Practice Variation in the Evaluation and Disposition of Febrile Infants ≤60 Days of Age

J Emerg Med. 2019 Jun;56(6):583-591. doi: 10.1016/j.jemermed.2019.03.003. Epub 2019 Apr 20.


Background: Febrile infants commonly present to emergency departments for evaluation.

Objective: We describe the variation in diagnostic testing and hospitalization of febrile infants ≤60 days of age presenting to the emergency departments in the Pediatric Emergency Care Applied Research Network.

Methods: We enrolled a convenience sample of non-critically ill-appearing febrile infants (temperatures ≥38.0°C/100.4°F) ≤60 days of age who were being evaluated with blood cultures in 26 Pediatric Emergency Care Applied Research Network emergency departments between 2008 and 2013. Patients were divided into younger (0-28 days of age) and older (29-60 days of age) cohorts for analysis. We evaluated diagnostic testing and hospitalization rates by infant age group using chi-square tests and by site using analysis of variance.

Results: Four thousand seven hundred seventy-eight patients were eligible for analysis, of whom 1517 (32%) were 0-28 days of age. Rates of lumbar puncture and hospitalization were high (>90%) among infants ≤28 days of age, with chest radiography (35.5%) and viral testing (66.2%) less commonly obtained. Among infants 29-60 days of age, lumbar puncture (69.5%) and hospitalization (64.4%) rates were lower and declined with increasing age, with chest radiography (36.5%) use unchanged and viral testing (52.7%) slightly decreased. There was substantial variation between sites in the older cohort of infants, with lumbar puncture and hospitalization rates ranging from 40% to 90%.

Conclusions: The evaluation and disposition of febrile infants ≤60 days of age is highly variable, particularly among infants who are 29-60 days of age. This variation demonstrates an opportunity to modify diagnostic and management strategies based on current epidemiology to safely decrease invasive testing and hospitalization.

Keywords: fever; guidelines infant; infectious disease; practice variation.

MeSH terms

  • Biomarkers / analysis
  • Biomarkers / blood
  • Cohort Studies
  • Critical Illness / epidemiology
  • Critical Illness / therapy
  • Diagnostic Tests, Routine / methods*
  • Diagnostic Tests, Routine / statistics & numerical data
  • Emergency Service, Hospital / organization & administration
  • Emergency Service, Hospital / statistics & numerical data
  • Female
  • Fever / diagnosis
  • Fever / epidemiology
  • Fever / therapy*
  • Hospitalization / statistics & numerical data
  • Humans
  • Infant
  • Infant, Newborn
  • Male
  • Practice Patterns, Physicians' / standards*
  • Practice Patterns, Physicians' / statistics & numerical data
  • Prospective Studies


  • Biomarkers