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South Australian Paediatric Clinical Practice Guideline 

Fever in Children  
aged 1-2 months 

  
  Department of Health and Wellbeing, Government of South Australia. All rights reserved.  

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Note:
This guideline provides advice of a general nature.  This statewide guideline has been prepared to promote and facilitate 
standardisation and consistency of practice, using a multidisciplinary approach.  The guideline is based on a review of 
published evidence and expert opinion.  
Information in this statewide guideline is current at the time of publication.  
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not 
sponsor, approve or endorse materials on such links. 
Health practitioners in the South Australian public health sector are expected to review specific details of each patient and 
professionally assess the applicability of the relevant guideline to that clinical situation. 
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the 
patient s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline. 
This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are 
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful 
confidential discussion. This includes: 

  The use of interpreter services where necessary, 
  Advising consumers of their choice and ensuring informed consent is obtained, 
  Providing care within scope of practice, meeting all legislative requirements and maintaining standards of 

professional conduct, and  
  Documenting all care in accordance with mandatory and local requirements 

 
Explanation of the aboriginal artwork: 
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture. The horse shoe shape 
design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant women. The smaller horse shoe shape in this 
instance represents the unborn child. The artwork shown before the specific statements within the document symbolises a footprint and demonstrates the need to move forward together in 
unison. 
 
 
 

     

 

 

 

 

 

 

 

The term  Aboriginal  is used to refer to people who identify as Aboriginal, Torres Strait Islanders, or both Aboriginal and Torres Strait 
Islander.  This is done because the people indigenous to South Australia are Aboriginal and we respect that many Aboriginal people prefer the 
term  Aboriginal .  We also acknowledge and respect that many Aboriginal South Australians prefer to be known by their specific language 
group(s) 

 Cultural safety enhances clinical safety.  

To secure the best health outcomes, clinicians must provide a culturally safe health 
care experience for Aboriginal children, young people and their families. Aboriginal 
children are born into strong kinship structures where roles and responsibilities are 
integral and woven into the social fabric of Aboriginal societies. 

Australian Aboriginal culture is the oldest living culture in the world, yet Aboriginal 
people currently experience the poorest health outcomes when compared to non-
Aboriginal Australians. 
 
It remains a national disgrace that Australia has one of the highest youth suicide rates 
in the world.  The over representation of Aboriginal children and young people in out 
of home care and juvenile detention and justice system is intolerable. 
 
The cumulated effects of forced removal of Aboriginal children, poverty, exposure to 
violence, historical and transgenerational trauma, the ongoing effects of past and 
present systemic racism, culturally unsafe and discriminatory health services are all 
major contributors to the disparities in Aboriginal health outcomes. 
 
Clinicians can secure positive long term health and wellbeing outcomes by making 
well informed clinical decisions based on cultural considerations. 

 



 Fever in Children aged 1-2 months 
 

 

  
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Purpose and Scope of PCPG 
The Management of the Children with Fever aged 1-2 months Clinical Guideline is primarily 
aimed at medical staff working in any of primary care, local, regional, general or tertiary 
hospitals. It may also assist the care provided by other clinicians such as nurses. The 
information is current at the time of publication and provides a minimum standard for the 
assessment (including investigations) and management of children with fever aged 1-2 
months; it does not replace or remove clinical judgement or the professional care and duty 
necessary for each specific case. 

Flowchart 

 

  



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Table of Contents 
 

Purpose and Scope of PCPG .................................................................................................... 2 

Important Points ......................................................................................................................... 4 

Abbreviations ............................................................................................................................. 4 

Definitions .................................................................................................................................. 5 

Fever ...................................................................................................................................... 5 

Serious Bacterial Infection (SBI) ............................................................................................ 5 

Occult Bacteraemia................................................................................................................ 5 

Fever without a focus ............................................................................................................. 5 

Introduction ................................................................................................................................ 6 

Assessment ............................................................................................................................... 6 

South Australian Ambulance Service (SAAS) Assessment and Referral .............................. 6 

Primary care / outpatient history and examination ................................................................ 7 

Investigations and Management of fever without focus ............................................................ 8 

Investigations ......................................................................................................................... 8 

Infants aged &lt;1 month ........................................................................................................... 8 

Assessment and management .............................................................................................. 8 

