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peds.febrile-infant.core.v1

Febrile infant (0-90 days)

pediatricsacutepediatricacuteinpatient
Start encounter →Print handoutPRODUCTION

PROMOTED 2026-05-25 (fix/planned-verify) PLANNED→INTEGRATED: authored seed routing manifest at prisma/seed/manifests/peds.febrile-infant.core.v1.ts (batch-23 scaffold template; terminology projected 1:1 from this dossier, no new codes); set manifest pointer. INTEGRATED requirements satisfied: manifest pointer set, workups non-empty (workup.pediatric_fever resolves in clinical-tools-registry), decision surface present (3 regimen_axes), test_files declared, evidence has primary_guideline + PMIDs + last_reconciled. SAFETY PASS 2026-05-25: live-verified all evidence.pmids vs PubMed E-utilities and all regimen RxCUIs vs RxNav. 6 of 7 PMIDs were FABRICATED (pointed to unrelated articles — prostaglandin/glia, ADA diabetes, medieval sign language, Thorax letter, collagen membrane, sex-and-smell) and were replaced with the real verified articles: 31479164→30776077 (Kuppermann PECARN JAMA Pediatr 2019), 26928912→27382134 (Gomez Step-by-Step Pediatrics 2016), 8121534→8065869 (Jaskiewicz Rochester Pediatrics 1994), 24127022→23378604 (Kimberlin neonatal HSV Pediatrics 2013), 8441244→8413453 (Baker Philadelphia NEJM 1993), 1613433→1731019 (Baskin Boston J Pediatr 1992). PMID 34281996 (Pantell AAP 2021 CPG) confirmed correct. Inline PMID 26928912 references (2 in flow/severity prose) also corrected to 27382134. All 4 RxCUIs confirmed correct: 733 ampicillin, 1596450 gentamicin, 281 acyclovir, 2193 ceftriaxone. NEXT STEPS (for SCAFFOLDED promotion): (1) author manifest at prisma/seed/manifests/peds.febrile-infant.core.v1.ts; (2) register dedicated Rochester / Step-by-Step / PECARN risk-stratification calculators in clinical-tools-registry.ts; (3) register protocol.febrile_infant.empiric_abx.v1 in clinical-tools-registry.ts; (4) RxCUI validation for ampicillin, gentamicin, ceftriaxone, acyclovir. AAP 2021 CPG technically covers 8-60d; extended to 0-90d in this dossier to cover 0-7d (per neonatal sepsis convention) and 61-90d (per Rochester/Philadelphia/Boston criteria). HSV pathway cross-references Kimberlin 2013 and Red Book 2021 for neonatal HSV classification (SEM/CNS/disseminated). Sibling differentiation from general pediatric fever and neonatal HSV engines documented. Deepened 2026-05-14 (shard-5-obped-id depth-pass-1): added co-located _briefs/peds.febrile-infant.core.v1.md (design brief — frame, 6-axis phenotype matrix [age × appearance × marker stratum × urinary source × HSV risk × likely aetiology], settings axis, severity-triggers cross-walk, Bayesian linkage summary, 12-phase author order, Stage-A API checklist, open-gaps log, schema proposal cache) + _research-bundles/peds.febrile-infant.core.v1.md (PMIDs, decision-threshold table per age band, LR table per finding, conditional dependencies, cross-dossier Bayesian routing, gap log). Closed audit-FAIL by: blanking manifest field at PLANNED (atoms field removed entirely; both files are out-of-shard scope); repointing workup.febrile_infant_sepsis → workup.pediatric_fever (canonical AAP 2021 + Step-by-Step + Rochester registry entry); repointing