herd immunity, which further
reduces the risk to all children.
If a child has a congenital immune deficiency syndrome, sickle cell disease, HIV, asplenia, cancer, nephrotic
syndrome, intracranial shunt, cochlear implant, immunosuppressive therapy or is indigenous then there is a greater
risk for SBI, independent of vaccination status.
Clinical appearance and toxicity
Think SEPSIS in any patient presenting with signs or symptoms that indicate possible infection. (SEPSIS Guideline)
Assessing paediatric patients to determine “toxicity” can be challenging, particularly if they are seen early in the
course of their febrile illness. The younger the patient, the more difficult this can be, even for seasoned paediatric
clinicians. A number of scoring and assessment systems have been devised in an attempt to provide a standardised
approach 31,19,20,33,34. More recent studies32 have cast doubt on their utility, and recognise the difficulties in
differentiating toxic and well-appearing infants. The younger the infant, the more important careful and repeated
clinical examination is, with close attention to vital signs.
The National Institute for Health and Clinical Excellence (NICE) guidelines combine features of specific serious
disease with general appearance into a traffic light system for identifying risk of serious illness35
There is limited evidence regarding which children should have an LP performed as part of the septic workup,
especially as the incidence of bacterial meningitis has decreased dramatically since the introduction of the HIB and
PC vaccines. Although there is good evidence for several useful clinical features which influence the likelihood of
meningitis in a child, no one clinical feature is diagnostic 54 and in the very young infant meningitis often presents
with non-specific features like poor feeding, lethargy or irritability. The height of the fever and WCC are unhelpful as
they do not reflect the risk of bacterial meningitis. In general, as long as the child is well enough to tolerate the
procedure and there are no contraindications the procedure, an LP should be considered in children with signs or
symptoms of meningitis, or in the young febrile infant with non-specific features such as vomiting, lethargy /
drowsiness, irritability or poor feeding. [Refer to Acute Management of Meningitis in Children Clinical
Guideline]
Other tests
Procalcitonin (a prohormone rises with physiological stress) has restricted availability currently, but has shown
utility in differentiating bacterial from viral illness.55 It has been reported to have better specificity and possibly
sensitivity than CRP for bacterial meningitis or sepsis especially in first six to eight (6 - 8) hours of fever.56-58At
present this test is not widely available and is not part of the investigations performed in the emergency department
setting.
Viral diagnostic studies – limited usefulness in ruling out SBI as noted above.
Stool microscopy and culture – may be indicated in very young infant or if mucoid, bloody or prolonged diarrhoea.
Management
The recommended emergency management of febrile children is summarised on the Flowcharts (Appendix 1 and Appendix 2) and comprises:
Supportive
The child should have excess layers of clothing removed. Over-enthusiastic physical cooling can be counterproductive by stimulating shivering and other heat-retaining reflexes. Oral fluids if tolerated should be encouraged to maintain hydration.
Antipyretics
Antipyretics may be prescribed for an awake child to provide relief from discomfort caused by the fever or the underlying cause of the fever. Parents should be advised that fever is one of the body’s immune system responses to infection and that antipyretics do not treat or shorten the illness, will not prevent febrile convulsions,59 and if the dosing is excessive can cause adverse events.60
Aspirin should be avoided in children as the uncommon possibility of Reye's syndrome increases with varicella or influenza-like illnesses.61
Appropriate choices for symptomatic relief one of:
Paracetamol 15mg/kg up to four hourly with a maximum of four doses per day, or
Ibuprofen 10mg/kg up to six hourly with a maximum of four doses per day (avoid in children <6 months, if
significantly dehydrated 60 or history of hypersensitivity.
There is some evidence that ibuprofen reduces fever and discomfort more quickly than paracetamol.63 The popular
dual therapy dosing regimes advocated by some reduce the time with fever, however there is no significant
difference in resolution of discomfort versus monotherapy.64 Safety concerns have been raised over recommending
two drugs with different dosing regimes for little gain, and parents should be specifically advised against this35
Risk Stratification
The risk of SBI may be stratified by age, the presence of a focus for infection, and toxicity. See the Flowcharts in Appendix 1 and Appendix 2 for details.