Admission Criteria .................................................................................................................. 8 

Referral Criteria ...................................................................................................................... 8 

Infants aged 1-2 months ............................................................................................................ 8 

Toxic on assessment ............................................................................................................. 8 

Referral Criteria ........................................................................................................................ 10 

References ............................................................................................................................... 10 

Acknowledgements .................................................................................................................. 11 

Document Ownership &amp; History ............................................................................................... 11 

 

Appendices 

APPENDIX 1   Urine Collection Methods ........................................................................... 12 

APPENDIX 2   CSF Interpretation ...................................................................................... 13 

APPENDIX 3   Contraindications to Lumbar Puncture ....................................................... 15 

APPENDIX 4   Investigations .............................................................................................. 16 

APPENDIX 5   Discharge Criteria ....................................................................................... 17 



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Important Points 

&gt; The flow diagram included in this document has been locally adapted from the Children s 
hospital at Westmead. The upper limit of normal for cut off values for both CRP and PCT 
investigations have been lowered to better reflect local SA clinical practice. These changes 
along with others however may invalidate the published findings from this protocol, in 
particular reducing the specificity and sensitivity of identifying severe bacterial infection 
(SBI). 

&gt; Children assessed as non-toxic but having any abnormal laboratory findings in this 
document do not automatically proceed to a full septic work up. The South Australian 
consensus recommendation is that they discuss the need for any additional investigations 
with a senior doctor first. This would generally include a consultant paediatrician, fellow or 
senior registrar. While this approach is likely to result in a reduction in the number of LP s 
performed compared to the published recommendations, there is also the potential for 
missing meningitis cases. 

&gt; All infants under 2 months of age with fever should have a bacterial source of infection 
sought clinically from history, examination and appropriate directed investigations. There is 
a difficult balance between missing SBI and unnecessarily invasive diagnostic testing and 
risks of unnecessary antibiotic exposure in early life. There is no single test, combination of 
tests or clinical findings that can reliably predict SBI with 100% accuracy in children. Hence 
the variation in approaches from the literature. 

&gt; All infants under 30 days of age should be managed according to the NEONATAL SEPSIS 
PATHWAY and any children requiring resuscitation should be also assessed and managed 
immediately according to the PAEDIATRIC SEPSIS GUIDELINE before following the fever 
without focus guideline. 

Abbreviations 
mg milligram(s) 
L litre(s) 
 g microgram(s) 
 L microlitre(s) 
kg kilogram(s) 
cm centimetre 
PCR polymerase chain reaction 
HSV herpes simplex virus 
VZV varicella-zoster virus 
UTI urinary tract infection 
IV intravenous 
IM intramuscular 
LP lumbar puncture 
NPA nasopharyngeal aspiration 
CNS central nervous system 
RR respiratory rate 
CBC complete blood count 
CRP C-reactive protein 
CSF cerebrospinal fluid 
URTI upper respiratory tract infection 
WBC white blood cell count 
WCC white cell count 
NICU neonatal intensive care unit 
CFU colony-forming unit 

 



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Definitions   

Fever &gt; For the purposes of this guideline fever is defined as axillary 
temperature&gt;=38 in hospital, or GP practice or home in the last 24 hours. 

&gt; For routine monitoring of stable patients, temperature may be measured 
at the axilla, rectally, orally or via the ear (tympanic). Rectal temperatures 
are considered the gold standard as they correlate better with core 
temperature.  Axillary temperatures have a lower correlation. Tympanic 
temperature measurements are less reliable and should not be 
preferentially used. If there is any doubt about a child s temperature, it 
should be repeated, and measurement of rectal temperature should be 
considered in infants 1-2 months age where other methods have been 
unsuccessful (this is rarely required in practice and appropriate local 
procedures should be followed as this is an invasive procedure). 

&gt; It should be noted that children, but particularly neonates, may respond to 
serious bacterial infection with hypothermia, thus any child with low 
temperature or other signs of toxicity should also be evaluated for 
infection/ bacteraemia. 

&gt; A fever recorded by thermometer at home should be approached in the 
same manner as a fever recorded in the hospital. 

Serious 
Bacterial 
Infection 
(SBI) 

&gt; Includes urinary tract infection, pneumonia, meningitis, bacteraemia or 
septicaemia, bone and joint infection, skin and soft tissue infection and 
bacterial enteritis. 

