Decreased Lumbar Puncture Utilization Following Implementation of Febrile Infant Guidelines in a Pediatric ED

Fever in infants under 60 days old raises concern for invasive bacterial infections. In 2021, the American Academy of Pediatrics (AAP) released updated guidelines, including revised recommendations for infants aged 22 to 28 days, to reduce unnecessary lumbar punctures (LP), hospitalizations, and antibiotic use. This study hypothesized that the guidelines would reduce LPs, specifically in the newly stratified age group.

We conducted a retrospective cohort study at a single pediatric emergency department of febrile infants aged 22 to 60 days presenting between October 1, 2019, and September 30, 2023, with October 1, 2021, being the division between groups. Infants were excluded if ill-appearing, <37 weeks of gestation, or had complex medical histories. The primary outcome was the proportion undergoing LP. Subgroup analysis was performed by age group, and those identified as low-risk by initial laboratory evaluation. Secondary outcomes included hospital admission, length of stay, and antibiotic use.

A total of 132 infants met the inclusion criteria (52 pre-guidelines, 80 post-guidelines), and no exclusion criteria were applied. Following guidelines, the proportion of LPs had a statistically significant decrease ( P =0.02), with the reduction maintained in the 22- to 28-day subgroup ( P =0.002). The rate of hospital admission and antibiotics followed a similar statistically significant decrease post-guideline introduction, which also maintained for the 22- to 28-day subgroup. There was no statistically significant difference for length of stay or in the 29- to 60-day subgroup analyses. For infants identified as low-risk by laboratory risk-stratification, we discovered a statistically significant reduction in LP following the guidelines ( P <0.001).

Implementation of the 2021 AAP guidelines was associated with reduced LPs, hospitalizations, and antibiotic use in infants aged 22 to 60 days, with the greatest impact in the 22- to 28-day subgroup. These guidelines improve risk stratification and reduce invasive interventions while maintaining safe care. While the small sample size limits generalizability, these findings suggest a positive shift in clinical practice.