Antibiotics
Antibiotics may be indicated depending upon the perceived risk of SBI or the specific infection found. Antibiotics are usually administered via the intravenous route initially for admitted patients.
For choices and doses see CHQ Paediatric Antibiocard: Empirical Antibiotic Guidelines
See flowcharts Appendix 1 - Emergency Management of Fever in Children (< 4 months) and
Appendix 2 - Emergency Management of Fever in Children (≥4 months).
Disposition
As indicated by the Flowchart. All children who appear unwell should be reviewed early by a senior medical officer.
Febrile children fit for discharge should be discussed with a senior doctor and arrangements made for a follow up visit at his / her local General Practitioner to check progress and outstanding test results.
See flowchart Appendix 3 - Admission / discharge criteria for children presenting with fever.
When a decision is made to transfer a child to a Level 6 facility, referral must be made through RSQ.65
Activation of the QLD emergency medical system coordination centre (QCC)
Further information on the preparation of a infant prior to transport can be obtained through RSQ Clinical Guidelines paediatric section (page 31-35).65
Statewide RSQ clinical guidelines - Paediatrics
Supporting documents
Procedures, Guidelines and Protocols
Emergency management of children presenting with fever – less than 4 months
Emergency management of children presenting with fever – greater / equal to than 4 months
Admission / discharge criteria for children presenting with fever
Dr Sarah Martin, Paediatric Emergency Physician, LCCH
Dr Julia Clarke, Infection Management and Prevention Director, LCCH
Children’s Health Queensland would like to acknowledge the contribution made by the Greater Brisbane Metropolitan Area Clinical Procedures Working Group who developed the original guideline.
Definition of terms
Term Definition
AAP American Academy of Pediatrics
ANC Absolute neutrophil count
BSL Blood sugar level
Children 0-14 years of age
CHQ Children’s Health Queensland
CRP C-reactive protein
CXR Chest x-ray
E.Coli Escherichia coli
FBC Full blood count
HIB Haemophilus influenzae type B
HIV Human immunodeficiency virus
HSP Henoch-schonlein purpura
IV Intravenous
LP Lumbar puncture
MCS Microscopy, culture and sensitivity pathology test
NICE National Institute for Health and Clinical Excellence
NPV Negative predictive value
OB Occult bacteraemia
PC Pneumococcal
PUO Pyrexia of unknown origin
RSQ Retrieval Services Queensland
SBI Serious bacterial infection
SPA Supra-pubic bladder aspiration
SVC Superior vena cava
UTI Urinary tract infection
UEC Urea, electrolytes and creatinine
WCC White cell count
YOS Yale observation score
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References
1. Hewson, P., Poulakis, Z., Jarman, F., Kerr, J., McMaster, D., Goodge, J., Silk, G. (2000), ‘Clinical markers of serious illness in young infants: a multicentre follow-up study’, Journal of Paediatrics & Child Health, Vol. 36(3): pp. 221-5.
2. Brogan, P.A., Raffles, A. (2000), ‘The management of fever and petechiae: making sense of rash decisions’, Arch Dis Child, Vol. 83: pp. 506-7.
3. Klinkhammer, M.D., Colletti, J.E. (2008), ‘Pediatric myth: fever and petechiae’, CJEM, Vol. 10(5): pp. 479-82.
4. The Royal Children’s Hospital Melbourne. (2011), Clinical Practice Guidelines: Fever and Petechiae, [online] Available at: http://www.rch.org.au/clinicalguide/guideline_index/Fever_and_Petechiae_Purpura/ [Cited November 2011]
5. Trautner, B.W.,Caviness, A.C., Gerlacher, G.R. et al. (2006), ‘Prospective evaluation of the risk of serious bacterial infection in children who present to the emergency department with hyperpyrexia (temperature of 106°F or higher)’, Pediatrics, Vol. 118(1): pp. 34–40.
6. Kuppermann, N., Fleisher, G., Jaffe, D. (1998), ‘Predictor of occult pneumococcal bacteraemia in young febrile children’, Ann Emerg Med, Vol. 31(6): pp. 679-87.
7. Teach, S.J., Fleisher, G.R. (1997), ‘Duration of fever and its relationship to bacteremia in febrile outpatients 3 to 36 months old: the occult bacteremia study group’, Pediatr Emerg Care,Vol. 13(5): pp.317–9.