&gt; The risk of SBI increases with the height of fever in children less than 6 
months compared to over 6 months of age. 

&gt; Note that SBI can be present with low-grade fever, in the absence of 
fever or with hypothermia particularly in the very young. 

&gt; In febrile children, the rate of SBI increases with decreasing age (13-25% 
age 0-4 weeks, 8% age 4-8 weeks, children aged 3-36 months ranges 
from 2 to 12%) 

Occult 
Bacteraemia 

&gt; Defined as bacteraemia in a child who has no clinical focus of infection. 

&gt; Conjugated Pneumococcal vaccine has dramatically reduced the 
incidence of occult Pneumococcal bacteraemia. There is, however, still 
too little clear epidemiological data upon which changes to the 
recommendations for empiric therapy of the febrile child can be based. 

Fever 
without a 
focus 

&gt; Literature suggests that SBI continues to occur in the presence of 
concomitant viral infections, with as many as 5% of patients with 
confirmed viral sources having urinary tract infections or other SBIs. 
Infants and children presenting with a fever and signs of a viral illness 
(URTI, bronchiolitis, croup, skin or mucosal lesions) may have 
investigations performed to confirm the viral aetiology (such as an NPA for 
respiratory viruses and sterile site PCR on blood for HSV, VZV, 
enterovirus, parechovirus) but should also be assessed for bacterial 
infections as outlined below. 

 
 
  



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Introduction 
&gt; Fever is one of the most common acute presentations in childhood. 

&gt; Many children will be only mildly unwell and will have a focus of infection identified on history 
and examination. The majority of febrile illnesses in young children are caused by viruses, but 
up to 5% of young children with a significant fever will have a bacterial cause 

&gt; The aim of this guideline is to detect those children at risk from serious bacterial infection 
(SBI) presenting with fever without focus. This requires a combination of clinical judgement, 
specific investigations and a period of observation. If the source of fever is found, then the 
appropriate treatment guideline for that diagnosis should be followed. 

&gt; This guideline MUST NOT be used for : 
1) Neonates, 30 days of age or less, refer to NEONATAL FEVER/SEPSIS GUIDELINE 

available at: https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/. 

2) Children with any underlying disorders that affect their immunity or might otherwise 
increase their risk for serious bacterial or viral infections e.g. cystic fibrosis, oncology 
patients, known acquired or congenital immune deficiency, those on long term 
immunosuppressive therapy. Refer to individual guidelines (e.g. FEBRILE 
NEUTROPENIA IN PAEDIATRICS) or seek specialist guidance. 

3) Any patient that meets criteria for sepsis or severe sepsis/septic shock please refer to 
local sepsis guidelines and seek specialist paediatric advice. 

4) Children aged &gt;2 months of age. 

If a child is already receiving antibiotics, any clinical signs may be more subtle and 
clinicians require a higher index of suspicion for the possibility of partially treated 
infections. 

&gt; The degree or height of fever, its speed of onset and its response to antipyretics are all poor 
predictors of serious illness by themselves. Any febrile child who appears unwell or  toxic  
should be investigated and treated according to the PAEDIATRIC SEPSIS PATHWAY 
irrespective of the degree or height of fever. 

Assessment 
South Australian Ambulance Service (SAAS) Assessment and Referral 
&gt; Primary and secondary survey should be completed, with a focus on assessing for the signs 

of toxicity as outlined in the table 1 below. 

o If shock is present it should be immediately managed with IV fluid resuscitation and 
intravenous antibiotics as per the NEONATAL OR PAEDIATRIC SEPSIS PATHWAY 
guideline available at: https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/.  

o In toxic infants with or without a petechial/purpuric rash, consideration should be given 
to a single immediate dose of IV/IM benzylpenicillin. 

This should be done in consultation with the on duty ambulance service medical officer / 
clinical support. 

&gt; Prehospital measurement of temperature may not be possible or reliable, and a domestic 
thermometer may read falsely low. If temperature can be formally assessed, it should be done 
via the axilla. A fever measured at home by the parents should be accepted as a documented 
fever. If temperature cannot be measured but the infant/child appears unwell or toxic to either 
prehospital providers or the parents, the child should receive further formal medical 
assessment. 

