Pediatric emergency medicine trisk 0660 0660
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observation without antibiotics or after empiric ceftriaxone are safe and effective
management strategies in this age group.
The febrile child between 2 and 24 months of age with signs suggesting a
serious focal infection (e.g., irritability, meningismus, tachypnea, flank
tenderness) should be evaluated with the appropriate diagnostic tests and treated
for any identified source (see Table 31.3 ). A chest radiograph should be
considered in febrile children with signs or symptoms of lower pulmonary
disease, particularly with hypoxia, work of breathing, or focal lung auscultatory
findings. An association between pneumonia and fever greater than 39°C with a
WBC greater than 20,000/mm3 in the absence of signs of pulmonary disease has
also been suggested. Therefore, if a CBC has been obtained and there is marked
increase in WBC count, in a child without otherwise identified source of fever, a
chest radiograph should be considered. If the child has neither clinical findings of
pulmonary disease nor the constellation of high fever associated with
leukocytosis, there is no need to perform chest radiography.
Young children with fever but no identifiable source on examination are at risk
for occult infections including occult bacteremia or UTI ( Table 31.4 ). In older
children, UTIs are accompanied by signs and symptoms such as dysuria,
frequency, urgency, incontinence, vomiting, or abdominal, suprapubic, and/or
flank pain. In young children, however, fever may be the only sign of a UTI.
Studies have established the overall prevalence of occult UTI in young children
without an identified source of infection to be between 3% and 9%, with a pooled
prevalence estimate of 5%. The risk is highest in febrile non-Black girls younger
than 2 years of age and in uncircumcised boys who are not toilet trained. Renal
scarring is associated with a febrile UTI in young children and may lead to further
sequelae such as hypertension and renal insufficiency. Therefore, laboratory
testing to evaluate for occult UTI is indicated for at-risk young febrile children
without an identifiable focus of infection. Certainly, any febrile child with a
history of UTI should be considered to be at risk for a recurrence. Risk
calculators have been developed (e.g., UTICalc at ) where
individual patient clinical factors can be entered and a predicted probability of
UTI is produced based on evidence-based algorithms. Risk factors for UTI in a
young child younger than 2 years of age without a prior history or overt signs of
UTI include age <12 months, maximum temperature of 39°C (102.2°F) or higher,
non-Black race, female or uncircumcised male, and lack of other identifiable
source of fever. Urine dipstick and culture should be performed for all children at
significant risk for occult UTI. Highest risk of UTI is if nitrite or leukocyte
esterase is found on urine dipstick. Screening urinalysis may be obtained via