panel.inflammatory_markers → panel.inflammation (canonical CRP+PCT panel); repointing panel.csf_analysis → panel.csf (canonical CSF analyser); removing workup.hsv_neonatal, calc.rochester_criteria, calc.step_by_step_pecarn, protocol.febrile_infant.empiric_abx.v1 entries (none resolve in clinical-tools-registry today; their absence does not block PLANNED status — registry additions deferred to a future shard with seed manifest authorship). Added 2 new severity triggers (age_0_to_7_days_any_fever life_threatening — full IBI workup + admit + empiric IV ampicillin + gentamicin + LP + HSV PCR + empiric acyclovir per neonatal-sepsis convention + Kimberlin 2013; abnormal_inflammatory_markers severe — PCT > 0.5 OR CRP > 20 OR WBC < 5K or > 15K OR ANC ≥ 4090 escalates workup including LP at 29-60 d, mandates admit + IV ceftriaxone, removes low-risk discharge eligibility per AAP 2021 Section 5/6 + Step-by-Step Gomez 2016). Appended Gomez 2016 PMID 27382134 to evidence.pmids (now 7 PMIDs). Bumped evidence.last_reconciled to 2026-05-14. Status remains PLANNED — SCAFFOLDED promotion requires manifest authorship which is out-of-shard. Phenotype matrix (age band × appearance × inflammatory marker stratum × urinary source × HSV risk features × likely aetiology by Step-by-Step / PECARN — 6-axis 240-cell cross-product collapsed by clinical meaning) encoded indirectly via severity_triggers (ill_appearing_febrile_neonate, hsv_concern_neonate, bacterial_meningitis_confirmed, neutropenia_febrile_infant, hemodynamic_instability_febrile_infant, age_0_to_7_days_any_fever, abnormal_inflammatory_markers) + per-setting playbook logic (ED, inpatient) + regimen_axes (0-28 d empiric, 29-60 d empiric, 61-90 d risk-stratified) + flow phase logic (FRAME / ENTRY / CONTEXT / RED_FLAGS / INITIAL_WORKUP / BRANCHING_WORKUP / DIFFERENTIAL / RISK_STRATIFICATION / TREATMENT / DISPOSITION / MONITORING / FOLLOWUP). First-class TS field for phenotype matrix is schema-blocked. Bayesian linkage (pre-test priors per age band: 0-7 d ~ 15-20% SBI; 8-21 d ~ 10-13%; 22-28 d ~ 7-8%; 29-60 d ~ 4-6%; 61-90 d ~ 3-5% — anchored to AAP 2021 evidence tables + PECARN Kuppermann 2019 + Step-by-Step Gomez 2016. LRs per finding: ill-appearing LR+ ~ 5-7; UA positive for UTI LR+ ~ 6-8; PCT ≥ 0.5 for IBI LR+ ~ 4-6; CRP > 20 LR+ ~ 2-3; Step-by-Step rule LR+ ~ 2.5-3 / LR− ~ 0.10-0.15; Rochester rule LR+ ~ 2-3 / LR− ~ 0.20; HSV risk feature for neonatal HSV LR+ ~ 5-10. T_treat ~ 2-3% post-test SBI (varies by age band); T_test ~ < 1% with Rochester / Step-by-Step / AAP Section 6 low-risk criteria met; T_treat for HSV ~ 0.5% drives empiric acyclovir. Cross-dossier routing: id.sepsis.peds.v1 if ill-appearing / Phoenix-2024 criteria met; id.bacterial-meningitis.peds.v1 if CSF culture or Gram-stain positive; id.neonatal_hsv.core.v1 if HSV PCR positive; peds.aki.v1 if aminoglycoside-related AKI develops) documented in _research-bundles/peds.febrile-infant.core.v1.md. ROS/DDx LR seed data audited by npm run audit:ros-ddx-coverage (cross-cutting; not touched by this shard). Prehospital recognition is currently encoded implicitly via existing entry_points + transitions[].admit; a first-class "prehospital" DossierSetting value is schema-blocked.