&gt; Non-toxic infants aged 1-2 months with a recorded or reported temperature ?38 degrees 
should be formally and promptly assessed by a medical practitioner in a clinical setting where 
investigations such as blood cultures, lumbar puncture and urinalysis can be safely 
performed. 

  





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&gt; Antipyretics are not necessary in the pre-hospital setting if a fever is present - they are 
primarily a comfort measure but do not prevent complications such as febrile convulsions. 
Parents may decide to give antipyretics at their own discretion (If used, paracetamol is 
preferred). 

Primary care / outpatient history and examination 
&gt; Every child presenting with fever should have a thorough history taken and examination 

focusing on symptoms and signs of specific infections as well as general assessment to their 
degree of illness (table 1). 

&gt; The child s immunisation status must also be checked, especially regarding Pneumococcal, 
Meningococcal and Haemophilus immunisations 

&gt; Younger infants usually present with non-specific symptoms and signs of illness, and 
localising signs of disease are often lacking. General aspects of the child's behaviour and 
appearance provide the best indication of whether a serious infection is likely. 

&gt; Because bacteraemia can occur with focal infections, it is recommended that when a source 
of infection is identified on physical examination, further evaluation be considered if the doctor 
judges that focal findings are insufficient to explain the degree of the child's fever and illness. 
If the source of the fever is found, then appropriate management should be instituted. 

Table 1   Extended assessment of Toxicity 

Note: Any child assessed as being  toxic  must be seen by the most experienced Medical 
Officer available as soon as possible. 

 Well Unwell Toxic 

Alertness / 
Activity 

Strong cry or not 
crying  
Content, smiles  
Stays awake 
Normal response 
to social cues 

Drowsy / decreased 
activity  
Poor smile/response to 
social cues  
Irritable 

Wakes only with prolonged 
stimulation or unable to 
rouse  
Weak/high pitched or 
continuous cry  
Bulging fontanelle 

Breathing Normal work of 
breathing 

Nasal flaring Chest in-drawing RR&gt;60 
Grunting 

Colour / 
Circulation 

Normal lips, skin 
and tongue colour 

Pallor per caregiver Pale, mottled  
Blue, ashen 
Cool Peripheries 
Bounding pulses or wide 
pulse pressure 

Fluid / Urine 
output 

Normal skin and 
eyes 
Moist mucous 
membranes 

Poor feeding in infant 
Dry mucous 
membranes  
Reduced urine output 

Reduced skin turgor 
Bilious vomiting 
Decreased fluid intake by 
&lt;1/2 normal  
Decreased urine output 
less than 4 wet nappies 
over 24 hours 

Other  New lump &gt;2cm Rigors, seizure 
Petechial rash 
Appears very unwell to 
healthcare professional 
Persistent tachycardia 



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Investigations and Management of fever without focus 
Investigations 

&gt; Children at higher risk of SBI should usually have appropriate investigations performed 
according to their age and risk group, as per flow chart. 

Infants aged &lt;1 month 
Assessment and management 
&gt; Refer to NEONATAL SEPSIS PATHWAY for assessment, investigation and management for 

all infants less than 30 days of age available at: 
https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/. 

Admission Criteria 
&gt; All neonates with fever and without a source of infection should be hospitalized. If this 

necessitates transfer from a rural facility, the first dose of antibiotics should usually be given 
prior to transfer. 

Referral Criteria 
&gt; Infants with fever who show any signs of toxicity and/or showing signs of meningococcal 

disease should be urgently reviewed by an experienced paediatrician and consideration given 
to referral to paediatric intensive care after need for any fluid resuscitation and antibiotics 
have been given. 

&gt; Retrieval to intensive care, if required, should be arranged by calling MedSTAR kids. 
Infants aged 1-2 months 
&gt; Referral for immediate investigations at an appropriate facility should be strongly considered 

in all infants aged 1-2 months of age presenting with fever and without focus.  

Toxic on assessment  
High risk category 

&gt; All Infant 1-2 months with any signs or symptoms in the  toxic  category should be assessed 
for sepsis/shock and receive appropriate resuscitation measures first. 

&gt; Infants should receive a full septic screen as below including LP (providing no 
contraindications) and commence empiric intravenous antibiotic therapy as soon as possible.  

