The advent of pneumococcal and Haemophilus influenzae vaccines has substantially reduced the risk for occult (unsuspected) serious bacterial infection or invasive bacterial infection in the febrile child. The challenge for emergency clinicians is to identify and treat children with serious illness while avoiding overtreatment. This issue reviews the epidemiology and management of fever in children aged 3 to 36 months, focusing primarily on previously healthy, well-appearing children without a source of fever whose evaluation and management are more ambiguous.
How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.
Subscribe to access the complete flowchart to guide your clinical decision making.
Subscribe for full access to all Tables.
Buy this issue and
Following are the most informative references cited in this paper, as determined by the authors.
2. * Baraff LJ, Bass JW, Fleisher GR, et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research. Ann Emerg Med. 1993;22(7):1198-1210. (Society guidelines) DOI: 10.1016/s0196-0644(05)80991-6
5. * Pantell RH, Roberts KB, Adams WG, et al. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics. 2021;148(2):e2021052228. (Practice guideline) DOI: 10.1542/peds.2021-052228
22. * Givens T, Avner J, DePiero A, et al. Fever caused by occult infections in the 3-to-36-month-old child. Pediatr Emerg Med Pract. 2007;4(7):1-22. (Review)
30. * Bachur R, Perry H, Harper MB. Occult pneumonias: empiric chest radiographs in febrile children with leukocytosis. Ann Emerg Med. 1999;33(2):166-173. (Prospective study; 278 patients) DOI: 10.1016/s0196-0644(99)70390-2
31. * Shaikh N, Hoberman A, Hum SW, et al. Development and validation of a calculator for estimating the probability of urinary tract infection in young febrile children. JAMA Pediatr. 2018;172(6):550-556. (Retrospective study; 2070 patients) DOI: 10.1001/jamapediatrics.2018.0217
32. * Baraff LJ. Management of fever without source in infants and children. Ann Emerg Med. 2000;36(6):602-614. (Systematic review) DOI: 10.1067/mem.2000.110820
43. * Murphy CG, van de Pol AC, Harper MB, et al. Clinical predictors of occult pneumonia in the febrile child. Acad Emerg Med. 2007;14(3):243-249. (Retrospective cross-sectional study; 1084 patients) DOI: 10.1197/j.aem.2006.08.022
45. * Bradley JS, Byington CL, Shah SS, et al. Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25e76. (Guidelines) DOI: 10.1093/cid/cir625
47. * Thigpen MC, Whitney CG, Messonnier NE, et al. Bacterial meningitis in the United States, 1998-2007. N Engl J Med. 2011;364(21):2016-2025. (Retrospective study; 3188 patients) DOI: 10.1056/NEJMoa1005384
59. * Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595-610. (Society guidelines) DOI: 10.1542/peds.2011-1330
120. *Kaluarachchi D, Kaldas V, Roques E, et al. Comparison of urinary tract infection rates among 2- to 12-month-old febrile infants with RSV infections using 1999 and 2011 AAP diagnostic criteria. Clin Pediatr (Phila). 2014;53(8):742-746. (Retrospective study; 359 patients) DOI: 10.1177/0009922814529015
140. Centers for Disease Control and Prevention. Demographic trends of COVID-19 cases and deaths in the US reported to the CDC. Accessed August 17, 2022. (National database)
142. *Centers for Disease Control and Prevention. Information for Pediatric Healthcare Providers. Accessed August 17, 2022. (Guidelines)
143. Centers for Disease Control and Prevention. Overview of testing for SARS-CoV-2 (COVID-19), the virus that causes COVID-19. Accessed September 1, 2022. (Guidelines)
147. *Centers for Disease Control and Prevention. Information for healthcare providers about multisystem inflammatory syndrome in children (MIS-C). Accessed September 1, 2022. (Guidelines)
149. Centers for Disease Control and Prevention. COVID data tracker: health department-reported cases of multisystem inflammatory syndrome in children (MIS-C) in the United States. Accessed August 17, 2022. (CDC data tracker)
151. American Academy of Pediatrics. Multisystem inflammatory syndrome in children (MIS-C) interim guidance. Accessed September 1, 2022. (Guidelines)
Subscribe to get the full list of 152 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.
Keywords: pediatric fever, young children, serious bacterial infection, invasive bacterial infection, acute otitis media, AOM, skin and soft-tissue infection, SSTI, osteoarticular infection, osteomyelitis, septic arthritis, bacterial pneumonia, meningitis, bacteremia, urinary tract infection, UTI, bacterial enteritis, Pediatric Assessment Triangle, PAT, Yale Observation Scale, fever more than 5 days, COVID-19, multisystem inflammatory syndrome in children, MIS-C
Nader Badri, MD; Lucas Friedman, MD
Jeffrey R. Avner, MD, FAAP; Jo-Ann O. Nesiama, MD, MS
October 1, 2022
October 1, 2025   CME Information
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 1 Pharmacology CME credit.
Price: $59
+4 Credits!