Study shows impact of AAP guidance for febrile infants
Key takeaways:
- Resource utilization decreased among infants aged 22 to 60 days, indicating adherence to the new guidelines.
- Younger infants were more likely to be hospitalized or receive antibiotics.
Febrile infants aged 22 to 60 days were less likely to be hospitalized or receive antibiotics after the AAP published updated recommendations for their management, according to a study published in Pediatrics.
The AAP’s guidance for fever management in infants, which was updated in August 2021, recommends three different algorithms for different age groups. For infants aged 8 to 21 days, the AAP recommends completing a full workup. In contrast, the guidelines suggest using less invasive approaches — including forgoing lumbar punctures — for infants aged 22 to 60 days who appear otherwise healthy, because their risk for meningitis is lower than infants younger than 22 days.
Elena Dingle, MD, PhD, from the department of graduate medical education at Akron Children’s Hospital in Akron, Ohio, and colleagues investigated changes in resource utilization and associated costs before and after the guidelines were published.
Their retrospective study included 33,736 infants aged 8 to 60 days (55.5% boys; median age, 38 days) who were diagnosed with fever at pediatric hospitals in the United States. There were 12,220 (36.2%) infants whose visits took place between Aug. 1, 2019, and July 31, 2021, and 21,516 (63.8%) whose visits occurred between Aug. 1, 2021, and July 31, 2023.
The proportion of febrile infants who were admitted decreased from 42.6% before the guidelines to 34.7% after the guidelines, a difference of 7.9 percentage points (95% CI, –9 to –6.8), according to Dingle and colleagues. Specifically, younger infants aged 8 to 21 days were more likely to be admitted (difference, 2.7 percentage points; 95% CI, 0.4-5), whereas older infants were less likely to be admitted (difference 8.9 percentage points for ages 22 to 28 days; 8.8 percentage points for ages 29 to 60 days).
Similarly, younger infants were more likely to receive antibiotics after the guidelines were published, but overall use of antibiotics (difference, –8.8 percentage points; 95% CI, –9.9 to –7.7), acyclovir (–2.4 percentage points; 95% CI, –3.1 to –1.8) and lumbar punctures (–9.9 percentage points; 95% CI, –10.9 to –8.9) decreased among all infants.
Providers were more likely to obtain inflammatory markers for infants who visited the hospital after the AAP’s guidelines were updated, the authors wrote.
Dingle and colleagues noted a small but significant increase in 7-day revisits for bacteremia or sepsis among febrile infants who visited the hospital after the new guidance rolled out (difference, 0.4 percentage points; 95% CI, 0.1-0.7).
The researchers found no significant difference in the incidence of invasive bacterial infections or 7-day revisits for meningitis in either time period. There was also no difference in overall median cost, but costs did increase significantly among infants aged 8 to 21 days (difference, $418; 95% CI, $267-$583).
“We observed an increase in hospitalizations and additional laboratory tests, such as urinalysis, urine cultures and antibiotic treatments, along with associated costs (among infants aged 8 to 21 days),” Dingle and colleagues wrote. “This indicates that academic children’s hospitals are following the guidelines for this age group, opting for less invasive approaches only for older infants.”
Although resource utilization decreased, there was a slight increase in delayed diagnoses of bacteremia and sepsis, highlighting the need to balance reducing unnecessary interventions with timely identification of serious conditions,” they concluded.
References:
- Dingle E, et al. Pediatrics. 2025;doi:10.1542/peds.2024-068028.
- Pantell RH, et al. Pediatrics. 2021;doi:10.1542/peds.2021-052228.
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