&gt; The following investigations are recommended as minimum for a full septic screen: 

o CBE with differential (+/- film) 
o Blood culture  
o Sterile site PCR panel from blood (HSV, VZV,  enterovirus, parechovirus, 

pneumococcal, meningococcal) 

o CRP 
o Pro-calcitonin (where testing is available) 
o Urinalysis and urine microscopy, urine culture (SPA/catheter/clean catch specimen) 
o Lumbar puncture (LP) should be performed in any child with signs or symptoms of 

meningitis and/or those appearing  toxic  and without contra-indications.  

o CSF request should include Microscopy/Gram staining/Culture/ PCR panel for CNS 
pathogens and biochemistry where ever possible. 

&gt; Chest X-ray, especially if increased work of breathing OR any respiratory symptoms or low 
oxygen saturation (&lt;=93% in room air) OR fever &gt;39 C and WBC&gt;20,000 (as screen for 
occult bacterial pneumonia). 

&gt; Combined nose/throat swab for respiratory viral screen if appropriate. 




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Non-toxic on assessment   
Low risk category 

&gt; A child is considered lower risk from serious infection providing they: 

a) Do not have any of the following abnormal laboratory results including:  WCC &gt;15 000 or 
&lt;4000, or absolute neutrophil counts &gt;10,000 or &lt; 1,000, and /or raised CRP&gt;20, and/or 
PCT &gt;0.5.   

b) Were born at full term (&gt;37 weeks gestation) 
c) Have had no previous prolonged NICU stay 
d) Have no chronic medical problems/diagnoses 
e) Did not receive antibiotic within 3 days of presentation 
f) Well appearing and easily consolable  
g) No evidence of any infection clinically 

Lower-risk infants without any toxic features on assessment and with normal investigations above 
still require hospital admission for a period of regular observation. Some of these infants may 
then be discharged providing they improve clinically and meet the discharge criteria. 

Intermediate category 
A non-toxic appearing child is considered may be considered at intermediate risk from serious 
infection if they have 1 or more of the following abnormal laboratory results including WCC &gt;15 
000 or &lt;4000, or absolute neutrophil counts &gt;10,000 or &lt; 1,000, and /or raised CRP&gt;20, and/or 
PCT &gt;0.5.  

These infants may require further investigations including full septic screen as above, before 
considering any empiric antibiotic therapy. 

 It is recommended that these infants are always discussed with a senior doctor 
(Paediatrician/Fellow or senior Registrar) before performing any additional investigations. 

All children in this category will require admission to hospital for observation and treatment if 
clinically indicated. 

Recommended empiric antibiotic therapy 
&gt; Infants requiring a full sepsis screen should be commenced and continued on empiric therapy 

below, until meningitis can be excluded or if the CSF status is unknown or unable to be 
interpreted (i.e. bloody tap, child too sick for LP, previous antibiotic therapy) then commence 
as per eTGA guidelines: 

o Cefotaxime 50 mg/kg IV 6 hourly 
PLUS  

o Amoxicillin 50mg/kg/Dose IV 6 hourly 
&gt; Consider adding intravenous acyclovir (20mg/kg/dose 8 hourly) for empiric treatment 

of HSV if this is clinically suspected or has if patient has had known contact with a 
person with active HSV infection.   
For infants at increased risk of MRSA infection (see below) add vancomycin to the 
above regimens 30mg/kg/dose up to 1.5 g IV 12 hourly. 

  



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Risk factors for infection with MRSA include: 

&gt; residence in an area with a high prevalence of MRSA (e.g. Northern Territory; remote 
communities in northern Queensland; regions north of metropolitan Perth in Western 
Australia, especially the Kimberly and Pilbara) 

&gt; previous colonisation or infection with MRSA, particularly if recent or associated with the 
current episode of care. 

&gt; frequent stays, or a current prolonged stay, in a hospital with a high prevalence of MRSA, 
particularly if associated with antibiotic exposure or recent surgery 

&gt; exposed to a care giver colonised or infected with MRSA. 

If Meningitis can be excluded in infants aged 1-2 months: 

&gt; Where all CSF parameters are considered to be within the normal range (see APPENDIX 2) 
and Gram stain is negative then it would be reasonable to give according to the eTGA 
guidelines: 

o Amoxicillin 50mg/kg/dose IV 6 hourly  
PLUS 

o Gentamicin* 7.5 mg/kg IV once daily.  
Gentamicin levels should be monitored according to local guidelines. 