Entry points (3)

  • vital_abnormality
    Fever ≥38°C (100.4°F) rectal in infant 0-90 days (AAP 2021 Pantell)
    fever_gte_38c_infant_0_90d
  • symptom
    Ill-appearing neonate requiring immediate stabilization (AAP 2021 Pantell)
    ill_appearing_neonate
  • history
    Maternal GBS colonization or chorioamnionitis with neonatal fever (AAP 2021 Pantell; CDC 2020 GBS)
    maternal_gbs_chorioamnionitis

Required inputs (8)

  • age_daysrequired
    demographic • used at FRAME
    Age tier drives entire workup algorithm: 0-28d vs 29-60d vs 61-90d (AAP 2021 Pantell)
  • temperaturerequired
    vital • used at FRAME
    Fever ≥38°C rectal defines inclusion; degree of fever factors into risk (AAP 2021 Pantell)
  • appearance_well_vs_illrequired
    symptom • used at RED_FLAGS
    Ill-appearing infant bypasses risk stratification → immediate full sepsis workup + empiric therapy (AAP 2021 Pantell)
  • wbcrequired
    lab • used at INITIAL_WORKUP
    WBC abnormality (<5000 or >15000) raises SBI probability; used in Rochester criteria (Jaskiewicz 1994; AAP 2021 Pantell)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    UTI is most common SBI in febrile infants; pyuria ≥10 WBC/hpf or positive LE (AAP 2021 Pantell; PECARN Kuppermann 2019)
  • csf_studiesrequired
    lab • used at INITIAL_WORKUP
    LP mandatory in 0-28d and ill-appearing any age; CSF pleocytosis, protein, glucose, culture, HSV PCR (AAP 2021 Pantell)
  • procalcitoninrequired
    lab • used at RISK_STRATIFICATION
    PCT ≥0.5 ng/mL high-risk marker for invasive bacterial infection (Step-by-Step Kuppermann JAMA Pediatr 2019; AAP 2021 Pantell)
  • crprequired
    lab • used at RISK_STRATIFICATION
    CRP ≥20 mg/L supports inflammatory marker-based risk stratification (Step-by-Step Kuppermann JAMA Pediatr 2019; AAP 2021 Pantell)

12-phase flow (12)

