Lecture on fever without a source in the newborn and the infant up to 3 months old.

1. Moises Auron, MD FAAP Pediatric Residency Program Noon Conference 8/21/2009

12. Yale Observation Scale Bang A. Indian J Pediatr 2009; 76 (6) : 599-604.

28. Differential Diagnosis of Fever Without Focus Common 3-36 months 0-3 months Viral Enterovirus, parainflueza, adenovirus, RSV, CMV, roseola, PV, influenza Same + HSV Bacterial (occult bacteremia) Strep pneumoniae, H.influenza, N. meningitidis, Salmonella Same + GBS Gram negative (E. coli, Kebsiella, Enterobacter cloacae, Salmonella) Listeria

29. Differential Diagnosis of Fever Without Focus Common 3-36 months 0-3 months Bacterial (UTI) Gram negative organisms (E. coli, Klebsiella) Same (other) Unlikely without signs meningitis

30. Differential Diagnosis of Fever Without Focus Rare 3m-36 months Connective Tissue Diseases Rheumatic fever, SLE, sarcoidosis, JRA Malignancies Leukemia, Lymphoma, neuroblastoma, Ewing sarcoma Poisoning Atropine, salicylates, cocaine, anticholinergics

35. Philadelphia Rochester Boston Age 29-60d < 60days 28-89d Temp > 38.2C > 38C > 38C History Not specified Term infant No perinatal Abx No underlying disease Not hospitalized longer than the mother No immunizations < 48h No antimicrobial < 48h Not dehydrated Physical Exam Well-appearing Unremarkable exam Well-appearing No ear, soft tissue or bone infection Well-appearing No ear, soft tissue, or bone infection Labs (define Lower risk) WBC<15,000 Band-neutrophil ratio<0.2 UA <10wbc/hpf Urine gm stain: negative CSF<8wbc CSF gm stain: negative CXR: no infiltrate Stool: no RBC, no WBC WBC 5,000-15,000 Absolute band <1500/mm3 UA < 10wbc/hpf Stool smeal <5WBC/hpf WBC <20,000 CSF<10/mm3 UA<10wbc/hpf CXR: no infiltrate

36. Three Most Common Strategies for Managing Febrile Infants Philadelphia Rochester Boston Higher Risk patients Hospitalize + Empiric antibiotics Hospitalize+ Empiric antibiotics Hospitalize+ Empiric antibiotics Lower risk patients Home No antibiotics Follow-up required Home No antibiotics Follow-up required Home Empiric antibiotics Follow-up required Reported Stats Sensitivity 98% Specificity 42% PPV 14% NPV 99.7% Sensitivity 92% Specificity 50% PPV 12.3% NPV 98.9% Sensitivity-not available Specificity 94.6% PPV-not available NPV-not available

42. Management: 0 months to 3 months Baraff LJ. Ann Emerg Med. 2000;36(6):602-614

45. Management: 3m to 36m Baraff LJ. Pediatr Ann. 1993; 22(8): 497-8.

61. Results: P < 0.001

65. Pediatrics. Aug 2003. 112(2): 282-284.

69. Pediatrics. Aug 2003. 112(2): 282-284. RR 0.09 [95% CI 0.02–0.38] P<0.0001