*If gentamicin cannot be used then Amoxicillin plus Cefotaxime is recommended using the 
doses as above. 

For infants at increased risk of MRSA infection (see criteria above) add vancomycin to 
the above regimens 30mg/kg/dose up to 1.5 g IV 12 hourly.  

&gt; The use of antipyretics should not be routine for all febrile infants, but it should be considered 
in those who appear distressed or unwell. 

 
Referral Criteria 
&gt; Infants with fever who are shocked, unarousable or showing signs of meningococcal disease 

should be urgently reviewed by an experienced paediatrician and consideration given to 
referral to paediatric intensive care after appropriate antibiotics have been given. 

&gt; Retrieval to intensive care, if required, should be arranged by calling MedSTAR kids on  
(08) 8222 4222. 

References 
1. Hess A, Hanna D, Ging J, et al. Implementation of an evidence based guideline for the 

management of fever in infants &lt;3 months old. J Paed Child Health, 2017;53 (suppl 3): 
20-21. 

2. Aldridge P, Rao A, Sethumadavan R, et al. Fever under 3 months and the full septic 
screen: Time to think again? A retrospective cohort study at a tertiary-level paediatric 
hospital. J Paed Child Health, 2018;54:272-273. 

3. Children s Hospital of Philadelphia. ED pathway for evaluation /Treatment of Febrile 
young Infants (0-56 days Old). https://www.chop.edu/clinical-pathway/febrile-infant-
emergent-evaluation-clinical-pathway. 

4. Febrile child. Royal Children s Hospital Melbourne  
https://www.rch.org.au/clinicalguide/guideline_index/Febrile_child/ 

5. eTG complete Therapeutic Guidelines, viewed 3 October 2019, 
https://tgldcdp.tg.org.au. 







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Acknowledgements 
The South Australian Child and Adolescent Health Community of Practice gratefully acknowledge 
the contribution of clinicians and other stakeholders who participated throughout the guideline 
development process particularly:  

Write Group  
Dr Brett Ritchie 
Dr Simon Chu 
Dr Brian Coppin 
 
SA Paediatric Clinical Practice Guideline Reference Group Members 

Document Ownership &amp; History 
Developed by: SA Child &amp; Adolescent Health Community of Practice 
Contact: Health.PaediatricClinicalGuidelines@sa.gov.au 
Endorsed by: SA Safety and Quality Strategic Governance Committee 
Next review due:  04/03/2025   
ISBN number:  978-1-74243-899-3  
PDS reference:  CG093 
Policy history: Is this a new policy (V1)?  N 
 Does this policy amend or update and existing policy?   Y 
 If so, which version? V3 
 Does this policy replace another policy with a different title?  Y 
 If so, which policy (title)?  Children with fever aged 1-2 months 

 

Approval 
Date Version 

Who approved  
New/Revised Version Reason for Change 

07/09/20 V3.1 Chair, Child and Adolescent Health Community of Practice Name change 

04/03/20 V3 
Deputy Chief Executive, 
Department for Health and 
Welfare 

Name change and formal review in 
line with 1-5 year scheduled review 
timeline. 

01/07/13 V2 SA Safety and Quality Strategic Governance Committee 
Formally reviewed in line with 2 
year scheduled timeline for review 

09/03/12 V1 SA Safety and Quality Strategic Governance Committee 

Original SA Safety and Quality 
Strategic Governance Committee 
approved version. 

 

  




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Appendices 

APPENDIX 1   Urine Collection Methods  

Screening methods 
1. Bag Urine 

Useful for collecting urine for urinalysis for screening purposes in infants and children who 
cannot void on request (approx. 0-3 years - not recommended in neonates) 

This method is only valid if negative and clinical suspicion is low. There is a high risk for 
contamination and it is therefore unreliable if positive even when a pure growth of 
organism is cultured. 

A bag sample of urine should only be sent to the laboratory for urinalysis and culture if a 
definitive sample cannot be obtained and treatment needs to be started urgently  
(e.g. a septic neonate with dry tap on suprapubic aspiration [SPA]). 

