Fever – Infants 0-90 days

We follow the generally accepted policy that infants under 3 months of age with a fever of 100.4° or greater should be evaluated in Bethel for severe bacterial infection and sepsis work up as appropriate. The CHA’s are not allowed to give infants less than 3 months of age antibiotics in the village without a physician’s order, and these infants should be evaluated in Bethel before being started on any antibiotic therapy.

Infants with fevers 100.4° or greater that have a normal exam and are clinically stable do not need to be medevaced, but they do need to come to Bethel on the first plane in the morning.

Infants with fever who appear ill, have respiratory distress, or are toxic in appearance should have a medevac arranged, and IM ceftriaxone should be given in the village if any delay is expected. A blood culture should be obtained prior to Ceftriaxone if the patient is in a SRC. Our guideline on management of fever in infants better details our usual management style.

If you have questions upon starting at YKHC, feel free to consult a pediatrician.

YKHC Clinical Guideline Background

The YK population is at higher risk for both bacterial and viral infections. Children in this region have a significantly higher incidence of invasive bacterial illnesses due to pneumococcal, meningococcal and haemophilus influenzae infections. This population also has higher rates of meningitis than the general population. YKHC health care providers must be more vigilant and aggressive in their evaluation, treatment and follow up of febrile infants. National guidelines also require specific modification for care of infants in this region. The YKHC Clinical guideline for Fever (0-90 days) has been created and is updated regularly using national guidelines and evidence-based literature in conjunction with local prevalence and resistance rates for invasive bacterial infections, antibiotic formulary options, local epidemiologic data, regional standards of care and expert opinion.

Because of the higher invasive bacterial infection rates and the geographic challenges and delays in getting patients to higher levels of care, our YKHC guideline recommends earlier and more thorough evaluation and treatment and longer observation times both for hospital and outpatient care. The wait and watch approach, even with a stratifying risk assessment, does not work as well for patients in a village with limited resources or families who are anxious to return to the village. This guideline includes an algorithm for general evaluation and care of febrile infants less than 90 days as well as village recommendations for stable and unstable infants, local antibiotic treatment options and an approach to special circumstances (such as pretreatment, fever with recent immunizations, CSF lab values, inability to obtain an LP and HSV workup when indicated).

This was one of the first statewide clinical guidelines created for Alaska. In 2002 YKHC, ANMC and a number of native hub regions collaborated to create a standardized approach for the care of febrile infants under 90 days of age. The goal was to create an evidenced based, quality care, clinical algorithm to guide the care of febrile infants in the continuum of care from village to regional to tertiary care treatment centers. The guideline was completed and adopted by YKHC in 2003.

Resources/References

• Lumbar Puncture (YKHC Wiki Procedure Guide)
• Ishimine, P. The evolving approach to the young child who has fever and no obvious source. Emerg Med Clin North Am. 2007 Nov;25(4):1087-115, vii. doi: 10.1016/j.emc.2007.07.012
• Gomez, et al. Diagnostic Value of Procalcitonin in Well-Appearing Young Febrile Infants. Pediatrics. 2012; 130 (5): 815-22.
• Hui C, et al. Diagnosis and Management of Febrile Infants (0–3 months). Evidence Report/Technology Assessment No. 205 (Prepared by the University of Ottawa Evidence-based Practice Center under Contract No. HHSA 290-2007-10059-I.) AHRQ Publication No. 12-E004-EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2012.
• Milcent, et al. Use of Procalcitonin Assays to Predict Serious Bacterial Infection in Young Febrile Infants. JAMA Pediatr. 2016; 170 (1): 62-9.
• Seattle Children’s Hospital, et al. Neonatal Fever Pathway.
• ANMC Clinical Guideline: Fever in Infants 0-90 days old.
• Fever in infant 0-90 days old YKHC Clinical Guideline
• YKHC Wiki RMT Guide for fever <90 days - unstable

YKHC Clinical Guidelines
Common/Unique Medical Diagnoses