A5V4d

Feverish illness in children
The infections may be those acquired from the mother at the time of delivery (e.g. group B
streptococcus), or hospital- or community-acquired infections. Rarely, -devastating infections such as
disseminated herpes simplex may present in the neonatal period. The host response to these
infections and those presenting later in early infancy is fairly non-specific. For this reason, the GDG
decided to provide separate recommendations for this group.
Narrative evidence
The studies suggested that SBI, particularly bacterial meningitis and urinary tract infection (UTI), are
more common in the first 3 months than later in childhood. Among a series of infants in this age group
with fever, the incidence of SBI lies in the range 6–10%. 108,162,163
Three EL 2+ studies 108,162,164 and an EL 2+ meta-analysis 163 were found suggesting that neither
clinical examination alone nor any single test is able to identify those with SBI. However, clinical
assessment and investigations combined can help to identify those infants more likely to have SBI.
These babies appear ill to the clinician and/or have one or more abnormal test results from the
following:
154
white blood cell count (WBC) > 15 × 10 9 /litre
urine microscopy > 10 WBC per high power field (hpf)
cerebrospinal fluid (CSF) with > 8 WBC per hpf or positive gram stain
if diarrhoea is present more than 5 WBC per hpf in stool.
Another meta-analysis 152 of febrile infants less than 3 months old studied the usefulness of chest Xrays.
This showed that chest radiographs were normal in 361 infants without respiratory signs.
However, of 256 infants with one or more respiratory sign, 85 (33.2%) had positive chest radiographs
for pneumonia. Signs included tachypnoea more than 50 breaths/minute, rales (crackles), rhonchi
(wheeze), coryza, grunting, stridor, nasal flaring and cough.
GDG translation
Because young infants with fever are at relatively high risk of SBI (especially meningitis) which cannot
be predicted by clinical features alone, the guideline development group (GDG) concluded that, on
the basis of clinical effectiveness and cost-effectiveness, all febrile infants less than 3 months old
require basic investigation as well as observation. This is not a change to usual clinical practice for
this patient group. Those in the high-risk groups (neonates and those appearing unwell or with
WBC < 5 × 10 9 /litre or > 15 × 10 9 /litre) should also be investigated for meningitis and receive empirical
parenteral antibiotics, since they have the highest risk of infection. The GDG was unable to
recommend a specific cut-off level for C-reactive protein (CRP), but expected paediatric specialists to
use the CRP result as part of their overall assessment of a child with fever.
Recommendations
Number Recommendation
Children younger than 3 months
48 Infants younger than 3 months with fever should be observed and have the
following vital signs measured and recorded:
temperature
heart rate
respiratory rate. [2007]
49 Perform the following investigations in infants younger than 3 months with fever:
full blood count
blood culture
C-reactive protein
urine testing for urinary tract infection*
* See Urinary tract infection in children, NICE clinical guideline 54 (2007).