(Some centres use sterile cotton balls in a nappy (after cleaning the area) to collect a 
sample equivalent to a bag specimen in non-toxic looking babies. There is some evidence 
for this.) 

2. Clean Catch 
Requires careful cleansing of skin and good technique 

These specimens can be readily contaminated by skin commensals.   

A pure growth of &gt; 105 cfu/ml in association with pyuria may indicate infection, but is less 
reliable than a definitive sample though better than a bag sample. 

Definitive methods 
1. Midstream specimen of urine (MSU) 

This can be obtained from children who can void on request. Clean catch specimens, 
particularly in females, are frequently contaminated. 

A pure growth of &gt; 105 cfu/ml (for coliforms) or &gt;104 for Gram positive pathogens in 
association with pyuria indicates infection. 

2. In-Out Catheter Specimens 
Useful from about 6 months of age but can be performed as young as neonates. 

These samples, once obtained, should always be sent for culture irrespective of 
microscopy screening results. Any growth &gt;105 cfu/ml (for coliforms) in association with 
pyuria indicates infection.  Note: the first part of the specimen can be contaminated and 
should ideally be discarded. Consider aspirating the catheter with 2 syringes and taking the 
1st 3 ml in the first syringe which should be discarded if sufficient urine is collected with the 
2nd syringe.  

3. Supra-pubic aspiration (SPA) 
Mostly used for infants less than 12 months but can be used up to 2 years of age. 

These samples, once obtained, should always be sent for culture irrespective of 
microscopy results. Any pure growth from SPA urine usually indicates infection but 
contamination by skin commensals or faecal flora may produce a mixed growth. 

Before attempting SPA, ultrasound guidance or a bladder scanner should be considered to 
demonstrate presence of urine in the bladder where this is available. 

Urine microscopy&gt;10 WCC/ uL with or without organisms should raise suspicion of 
possible UTI. Urine dipstick analysis provides clinicians with rapid result and should be 
performed on all urine collected for suspected UTI. 

  



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APPENDIX 2   CSF Interpretation 

Normal values 

&gt; The presence of any neutrophils in the CSF is unusual in normal children and should raise 
concern about bacterial meningitis 

&gt; Meningitis can occur in children with normal CSF microscopy. If it is clinically indicated, 
children who have a  normal  CSF should still be treated with IV antibiotics +/- IV antiviral if 
indicated pending STERILE SITE PCR panel and routine culture result. 

Interpretation of CSF results 

&gt; Gram stain may be negative in up to 60% of cases of bacterial meningitis even without prior 
antibiotics. 

&gt; Neither a normal Gram stain, nor a lymphocytosis excludes bacterial meningitis. 

&gt; Neutrophils may predominate in viral meningitis even after the first 24 hours. 

&gt; CSF findings in bacterial meningitis may mimic those found in viral meningitis (particularly 
early on). It may be possible with modest accuracy to judge whether bacterial or viral is more 
likely based on CSF parameters. However if the CSF is abnormal the safest course is to treat 
as if it is bacterial meningitis 

Other factors affecting results 
 

  

 White cell count Biochemistry 

Neutrophils 
(x 106/L) 

Lymphocytes 
(x 106/L) 

Protein 
(g/L) 

Glucose  
(CSF: blood ratio) 

Normal 
(&gt;1 month of age) 0 &lt;5 &lt;1.0 

&gt;0.6 

(or &gt;2.5mmol.L) 

 

 

White cell count Biochemistry 

Neutrophils 
(x 106/L) 

Lymphocytes 
(x 106/L) 

Protein 
(g/L) 

Glucose  
(CSF: blood ratio) 

Bacterial 
Meningitis 

100-10,000 

but may be  
normal 

Usually &lt;100 &gt;1.0 

but may be  
normal 

&lt;0.4 

but may be  
normal 

Viral 
Meningitis 

Usually &lt;100 10-1000 

but may be 
normal 

0.4-1.0 

but may be 
normal 

Usually normal 



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1. Antibiotics prior to lumbar puncture 
Prior antibiotics usually prevent the culture of bacteria from the CSF. Antibiotics are 
unlikely to significantly affect the CSF cell count or biochemistry in samples taken &lt;24 
hours after antibiotics. 

2. Seizures 
Recent studies do not support the earlier belief that seizures can increase cell counts in 
the absence of meningitis. It is safest to assume that seizures do not cause an increased 
CSF cell count. 

