For decades, the care of infants with a fever who were between eight and 60 days old has varied wildly, with some being observed for a just a few hours in the emergency room and others getting a full workup, including a lumbar puncture and other invasive tests and hospitalization that could potentially go on for as long as five days.
But a new set of guidelines published in Pediatrics will help doctors decide which of these extremely fragile babies will need to be hospitalized and get extensive testing and which will not. And because the recommendations come with the imprimatur of the American Academy of Pediatrics, they are likely to be followed by the vast majority of doctors.
“Most of these infants never get a fever, but when one does it can be pretty scary,” said Dr. Sean O’Leary, a coauthor of the guidelines, vice chair of the Committee on Infectious Diseases for the American Academy of Pediatrics, and a professor of pediatrics at the University of Colorado, Anschutz Medical Campus. “What is good about these guidelines from the perspective of a parent is they are based on all the science accumulated over the decades on how to manage an infant with a fever.”
For parents who don’t want a serious illness to be missed but don’t want their babies to have an extensive workup the infant doesn’t need, “they are good news,” O’Leary said.
Any time an infant younger than 60 days develops a fever, even though the baby looks healthy otherwise, parents should reach out to their pediatrician for guidance, O’Leary said. With older babies, the parents wait a day or so to see if the fever clears.
This is the first attempt to standardize care for babies with a fever in this age group, said Dr. Eric Biondi, an associate professor of pediatrics at the Johns Hopkins School of Medicine and director of pediatric hospital medicine at the Johns Hopkins Children's Center in Baltimore.
These guidelines apply to infants who “look otherwise good and just have a fever,” Biondi said.
“The problem is these babies can’t tell us much and their immune systems are not as strong as they will be when they get a little older,” he added. “A little fever could be the sign of a bad bacterial infection, such as bacteria in the blood, meningitis or a urinary tract infection. For a long time, because of that, we’ve probably been over diagnosing, over treating, over lumbar puncturing and over hospitalizing.”
Up until now the kind of care an infant received depended on where they got treatment, Biondi said. “At one site, they might get a lumbar puncture, have invasive testing and get hospitalized,” he added. “The same infant at another hospital might just get a few hours of observation in the emergency room.”
Even with the new guidelines, “there will always be a subset of babies who get the full workup,” Biondi said. “But we can try to avoid doing that for every infant.”
The recommendations are also meant to encourage shared decision-making between the pediatrician and the family, Biondi said. In certain scenarios, there might be a 1 in 1,000 chance the baby has meningitis, he added.
“Maybe the family is OK with that risk and they don’t want a lumber puncture and don’t want to have the baby admitted to the hospital,” Biondi said. “Or the parents might say that’s too much of a risk, please admit the baby and rule that out.”
Involving parents will also help the doctor get a clearer picture of what’s been going on with the baby, said Dr. Pamela Schoemer, a pediatrician and director of quality, safety and outcomes at UPMC Children’s Community Pediatrics in Pittsburgh. “This reinforces to physicians that they need to discuss everything with families.”
Prior to the new guidelines “we had one set workup for all these babies,” Schoemer said. “This stratifies the children by risk.”
While some children will have markers that indicate they are more at risk “and maybe those babies do need to stay in the hospital and get IV antibiotics,” Schoemer said. “But some may just need to be observed and that might be something that can be done at home.”