  1. 1FRAME
    Confirm febrile infant criteria: age 0-90 days + temperature ≥38°C rectal; assign age tier (0-28d / 29-60d / 61-90d) per AAP 2021 Pantell
    inputs: age_days, temperature
    advance: Age tier assigned + fever confirmed
  2. 2ENTRY
    Identify trigger: new fever in well infant, referral from nursery, maternal risk factors (GBS, chorioamnionitis, prolonged rupture of membranes) (AAP 2021 Pantell; CDC 2020 GBS)
    inputs: maternal_gbs_chorioamnionitis
    advance: Entry trigger and maternal history captured
  3. 3CONTEXT
    Gestational age, birth history, immunization status, sick contacts, antibiotic pre-treatment, feeding pattern, urine output (AAP 2021 Pantell)
    inputs: age_days, appearance_well_vs_ill
    advance: Birth history + feeding + exposure history documented
  4. 4RED_FLAGS
    Ill-appearing (lethargy, poor perfusion, respiratory distress, bulging fontanelle, petechiae, seizure) → immediate full sepsis workup + empiric antibiotics regardless of age tier (AAP 2021 Pantell)
    inputs: appearance_well_vs_ill
    advance: Appearance classified as well vs ill; ill-appearing → bypass to TREATMENT
  5. 5INITIAL_WORKUP
    0-28d: CBC, blood culture, UA + urine culture, LP (CSF cell count, protein, glucose, culture, HSV PCR if ≤21d), consider CXR if respiratory symptoms (AAP 2021 Pantell); 29-60d: same + procalcitonin + CRP; LP if inflammatory markers elevated or UA positive (AAP 2021 Pantell); 61-90d: UA + urine culture, inflammatory markers, blood culture; LP only if high-risk features (Rochester/Philadelphia/Boston criteria)
    inputs: wbc, urinalysis, csf_studies, procalcitonin, crp
    actions: workup.pediatric_fever, panel.cbc, panel.inflammation
    advance: Labs + cultures obtained per age-tier protocol
  6. 6BRANCHING_WORKUP
    HSV-specific workup if ≤21d or HSV risk factors (maternal HSV, vesicular lesions, seizures, elevated AST/ALT): HSV PCR from CSF + blood + surface swabs + hepatic panel (AAP 2021 Pantell; Kimberlin Red Book 2021)
    advance: HSV risk assessed; HSV workup sent if indicated
  7. 7DIFFERENTIAL
    Viral fever (RSV, enterovirus, influenza, parechovirus per PECARN 2019) vs UTI (most common SBI; PECARN Kuppermann 2019) vs bacteremia vs meningitis (bacterial or HSV per Kimberlin 2013) vs late-onset GBS (CDC 2020)
    advance: Diagnostic probability assigned per culture + inflammatory marker profile
  8. 8RISK_STRATIFICATION
    Apply age-appropriate criteria: 0-28d = high-risk by default (AAP 2021 Pantell); 29-60d = Step-by-Step (Gomez Pediatrics 2016 PMID 27382134; PECARN derivation Kuppermann JAMA Pediatr 2019) using PCT + CRP + UA + ANC; 61-90d = Rochester criteria (Jaskiewicz 1994) or Philadelphia criteria (Baker 1993) or Boston criteria (Baskin 1992). Dedicated Rochester / Step-by-Step calculators not yet wired in clinical-tools-registry — see notes for deferred registry additions.
    inputs: procalcitonin, crp, wbc, urinalysis
    advance: Risk category assigned (high-risk → admit + empiric abx; low-risk → observe or discharge with follow-up)
  9. 9TREATMENT
    Empiric antibiotics by age tier: 0-28d ampicillin 50 mg/kg IV q8h + gentamicin 4 mg/kg IV q24h + acyclovir 20 mg/kg IV q8h if HSV concern (AAP 2021 Pantell; Kimberlin 2013); 29-60d ceftriaxone 50 mg/kg IV/IM ± ampicillin 50 mg/kg IV q6h for Listeria/enterococcal coverage (AAP 2021 Pantell); 61-90d ceftriaxone 50 mg/kg IM if high-risk OR close observation if low-risk (AAP 2021 Pantell; Rochester criteria). Dedicated febrile-infant empiric-abx protocol not yet wired in clinical-tools-registry — regimen is rendered via regimen_axes[].
    inputs: age_days, appearance_well_vs_ill, csf_studies
    advance: Empiric regimen initiated per age tier or observation plan documented
  10. 10DISPOSITION
    0-28d: admit all (AAP 2021 Pantell); 29-60d: admit if ill-appearing, inflammatory markers elevated, or positive UA; observe 24-36h if well-appearing + low-risk markers (AAP 2021 Pantell); 61-90d: discharge with 24h follow-up if low-risk by Rochester/Philadelphia/Boston; admit if high-risk (AAP 2021 Pantell)
    advance: Disposition + level of care set per age tier + risk category
  11. 11MONITORING
    Inpatient: vitals q4h, clinical reassessment q8-12h, culture follow-up at 24h and 48h; if on acyclovir monitor renal function + CBC q48h (Kimberlin 2013); repeat LP if CSF initially abnormal and not improving at 48-72h (AAP 2021 Pantell)
    advance: Monitoring orders documented + culture tracking plan in place
  12. 12FOLLOWUP
    Discharge with reliable caregiver + 24h PCP follow-up if sent home on observation (AAP 2021 Pantell); return precautions for fever recurrence, poor feeding, lethargy, irritability; final culture check at 48-72h for all blood/urine/CSF cultures (AAP 2021 Pantell)
    advance: Follow-up appointment confirmed + return precautions given + culture tracking complete