Fever in Children Aged 3 to 36 Months: Management in the ED

Fever in Children Aged 3 to 36 Months: Management in the Emergency Department (Pharmacology CME)

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Table of Contents

About This Issue

The differential diagnosis of fever in children aged 3 to 36 months is broad. The challenge for emergency clinicians is to identify and treat children with serious illness while avoiding over testing and over treating. This issue offers evidence-based recommendations for 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. In this issue, you will learn:

Common causes of fever in early childhood

How assessment tools such as the Pediatric Assessment Triangle and the Yale Observation Scale can be used to determine which febrile children may have a serious illness

The best methods for measuring temperature

Physical examination findings that are associated with some of the common causes of fever in young children

When diagnostic studies are indicated

Recommendations for treatment with antibiotic and antiviral medications

Which children require admission

Table of Contents
  1. About This Issue
  2. Abstract
  3. Case Presentations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Etiology and Pathophysiology
    1. Acute Otitis Media
    2. Skin and Soft-Tissue Infection
    3. Osteoarticular Infection
    4. Bacterial Pneumonia
    5. Meningitis
    6. Bacteremia
    7. Urinary Tract Infection
    8. Bacterial Enteritis
  7. Differential Diagnosis
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. Physical Examination Findings, by Condition
      1. Acute Otitis Media
      2. Skin and Soft-Tissue Infections
      3. Osteoarticular Infection
      4. Pneumonia
      5. Meningitis
  10. Diagnostic Studies
    1. Inflammatory Markers and Blood Cultures
      1. Skin and Soft-Tissue Infections
      2. Septic Arthritis
    2. Urinalysis, Urine Dip, Urine Culture, and Bladder Ultrasound
    3. Chest X-Ray and Chest Ultrasound
    4. Cerebrospinal Fluid Studies
    5. Stool Testing
    6. Viral Testing
  11. Treatment
    1. Antipyretics
    2. Antibiotics and Antivirals
      1. Acute Otitis Media
      2. Osteomyelitis, Septic Arthritis, Meningitis, and Sepsis
      3. Pneumonia
  12. Special Populations
    1. Immunocompromised Children
    2. Children With Fever for More Than 5 days
  13. Controversies and Cutting Edge
    1. COVID-19
    2. Multisystem Inflammatory Syndrome in Children
    3. Serological Biosignatures
  14. Disposition
  15. Summary
  16. Time- and Cost-Effective Strategies
  17. 5 Things That Will Change Your Practice
  18. Risk Management Pitfalls in Febrile Children Aged 3 to 36 Months
  19. Case Conclusions
  20. Clinical Pathways
    1. Clinical Pathway for Management of Well-Appearing Children Aged 3 to 36 Months With Fever
    2. Clinical Pathway for Management of Ill-Appearing Children Aged 3 to 36 Months With Fever
  21. Tables
  22. References


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.

Case Presentations

A 3-month-old boy presents with cough, congestion, and fever…
  • The boy’s mother tells you she measured the boy’s temperature at home, and it was 104.2°F (40.1°C). She says he has been sick for the past 3 days.
  • The history reveals that the infant has received all his recommended vaccinations, is uncircumcised, and was born at term without any complications. The prenatal course was unremarkable. On examination, he is fussy but consolable. He is congested, with no respiratory distress.
  • The diagnosis of a viral infection, such as bronchiolitis, is possible, but you also consider the possibility of a concurrent bacterial infection. Is the height of the fever concerning enough to warrant further testing?
An 18-month-old unvaccinated girl presents with the primary concern of fever…
  • The mother says her daughter has felt “hot to the touch” for the past 4 days, but the girl is afebrile in the ED, without any antipyretics given at home. The girl is otherwise asymptomatic.
  • On examination, the girl is well-appearing with normal vital signs. No focal bacterial infection is found.
  • Should you consider this patient febrile if there are no documented fevers at home or in the ED? Does this patient need a workup for fever without a source?
A previously healthy 3-month-old boy presents with fever for the past 2 days…
  • The boy is circumcised and unvaccinated. He has been febrile to 39.8°C for the past 2 days but looks well.
  • What is the likelihood that this patient has an invasive bacterial infection or a serious bacterial infection? If discharged home, should antibiotics be started and how soon should they follow up?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathways

Clinical Pathway for Management of Well-Appearing Children Aged 3 to 36 Months With Fever

Subscribe to access the complete flowchart to guide your clinical decision making.


Table 1. Differential Diagnosis for Elevated Temperature

Table 2. Pediatric Assessment Triangle Components and Normal Findings
Table 3. Yale Observation Scale
Table 4. Common Oral Antibiotic Medications for Cystitis and Pyelonephritis

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Key References

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


Publication Information

Nader Badri, MD; Lucas Friedman, MD

Peer Reviewed By

Jeffrey R. Avner, MD, FAAP; Jo-Ann O. Nesiama, MD, MS

Publication Date

October 1, 2022

CME Expiration Date

October 1, 2025    CME Information

CME Credits

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.

Pub Med ID: 36121775

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