3. Traumatic tap 
Some guidelines suggest that in traumatic taps 1 white blood cell can be allowed for every 
500 to 700 red blood cells and 0.01g/L protein for every 1000 red cells. 

However, rules based on a  predicted  white cell count in the CSF are not reliable. 

In order not to miss any patients with meningitis, guidelines relating to decisions about who 
not to treat for possible meningitis need to be conservative. The safest interpretation of a 
traumatic tap is to count the total number of white cells, and disregard the red cell count. If 
there are more white cells than the normal range for age, then the safest option is to treat. 

Sterile site PCR 
Blood and CSF PCR are routinely available for Neisseria meningitidis, Pneumococcus, 
Enterovirus, Herpes Simplex, VZV and parechovirus. 

As results are not immediately available, they will only help with decisions concerning need 
for ongoing antibiotic and antiviral therapy. 

  



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APPENDIX 3   Contraindications to Lumbar Puncture 

&gt; Coma: absent or non-purposeful response to painful stimulus.  

&gt; Signs of raised intracranial pressure: e.g. drowsy, diplopia, abnormal pupillary responses, 
unilateral or bilateral motor posturing or papilloedema (NB. papilloedema is an unreliable and 
late sign of raised ICP in meningitis; a bulging fontanelle in the absence of other signs of 
raised ICP is not a contraindication).  

&gt; Cardiovascular compromise/ shock  

&gt; Respiratory compromise  

&gt; Focal neurological signs or seizures  

&gt; Recent seizures (within 30 minutes or not regained normal conscious level afterwards).  

&gt; Coagulopathy/thrombocytopenia  

&gt; Local infection (in the area where an LP would be performed)  

&gt; The febrile child with purpura where meningococcal infection is suspected with risk of 
disseminated intravascular coagulation.  

  



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APPENDIX 4   Investigations 

1. CXR should be performed in all infants with fever and no focus under 3 months of age. 
Indications for those over 3 month s age include: increased respiratory effort, tachypnoea, 
SaO2&lt;93% in room air and WCC&gt;20,000. 

2. Investigation criteria suggestive of infection in presence of fever: 
WCC &lt;5,000 OR &gt;15000 

Absolute neutrophil count &lt;1,000 OR &gt;10,000 

CRP&gt;20 

CSF&gt;5 WBC 

Urine microscopy with &gt;10 WBC/uL or bacterial seen 

CXR signs of consolidation, collapse 

3. Lumbar puncture 
Should be performed (providing no contra-indications) in all infants under 3 months of age 
with fever and without focus. For older febrile children without focus, indications include: 
any unwell appearing child (especially under 12 months age where it is difficult to clinically 
evaluate signs of meningitis), full or bulging fontanelle, vomiting, lethargy and drowsiness, 
seizures. 

  



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APPENDIX 5   Discharge Criteria 

Criteria for discharging and infant or child with fever without focus should usually include: 

&gt; Age greater than 3 months 

&gt; No toxic appearance features  

&gt; No indications for ongoing intravenous therapy 

&gt; No higher risk laboratory investigation criteria 

&gt; Able to maintain adequate oral intake to maintain hydration 

&gt; Consideration of social circumstances of child, family, transport, etc. 

&gt; Education with parent information sheet, agreement with and compliance of management by 
parent/care provider 

&gt; Review by medical practitioner within 24 hours 

 
 


	Purpose and Scope of PCPG
	Important Points
	Definitions
	Fever
	Serious Bacterial Infection (SBI)
	Occult Bacteraemia
	Fever without a focus
	Introduction
	Assessment
	South Australian Ambulance Service (SAAS) Assessment and Referral
	Primary care / outpatient history and examination

	Investigations and Management of fever without focus
	Investigations
	Infants aged &lt;1 month
	Assessment and management
	Admission Criteria
	Referral Criteria

	Infants aged 1-2 months
	Toxic on assessment

	Referral Criteria
	References
	Acknowledgements
	Document Ownership &amp; History
	Appendices
	APPENDIX 1   Urine Collection Methods
	APPENDIX 2   CSF Interpretation
	APPENDIX 3   Contraindications to Lumbar Puncture
	APPENDIX 4   Investigations
	APPENDIX 5   Discharge Criteria


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