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Fever in pediatric primary care: occurrence, management, and outcomes
J A Finkelstein1, C L Christiansen, R Platt
1Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts, USA. jonathan_finkelstein@hphc.org
Insights
In pediatric primary care, most children with fever were treated with antibiotics. For children with high fevers and no clear source, testing rates were consistent with recommendations, and serious infections like meningitis were rare.
Area of Science:
- Pediatric primary care
- Infectious disease epidemiology
- Clinical management of febrile children
Background:
- Fever is a common reason for pediatric primary care visits.
- Accurate diagnosis and management of febrile children are crucial to prevent serious outcomes.
- Understanding current practices in fever management is essential for evidence-based care.
Purpose of the Study:
- To describe the epidemiology of fever in children.
- To analyze the management and outcomes of febrile children in primary care.
- To evaluate the incidence of serious infections like meningitis and sepsis.
Main Methods:
- A cohort of 20,585 children aged 3-36 months was studied.
- Automated medical records were used to analyze office visits for fever (temperature ≥38°C).
- Diagnoses, laboratory tests, antibiotic prescriptions, follow-up care, and hospitalizations for serious infections were reviewed.
Main Results:
- Among initial illness visits, 41% of children had no diagnosed bacterial or viral source.
- Laboratory testing was performed in 13% of those with temperatures 38-39°C and 36% with temperatures ≥39°C.
- Bacterial meningitis or meningococcal sepsis occurred in 56 per 100,000 child-years, with few cases preceded by specific warning signs.
Conclusions:
- Most febrile children in ambulatory settings received antibiotic treatment.
- Laboratory testing and follow-up for highly febrile children without a source were common and aligned with recommendations.
- The low incidence of meningitis and death suggests current testing and treatment rates are unlikely to significantly impact population-level rates.
Objective:
To describe the epidemiology, management, and outcomes of children with fever in pediatric primary care practice.
Patients:
A cohort of 20 585 children 3 to 36 months of age cared for in 11 pediatric offices of a health maintenance organization between 1991 and 1994.
Methods:
Using automated medical records we identified all office visits with temperatures >/=38 degrees C for a random sample of 5000 children, and analyzed diagnoses conferred, laboratory tests performed, and antibiotics prescribed. We also determined the frequency of in-person and telephone follow-up after initial visits for fever. Finally, we reviewed hospital claims data for the entire cohort of 20 585 to identify cases of meningitis, meningococcal sepsis, and death from infection.
Results:
Among 3819 initial visits of an illness episode, 41% of children had no diagnosed bacterial or specific viral source. Of these, 13% with a temperature of 38 degrees C to 39 degrees C and 36% with a temperature of >/=39 degrees C received laboratory testing. Almost half (43%) received some documented follow-up care in the subsequent 7 days. Among the 26 970 child-years of observation in the entire cohort, 15 children (56 per 100 000 child-years) were treated for bacterial meningitis or meningococcal sepsis. Five had an office visit for fever in the week before hospitalization, but only 1 had documented fever >/=39 degrees C and received neither laboratory testing for occult bacteremia nor treatment with an antibiotic.
Conclusion:
The majority of febrile children in ambulatory settings were diagnosed with a bacterial infection and treated with an antibiotic. Of highly febrile children without a source, 36% received laboratory testing consistent with published expert recommendations, and short-term follow-up was common. Meningitis or death after an office visit for fever without a source was predictably rare. These data suggest that increased testing and/or treatment of febrile children beyond the rates observed here are unlikely to affect population rates of meningitis substantially.