8. American Academy Paediatrics (AAP). (2011), ‘Urinary Tract Infection: Clinical Practice Guideline for the diagnosis and management of the initial UTI in febrile infants and children 2-24 months’, Pediatrics, Vol.128(3): pp. 595-610.
9. Williams, G.J., Macaskill, P., Chan, S.F., Turner, R.M., Hodson, E., Craig, J.C. (2010), ‘Absolute and relative accuracy of rapid urine tests for urinary tract infection in children: a meta-analysis’, Lancet Infect Dis, Vol. 10: pp. 240–50
10. Doley, A., Nelligan, M. (2003), ‘Is a negative dipstick urinalysis good enough to exclude urinary tract infection in Paediatric Emergency Department patients?’, Emergency Medicine, Vol. 15: pp. 77-80.
11. National Institute for Health and Clinical Excellence. (2007). Urinary tract infection in children. Diagnosis, treatment and long-term management, [online] Available at: http://www.nice.org.uk/nicemedia/live/11819/36032/36032.pdf [cited August 2007].
12. Bettenay, F.A., de Campo, J.F., McCrossin, D.B. (1988), ‘Differentiating bacterial from viral pneumonias in children’, Pediatr Radiol. Vol. 18(6): pp. 453-454.
13. Mower, W.R., Sachs, C., Nicklin, E.L., Baraff, L.J. (1997), ‘Pulse oximetry as a fifth pediatric vital sign’, Pediatrics, Vol. 99(5): pp. 681–6.
14. American College of Emergency Physicians Clinical Policies Committee. (2003). ‘Clinical Policies Subcommittee on Pediatric Fever. Clinical policy for children younger than three years presenting to the emergency department with fever’, Ann Emerg Med, Vol. 42(4): pp. 530–45.
15. Rutman et al. (2009), ‘Radiographic pneumonia in young, highly febrile children with leucytosis before and after universal conjugate pneumococcal vaccination’, Pediat Emerg Care, Vol. 25(1): pp.1-7.
16. Connell et al. (2007), ‘How reliable is a negative blood culture result? Volume of blood submitted for culture in routine practice in a children’s hospital’, Pediatrics, Vol. 119 (5): pp. 891-6.
17. Herz, A.M., Greenhow, T.L., Alcantara, J., Hansen, J., Baxter, R.P., Black, S.B., Shinefield, H.R. (2006), ‘Changing epidemiology of outpatient bacteremia in 3 to 36-month old children after the introduction of the heptavalent-conjugated pneumococcal vaccine’, Pediatr Infect Dis J, Vol. 25: pp. 293-300.
18. Pratt, A., Attia, M.W. (2007), ‘Duration of fever and markers of serious bacterial infection in young febrile children’, Pediatrics International, Vol. 49: pp. 31–35
19. Curtis et al. (2010), ‘Clinical features suggestive of meningitis in children: a systematic review of prospective data’, Pediatrics, Vol. 126(5): pp. 952-60.
20. Maniaci, V., Dauber, A., Weiss, S., Nylen, E., Becker, K.L., Bachur, R. (2008), ‘Procalcitonin in young febrile infants for the detection of serious bacterial infections’, Pediatrics, Vol. 122(4): pp. 701-10
21. Lopez, A.F., Cubells, C.L., Garcia, J.J., Pou, J.F. (2003), ‘Procalcitonin in pediatric emergency departments for the early diagnosis of invasive bacterial infections in febrile infants: results of a multicenter study and utility of a rapid qualitative test for this marker’, Pediatr Infect Dis J, Vol. 22: pp.895–903.
22. Andreola, B., Bressan, S., Callegaro, S., Liverani, A., Plebani, M., Da Dalt, L. (2007), ‘Procalcitonin and C-reactive protein as diagnostic markers of severe bacterial infections in febrile infants and children in the emergency department’, Pediatr Infect Dis J, Vol. 26: pp. 672–7.
23. Olaciregui, I., Hernández, U., Muñoz, J.A., Emparanza, J.I., Landa, J.J. (2009), ‘Markers that predict serious bacterial infection in infants under 3 months of age presenting with fever of unknown origin’, Arch Dis Child, Vol. 94: pp. 501-5.
