The American Academy of Pediatrics released a clinical practice guideline for the management of febrile infants in August 2021 to compile nearly 40 years of research into a cohesive text that would provide a framework for the clinician in safely managing these patients in a variety of settings. (1) This guideline incorporates shared decision-making with the caregiver to guide treatment when appropriate and provides algorithms for 3 age groups: 8 to 21 days, 22 to 28 days, and 29 to 60 days. This guideline applies to previously healthy, well-appearing infants born at 37 weeks’ gestation or later who have a temperature of at least 100.4°F (≥38.0°C) in the previous 24 hours at home or in a clinical setting. Infants younger than 8 days and those with diagnosed focal infections are excluded. The highlighted changes to historical practice are in the 2 older age groups. In 22- to 28-day-old infants, if initial laboratory work is normal, shared decision-making is used to direct lumbar puncture and hospital admission with the possibility of monitoring the patient at home or in the hospital. In 29- to 60-day-old infants, admission to the hospital is indicated only if laboratory evaluation is concerning for meningitis or based on clinician judgment. The occurrence of invasive bacterial infection in a febrile infant with a positive viral test is still not well-measured, as broad viral panels are more recently developed technology. As this research evolves and expected advancements in early detection of infectious organisms and biomarkers occur, this new information will need to be incorporated into the existing evidence.
Advocacy in Neonatal Fever
Our practice norms are equally as important for us to think about as policies that dictate behavior, even when they are not written down explicitly. I am very pleased that the AAP has adopted shared decision making with patients and families. I have had more than a handful of parents who have asked that we deviate from the guidelines in a very reasonable manner. These interactions have always given me pause. From one perspective the recommended work up can seem very invasive and upsetting to parents when their newborn child seems fine aside from a temperature difference. They would like to advocate for their child from a point of comfort. On the other, I want to advocate for the health of the child based on the current body of medicine. When the stakes are as high as these, the shared decision making model is an excellent first step in building rapport and obtaining buy in from patients and family, and it is wonderful that these new guidelines offer this solution first and foremost. This way we can both advocate for the best interest of the child.
Having the evidence available to stratify risk by age and inflammatory markers to help determine the need for hospitalization is also a blessing. There is no place a new parent would rather be than at home, squaring away their new lives with their child. Having options such as shortened hospital stays of 24-36 hours, or outpatient treatment with follow up in 24 hours with return precautions will be a great tool for parents to gain agency in the management process. And we can advocate for the family unit to not be disrupted.
Lastly, these guidelines embolden me as a physician to use my own clinical decision making skills to advocate for my patients to the best of my ability, without adhering to a guideline that does not consider patients on a case by case basis. As much as it is important families to advocate for their opinions, it is also important to advocate for our own clinical assessments as they are the very foundation of our care. I belive having "well-appearing" from a clinican's standpoint in the criteria is an integral step to maintaining the autonomy of the individual physician and places an important roadblock in the algorithm that forces us to consider the patient, and not the disease.
Overall, great article. Thanks to all of the individuals who met multiple times and reviewed countless pieces of literature to unify the past and the present into a cohesive set of guidelines which improves the agency of all parties.