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Coming in Hot! Recap of AAP Febrile Infant Guidelines

July 27, 2022

Written by Davin Brar

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The AAP recently released further guidance on the workup and treatment of febrile infants aged 8-60 days. See below for a short recap of these important recommendations.

Editor’s note: We covered the original article, but this was a concise synopsis that’s a helpful refresher. ~Clay Smith

Why does this matter?
Balancing the workup and treatment of febrile infants can be difficult. We don’t want to miss serious bacterial infection (SBI), but we also don’t want to subject infants to unnecessary tests, invasive procedures, or costly hospitalizations. Using evidence-based guidelines can help diagnose SBI, ensure a safe disposition for febrile infants, and reduce unnecessary resource utilization and healthcare costs. 

Recapping the febrile infant rule
The AAP recently released new guidelines for febrile infants aged 8-60 days. Patients included in this guideline had to be previously healthy, well appearing, term (>37 weeks gestation), and 8-60 days old with a temperature ≥38.0°C. Patients were excluded if they had evidence of focal bacterial infection, clinical bronchiolitis, immunocompromise, congenital abnormalities, or if they received vaccinations in the previous 24 hours.

The AAP addressed several issues since prior recommendations including age-based risk stratification, changes in bacteriology, prevalence of bacterial meningitis, subjectivity of characterizing “well appearing infants,” cost of unnecessary care, availability of testing, and implementing shared decision making.

The AAP provided three algorithms (see links below) for diagnostic testing of febrile infants 8-21 days, 22-28 days, and 29-60 days old. There are several nuances to these recommendations, and they range from strong to weak quality of evidence. You should really read the entire paper, but we have summarized some of the key points below.

Infants aged 8-21 days
Similar to prior recommendations, infants aged 8 to 21 days should undergo a complete sepsis workup (A, strong), receive parenteral antibiotics (A, strong), and be hospitalized (B, moderate).

Infants aged 22-28 days
Infants aged 22-28 days should receive urinalysis (UA, and a urine culture if positive), blood culture, and inflammatory markers (IM) (A, strong). The decision to obtain CSF is dependent on the UA and IM as well as clinical discretion (B, moderate). This differs from prior recommendations in that some febrile infants 22-28 days old may not require a lumbar puncture (LP), and some may not even need to be hospitalized. Infants aged 22-28 days can be discharged home if the UA, IM, and CSF are all normal and follow up in 24 hours can be arranged (B, moderate). Physicians may administer parenteral antibiotics to infants treated at home even if the UA, IM, and CSF are all normal (C, moderate).

Infants aged 29-60 days
Infants aged 29-60 days should get a UA, blood culture, and IM (A, strong). If the UA and IM are normal, CSF likely does not need to be obtained and patients may be observed at home (B, moderate). If IM are abnormal, consider a LP (C, weak), parenteral antibiotics (B, moderate), and hospitalization (B, moderate). If the UA is abnormal, urine culture should be obtained, and oral antimicrobials should be initiated if the IMs and CSF (if obtained) are all normal (B, strong).

Shared decision making also plays a significant role in these cases. Clinicians, health systems, and families will all have different risk tolerances when it comes to febrile infants. The AAP recommends using shared decision making with the family along with these guidelines to determine the best course of action regarding invasive testing, treatment, and disposition.

These guidelines are limited by location of practice, availability/timing of laboratory testing, and ability for patients to follow up as outpatients. In addition, the recommendations are relatively complex and don’t fully take into account the impact of viral testing. Further research could help simplify these guidelines and provide additional guidance on how to best care for febrile infants.

Here are the full guidelines from AAP:
Clinical Practice Guideline: Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old | Pediatrics | American Academy of Pediatrics (aap.org)

Algorithms for Febrile Infant Management
See prior JournalFeed post.

Edited and Peer Reviewed by Sam Parnell

Clinical Guideline Synopsis of Evaluation and Management of Well-Appearing Febrile Infants Aged 8 to 60 Days. JAMA Pediatr. 2022 Jun 1;176(6):602-603. doi: 10.1001/jamapediatrics.2022.0066.

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