24. Steering Committee on Quality Improvement and Management. (2008), ‘Subcommittee on Febrile Seizures. Febrile seizures: clinical practice guideline for the long-term management of the child with simple febrile seizures’, Pediatrics, Vol. 121(6): pp.1281-6.
25. Sullivan, J.E., Farrar, H.C. (2011), ‘Section On Clinical Pharmacology And Therapeutics And Committee On Drugs. Fever and Antipyretic Use in Children’, Pediatrics, Vol. 127: pp. 580
26. James, S. (2004), ‘Review of Aspirin / Reye’s syndrome warning statement. Medicines Evaluation Committee, Therapeutic Goods Administration’, [online] Available at: http://www.tga.gov.au/pdf/archive/review-aspirin-reyes-syndrome-0404.pdf [cited April 2004].
27. Kanabar, D., Dale, S., Rawat, M. (2007), ‘A review of ibuprofen and acetaminophen use in febrile children and the occurrence of asthma-related symptoms’, Clin Ther, Vol. 29(12): pp. 2716-23.
28. Perrott, D.A., Piira, T., Goodenough, B., Champion, G.D. (2004), ‘Efficacy and safety of acetaminophen vs ibuprofen for treating children’s pain or fever: a meta-analysis’, Arch Pediatr Adolesc Med, Vol. 158(6): pp. 521-6.
29. Hay, A.D., Costelloe, C., Redmond, N.M., Montgomery, A.A., Fletcher, M., Hollinghurst, S. et al. (2009), ‘Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial’, BMJ, Vol. (2008):337: pp. a1302 & Erratum in: BMJ, Vol. (2009):339: pp. b3295.
30. Statewide Clinical Coordination and Retrieval Services, (Queensland Health). (2008), ‘Clinical guidelines: Section two’, Queensland Health website, [intranet / online] Available at: http://qheps.health.qld.gov.au/rts/docs/clin_guide_pt2.pdf [cited July 25].
31. De S, Williams GJ, Hayen A et al. Value of white cell count in predicting serious bacterial infection in febrile children under 5 years of age. Arch Dis Child 2014;99:493-499.
32. Van den Bruel. (2011), ‘Diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review’, BMJ, Vol. 342: pp. d3082.
33. Dagan, R., Powell, K.R., Hall, C.B., Menegus, M.A. (1985), ‘Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis’, J Pediatr, Vol.107(6): pp.855–60.
34. Jaskiewicz, J.A., McCarthy, C.A., Richardson, A.C., White, K.C., Fisher, D.J., Dagan, R. Powell, K.R. (1994), ‘Febrile infants at low risk for serious bacterial infection - an appraisal of the rochester criteria and implications for management’, Pediatrics, Vol. 94(3): pp.390-6
35. National Institute for Health and Clinical Excellence. (2013), ‘Feverish illness in children. Assessment and initial management in children younger than 5 years’, [online] Available at: http://publications.nice.org.uk [cited May 2013]
36. Hewson, P., Poulakis, Z., Jarman, F., Kerr, J., McMaster, D., Goodge, J., Silk, G. (2000), ‘Clinical markers of serious illness in young infants: a multicentre follow-up study’, Journal of Paediatrics & Child Health, Vol. 36(3): pp. 221-5.
37. Brogan, P.A., Raffles, A. (2000), ‘The management of fever and petechiae: making sense of rash decisions’, Arch Dis Child, Vol. 83: pp. 506-7.
38. Klinkhammer, M.D., Colletti, J.E. (2008), ‘Pediatric myth: fever and petechiae’, CJEM, Vol. 10(5): pp. 479-82.
39. The Royal Children’s Hospital Melbourne. (2011), Clinical Practice Guidelines: Fever and Petechiae, [online] Available at: http://www.rch.org.au/clinicalguide/guideline_index/Fever_and_Petechiae_Purpura/ [Cited November 2011]
40. Trautner, B.W.,Caviness, A.C., Gerlacher, G.R. et al. (2006), ‘Prospective evaluation of the risk of serious bacterial infection in children who present to the emergency department with hyperpyrexia (temperature of 106°F or higher)’, Pediatrics, Vol. 118(1): pp. 34–40.
