Ampicillin plus either gentamicin or a thirdgeneration cephalosporin provide adequate coverage.

Ceftriaxone is usually avoided in patients less than 2-4

weeks secondary to concern for biliary sludging. Acyclovir

is not recommended empirically for this age group, but

may be added to cover HSV if there is a history of seizures,

skin lesions are present, or the patient is acutely ill.

Infants who are 1-3 months old who fully meet lowrisk criteria may be given a single dose of ceftriaxone

before discharge to cover occult bacteremia or UTis.

However, this dosing does not fully cover meningitis from

these organisms and can complicate future decision making if the CSF has not been obtained before administration

of antibiotics. Do not administer antibiotics in these

patients unless a lumbar puncture has been performed.

Alternatively, some providers will observe patients in this

category as long as they have reliable caregivers

who are able to evaluate the infant for changes in symptoms and readily access further care if the patient's condition changes. In both approaches, it is imperative that the

PEDIATRIC FEVER

provider has a reliable way to reach the primary caregiver

and is able to communicate clearly regarding expectations.

Follow-up within 24 hours should be arranged before discharge. Infants who do not meet low-risk criteria should

have a full sepsis work-up, receive empiric antibiotics, and

be admitted for further inpatient monitoring.

Infants and children 3-36 months with a temperature

>39°C and elevated WBC > 15,000 historically received

ceftriaxone 50 mglkg for possible occult bacteremia after

blood cultures have been obtained. Because of decreased

rates of occult bacteremia secondary to widespread

pneumococcal vaccination, outpatient observation without

empiric antibiotics is reasonable. Children in this age

group with a urinalysis consistent with UTI who are

otherwise well-appearing may be treated as outpatients

with oral antibiotics (usually a third-generation cephalo ­

sporin). Children in this age group with a temperature

<39°C and a reassuring physical examination can be

reasonably managed as outpatients if good follow-up can

be assured. Lastly, if meningitis is highly s uspected or CSF

Gram stain identifies an organism in any of the preceding

age groups, ceftriaxone 100 mg/kglday and vancomycin

should be administered promptly in the ED.

DISPOSITION

..... Admission

Toxic-appearing infants and children with fever require a

full septic work-up, urgent treatment with broad-spectrum

antibiotics, and admission. Additionally, all infants

< 1 month of age with documented fever or history of fever

at home should be admitted for further observation and

treatment after a full septic work-up. Well-appearing

infants 1-3 months with a high risk of SBI or with a

documented focal bacterial illness also require admission.

If a patient is immunocompromised and presenting with

fever, they also are also usually treated with broad-spec ­

trum antibiotics and admitted.

..... Discharge

Febrile patients older than 3 months who are wellappearing, vaccinated, and have access to appropriate

follow-up can be discharged home. Additionally, low-risk

patients who are 1-3 months old may also be discharged

home as long as reliable follow-up within 24 hours can be

guaranteed.

SUGGESTED READING

Alpern ER, Henretig FM. Fever. In: Fleisher GR, Ludwig S.

Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia,

PA: Lippincott Williams & Wilkins, 20 10, pp. 266-274.

Avner JR, Baker MD. Management of fever in infants and children. Em erg Med Clin North Am. 2002;20:49-Q?.

Wang VJ. Fever and serious bacterial illness. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 201 1, pp. 750-755.

Respiratory Distress

La u ren Emily Bence, MD

Al isa A. McQueen, MD

Key Points

• Respiratory disorders a re potentially l ife-threatening

and must be identified and treated ra pid ly.

• Certa in physiologic differences make pediatric patients

more at risk of respiratory fa i l ure than adu lts.

• Conduct patient assessment in a calm, efficient manner,

attempting to local ize the underlying source of distress.

INTRODUCTION

Respiratory distress is a very common presentation in the

emergency department (ED).