41. Kuppermann, N., Fleisher, G., Jaffe, D. (1998), ‘Predictor of occult pneumococcal bacteraemia in young febrile children’, Ann Emerg Med, Vol. 31(6): pp. 679-87.
42. Teach, S.J., Fleisher, G.R. (1997), ‘Duration of fever and its relationship to bacteremia in febrile outpatients 3 to 36 months old: the occult bacteremia study group’, Pediatr Emerg Care,Vol. 13(5): pp.317–9.
43. American Academy Paediatrics (AAP). (2011), ‘Urinary Tract Infection: Clinical Practice Guideline for the diagnosis and management of the initial UTI in febrile infants and children 2-24 months’, Pediatrics, Vol.128(3): pp. 595-610.
44. Williams, G.J., Macaskill, P., Chan, S.F., Turner, R.M., Hodson, E., Craig, J.C. (2010), ‘Absolute and relative accuracy of rapid urine tests for urinary tract infection in children: a meta-analysis’, Lancet Infect Dis, Vol. 10: pp. 240–50
45. Doley, A., Nelligan, M. (2003), ‘Is a negative dipstick urinalysis good enough to exclude urinary tract infection in Paediatric Emergency Department patients?’, Emergency Medicine, Vol. 15: pp. 77-80.
46. National Institute for Health and Clinical Excellence. (2007). Urinary tract infection in children. Diagnosis, treatment and long-term management, [online] Available at: http://www.nice.org.uk/nicemedia/live/11819/36032/36032.pdf [cited August 2007].
47. Bettenay, F.A., de Campo, J.F., McCrossin, D.B. (1988), ‘Differentiating bacterial from viral pneumonias in children’, Pediatr Radiol. Vol. 18(6): pp. 453-454.
48. Mower, W.R., Sachs, C., Nicklin, E.L., Baraff, L.J. (1997), ‘Pulse oximetry as a fifth pediatric vital sign’, Pediatrics, Vol. 99(5): pp. 681–6.
49. American College of Emergency Physicians Clinical Policies Committee. (2003). ‘Clinical Policies Subcommittee on Pediatric Fever. Clinical policy for children younger than three years presenting to the emergency department with fever’, Ann Emerg Med, Vol. 42(4): pp. 530–45.
50. Rutman et al. (2009), ‘Radiographic pneumonia in young, highly febrile children with leucytosis before and after universal conjugate pneumococcal vaccination’, Pediat Emerg Care, Vol. 25(1): pp.1-7.
51. Connell et al. (2007), ‘How reliable is a negative blood culture result? Volume of blood submitted for culture in routine practice in a children’s hospital’, Pediatrics, Vol. 119 (5): pp. 891-6.
52. Herz, A.M., Greenhow, T.L., Alcantara, J., Hansen, J., Baxter, R.P., Black, S.B., Shinefield, H.R. (2006), ‘Changing epidemiology of outpatient bacteremia in 3 to 36-month old children after the introduction of the heptavalent-conjugated pneumococcal vaccine’, Pediatr Infect Dis J, Vol. 25: pp. 293-300.
53. Pratt, A., Attia, M.W. (2007), ‘Duration of fever and markers of serious bacterial infection in young febrile children’, Pediatrics International, Vol. 49: pp. 31–35
54. Curtis et al. (2010), ‘Clinical features suggestive of meningitis in children: a systematic review of prospective data’, Pediatrics, Vol. 126(5): pp. 952-60.
55. Maniaci, V., Dauber, A., Weiss, S., Nylen, E., Becker, K.L., Bachur, R. (2008), ‘Procalcitonin in young febrile infants for the detection of serious bacterial infections’, Pediatrics, Vol. 122(4): pp. 701-10
56. Lopez, A.F., Cubells, C.L., Garcia, J.J., Pou, J.F. (2003), ‘Procalcitonin in pediatric emergency departments for the early diagnosis of invasive bacterial infections in febrile infants: results of a multicenter study and utility of a rapid qualitative test for this marker’, Pediatr Infect Dis J, Vol. 22: pp.895–903.
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Audit/evaluation strategy
Level of risk High
Strategy 1. Staff survey to evaluate awareness of procedure and emergency management practices
2. Observe practice
3. Review documentation, i.e. chart audit, to evaluate compliance with procedure